Prepared by:

WILLYN B. ADRIAS, RN.,MN.

NURSING MANAGEMENTCOURSE OUTLINE

a. Definition of Nursing Managementb. Levels of Skills Management

1. Conceptual2. Interpersonal3. Technical

c. Management Functions of the Nurse1. PLANNING a. Principles b. Characteristics c. Barriers d. Elements/Components (Vision, Mission, Philosophy, Setting

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

2. ORGANIZING a. Organizational Concepts & Principles b. 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. DIRECTING a. Principles b. Communication of Management (Upward, Downward, Lateral)

c. Delegation Concepts, Principles, Process d. Problem-Solving, Decision-Making Methods, Process e. Management Conflict (Causes, Nature/Types, Conflict

Resolution)

4. CONTROLLING a. Principles b. Performance-Appraisal-Principles-Process c. Discipline-Principles-Process d. Nursing Audit-Principles-Process e. 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 Education & Practice)

g. Current Issues and Trends in Nursing Management

OVERVIEW OF NURSING MANAGEMENT

THE NURSING MANAGEMENT PROCESS

Management is a process by which a cooperative group direct actions towards common goals. It involves techniques by which a distinguished group of people coordinates the services of the people. Over time, management has evolved into more than the use of means to accomplish given ends. It now includes moral and ethical standards in the selection of right ends toward which managers should strive.

Classic Three-fold ConceptBy Harbizon and Myers

Management is:1. an economic resource,2. a system of authority, and3. and elite class

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

As a system of authority management first develops with top individuals determining the course of action for the rank and file. Humanitarian concepts have later developed paternalistic approaches. This is followed by constitutional management which emphasizes definite and consistent concern for policies and procedures in dealing with the working group. The trend toward a democratic and participative approach follows as employees receive higher education.

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

Modern management theory evolved from the work of Henri Fayol, who identified 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, to coordinate, and to control. To foresee and provide means [of] examining the future and drawing up plan of action. To organize means building up the dual structure, material and human, of the undertaking. To command means binding together, unifying and harmonizing all activity and effort. To

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

The management process is universal. It is used in business, in the practice of one’s profession, and even in running one’s day-to-day personal affairs. For nurses, knowledge of this process assures them of the smooth functioning of their units to attain their goal of quality care through the judicious use of available human and material resources within specified periods.

ROLE OF MANAGERSBy Mintsberg

These roles describe what managers actually do.

INTERPERSONAL ROLEThe interpersonal role shows the manager:

1. As a symbol…because 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 information

from both external and internal sources3. As spokesperson or representative of the organization

- represents subordinates to superiors and the upper management to the subordinates

DECISIONAL ROLEThe decisional role makes the manager:

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

2. A trouble-shooter…handles unexpected situations such as resignation of subordinates,

firing of subordinates, losses of clients3. As negotiator…

when conflicts arise

DEVELOPING FUTURE MANAGERS

Managerial development programs are very useful means of getting qualified 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 in the correct manner with the right technique.

2. HUMAN RELATIONSHIP SKILLS – pertains to dealing with people & how to “get along “ with them

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

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

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

2. ATTITUDE FACTORS – beliefs, feelings, and values that may be based on emotions and may not be subjected to conscious verbalization. Interest in one’s work, confidence in one’s mental competence, desire to accept responsibility, respect for the dignity of one’s associates, desire for creative contribution are some attitudes acquired by proper education.

3. ABILITY FACTORS – include skill, art, judgment, wisdom. These are abstract factors but they direct one’s thinking to factors that can be developed by the individual manager who takes time to consider them.

MAJOR MANAGEMENT FUNCTIONS1. PLANNING2. ORGANIZING3. DIRECTING4. CONTROLLING

While planning is the first function, one must recognize that it permeates into the other functions which dependent on it. By forecasting one can estimate the future; by setting objectives the results to be achieved can be determined; by developing and scheduling programs, the activities needed within a set time frame can be defined; by preparing the budget, tools and resources can be allocated while establishing policies and procedures that will define the course of action and standards.

Organizing establishes formal authority. It sets up the organizational structure by identifying groupings, roles, and relationships within the agency. This is depicted in an organizational chart. Job descriptions define the 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 covers recruiting, selecting, orienting, and developing personnel to accomplish the goals of the organization. The selected personnel are then distributed in the various areas of the agency where they are qualified to belong. Staffing schedules are made to meet the needs of clients, personnel, and agency.

Directing or leading actuates efforts to the accomplishment of goals. This includes utilization of various modalities of nursing care through the nursing 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 making sound decisions.

Controlling leads to the assessment and regulation of performance of workers. To ensure the attainment of objectives, certain standards are utilized to measure performance, monitor and evaluate nursing care, including the utilization of resources. Control promptly reveals deviations from 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, both curative and preventive, & whose out-patient services reach out to the family in its home environment; it is also a center for the training of health workers and for bio-social research. (WHO)

- a place devoted primarily to the maintenance & operation of facilities for the diagnosis, treatment, and care of individuals suffering from illness, disease, or deformity, or in need of obstetrical or other medical or nursing care. (Hospital Licensure Law, RA 4226)

- any institution, building or place where there are beds, cribs or bassinets for use of patients for 24 hours or longer, in the treatment of diseases, diseased conditions, injuries, deformities, and all institutions 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 diseases and offer health and medical careEx. National Children’s 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 other political subdivision, board or other agency thereof.Ex.

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

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, established and operated w/ funds, raised capital or other means by private individuals. Associations, corporations, religious organizations, firms, companies or joint stock associations.Ex.

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

b. Civic Organizations – Quezon Institute run by Philippine Tuberculosis Society

c. Community – Romero Community Hospitald. Private – St. Luke’s Medical Hospital

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

Training Program in one or more specified specialty or disciplineEx. Jose Reyes Memorial Hospital, Tondo Medical Center, Quirino Memorial Medical Center, and St. Luke’s Medical Center

2. Non-training Hospital – may be departmentalized but without an accredited Residency Training Program

HOSPITAL CATEGORIES

1. PRIMARY LEVEL HOSPITALS – composed of municipal and Medicare hospitals which have facilities and capabilities for first contact emergency care and hospitalization of simple cases.

2. SECONDARY LEVEL HOSPITALS – district hospitals with capabilities and facilities for medical care of cases requiring hospitalization. It has expertise 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 sophisticated diagnostic and therapeutic equipment and expertise of trained specialists and sub-specialists

4. SPECIAL TERTIARY LEVEL HOSPITALS – fully equipped with sophisticated diagnostic and therapeutic facilities for specific medical problem areas.Ex: Lung Center of the Philippines, The Philippine Heart Center, the Philippine Children’s Medical Center, and the National Kidney and Transplant Institute.

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

Planning, a basic function of management is a principal duty of all managers. It is a systematic process and requires knowledgeable activity based on sound managerial theory. The first element of management defined by Fayol planning, which he defines as making a plan of action to provide for the foreseeable future. This plan of action must have unity, continuity, flexibility, and precision.

Rowland and Rowland state that planning is largely a process of forecasting and decision making. It is future oriented, spanning time beginning in the 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 disaster plans. These allow workers to function more clearly and efficiently when actual emergencies occur such as fire, typhoons, earthquakes, or during New Year celebrations and/or other occasions when more people are likely to get hurt.

5. Planning is cost effective. Costs can be controlled through planning for efficient operation. For example, projecting the number of operations in a given day, including daily dressings, helps in determining accurately the needed 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 reduces the recurrence of problems and provides better ideas in modifying or avoiding them.

7. Planning leads to the realization of the need for change. Many hospitals have found out that in-patient hospital days can be greatly reduced by having the laboratory and diagnostic work-up in the OPD rather than have these examinations on admission. Minor surgeries are also done at the OPD so that more hospital beds can be allotted to critically-ill patients or for those needing specialized services.

8. Planning is necessary for effective control. Nurse-managers evaluate the environment or setting in which they work or where the patients are confined and make necessary recommendations to make hospital conditions more therapeutic not only for the patients but for the workers as well. Performance of workers and evaluation of services to patients based on 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 the agency;

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 their weaknesses 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 easy accomplishment of the agency’s objectives which are necessary for group effort.

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

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

SETTING THE VISION/MISSION, PHILOSOPHY, GOALS AND OBJECTIVES

Successful organizations, both for-profit and not-for-profit, have learned that they must focus their resources on a limited number of activities. Trying to be all 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 a focused approach, but cost constraints have forced them to reexamine their mission, vision, and goals. Comprehensive strategic planning, often using outside consultants, can produce a plan to guide the organization in the near future. (Few organizations today, especially in health care, attempt to plan more than a few years into the future.)

VISION A vision statement outlines the organization’s future role and action. It

gives the agency something to strive for.

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

Example: “Our vision is regional integrated healthcare delivery system providing premier healthcare services, professional and community education, and healthcare research,” from the BJC Health System in St. Louis, exemplifies a vision statement.

MISSION The mission statement outlines the agency’s 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 the organization’s reason for existence. Developing the mission is the necessary first step in designing a strategic plan.

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

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

If, for example, a proposed activity does not promote the organization’s stated mission, it probably would not be pursued.

ExamplesDepartment of Health

The DOH shall be responsible for the formulation, implementation, and coordination of policies and programs in the field of health. The primary function is the promotion, preservation, or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services.

Vision Health 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 in pursuit of high quality health care services, through an effective, responsive, and integrated referral and networking system with other health and welfare agencies, 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, the services provided shall enable the people to improve their health and increase control over it.

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

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

PHILOSOPHY

A philosophy describes the vision. It is a statement of beliefs and values that direct one’s life or practice. In an organization, the philosophy is the sense of purpose of the organization and the reason behind the structure and goals.

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. It is an intentionally chosen set of values or purposes that serve as the bases for determining 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 in partnership with public counterparts, the clients, families, and communities.

2. The clients are the reason for the hospital’s existence. Therefore, all services are directed toward their care and rehabilitation.

3. The health personnel’s 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, individualized nursing care to patients based on their assessed nursing needs. Nursing care is coordinated and collaborated with the health team.

3. The most important asset of an institution is its staff. To provide the best quality of nursing care, nursing personnel should be adequately prepared by education, experience and training to assume the duties and responsibilities of their position. They are to be treated with dignity and respect.

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

GOALS Goals 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.

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

organization’s mission and purpose will be achieved and the philosophy or belief sustained.

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

Moore states, “ If objectives are presented in terms of what can be observed, they can serve as evaluation tools of nursing care and personnel performance, and as a basis for planning educational programs, staffing, requisition of supplies and equipment, and other functions associated with the nursing department.”

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

EXAMPLESGeneral Objectives

To provide the best possible care services to its clients in a high quality setting conducive to attaining its vision as a center of wellness and standard medical center.

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

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

2. To provide the best quality, accessible and cost effective health services to all its clients ensuring preservation of their basic human rights for independence of expression, decisions, and actions, and concern for personal dignity and human relationships.

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

Objectives of a Nursing UnitThe objectives of this unit shall be

1. To provide individualized, total patient care based on physical, emotional and 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 the

hospital.4. To coordinate services with other hospital divisions, members of the

health team and the community for optimum patient care while hospitalized 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 which may 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? What equipment and supplies have been used or needed? What steps are necessary in the procedure? What sequence of activities was previously used? What other efficient methods may 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 in relation to those activities immediately preceding and following it? Where could supplies be stored, cleaned and so forth?

4. How How will the job be done? What are the steps to be followed in doing the procedure? How will the time and energy of personnel be used? How much will it cost? How much time will it require?

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

6. Why To each of the questions, ask why. Why is this job, this procedure, this step necessary? Why is this done in this way, 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? Can somebody else do it better? Can we get a machine to help? Can we get enough money?

TIME MANAGEMENTTime management is a technique for allocating one’s tome through the

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

“Work smarter, not harder.”

One’s personality, education and culture influence how he or she manages time. The way one views time influence the degree of stress he or she will 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 deadlines5. 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 needed to solve the problems.

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

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

4. Deferring, postponing, or putting off decisions, actions, or activities can become a habit which oftentimes cause lost opportunities and productivity, generating personal or interpersonal crises. Learning to understand why one procrastinates makes him/her aware that a plan can be initiated to prevent procrastination.

5. Delegation permits the manager to take authority for decision making and to assign tasks to the lowest level possible consistent with his/her judgment, facts, and experience. A nurse manager oftentimes does something 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 time problems.

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 what you expect to accomplish yearly, monthly, weekly, daily.

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

5. Devote a few minutes at the beginning each day for planning. Prepare a list 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 quiet office time. Avoid having an “open door” policy during the entire workday.

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

9. In a meeting, define the purpose clearly before starting. Distribute the agenda in advance and control interruptions during the meeting. Conduct the 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”.

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

PREPARING THE BUDGET

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

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

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

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

A nursing budgetis a plan for allocation of resources based on preconceived needs for a proposed 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 period

b. EXPENSE BUDGET – describes the expected activity in operational and financial terms for a period of time

c. CAPITAL BUDGET – outlines the programmed acquisitions, disposals and improvements in an institution’s physical capacity

d. CASH BUDGET – represents the planned cash receipts and disbursements as well as the cash balances expected during the planning period.

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 illness2. The size of the hospital and its bed capacity3. The physical layout of the hospital, size and plan of wards and units,

nurse’s station, treatment rooms, etc4. Personnel policies

a. Salariesb. Extent of vacation, sick leaves, holidaysc. Provision for staff development programs including instructional

staff5. 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 classification12.The method of patient assignment13.The amount and kind of labor-saving devices and equipment;

intercommunication system14.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 the estimated 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 be collected from patients and allocating it to cash disbursements required to meet obligations 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.

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 expected replacements, improvements and additions to fixed assets.

ESTABLISHING NURSING STANDARDS, POLICIES & PROCEDURES

NURSING STANDARDSprovide professionally desirable norms against which the department’s

performance can be measured.

Standards of care are specific, detailed plans of care for individuals with specific health problem. The purpose of standard of care is to establish the best practice and eliminate as much variations as possible. Standards of care often include aspects of medical care and various therapies as well as nursing care. They identify specific desired outcomes for each day of hospitalization and actions 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 be incorporated into care pathways, critical or clinical pathways. Designed to direct the health care team in daily care, these identify both outcomes and care activities that are expected to be appropriate for each 24-hour period of hospitalization. The standards of care become the basis for determining the level of care delivered and for quality improvement within the organization as well as for cost analysis.

Standards of nursing practice are authoritative statements that describe a common and acceptable level of professional nursing performance. Standards of 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 Goals

The nursing service has a written set of philosophy and goals that reflects the standards prescribed by the nursing profession and provides direction towards the development of programs to improve the delivery of nursing care. It shall consider that such philosophy and goals are congruent with the service goals 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 needs that 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 and quantity 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 necessary in organizational and departmental planning.

They govern action of workers and supervisors at all levels and are intended to achieve pre-intended goals. They serve as basis for future actions and decisions; 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.

3 general areas in nursing that require policy formulation1. Areas in which confusion about locus of responsibility might result in

negligence or malperformance of an act necessary to a patient’s welfare2. Areas pertaining to the protection of patient’s 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 occurrence

2. Admissions – receiving, consent, notifying doctor, care of patients3. Autopsies – obtaining informed consent4. Breakage – classification, responsibility, reporting5. Bulletin Boards – 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 team

9. Death – notification, care and identification, care of personal belongings, death certificate

10.Discharge – time, clearances, discharge planning, accompaniment of patient

11.Doctor’s Orders – written, verbal, by telephone12.Equipment and Supplies – list of expendable and non-expendable items,

care, lending, requesting, repairing13.Fire regulations – drills, prevention14.Nursing Care

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

b. charting – forms used, use of various colors of ink, format considering legal implications

c. daily assignment – 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, remunerationi. reasonable and due care – definition, explanation, legal

implicationsj. 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 situations

such as reporting complaints or disciplinary instances2. those involving patient care

Procedures that involve patient care should consider the safety and comfort of the patient while undergoing it, use of supplies and equipment, and good 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 administration 2. Catheterization 3. Bed Making4. Cleansing enema5. Douche, vaginal6. Dressings, sterile, dry7. AM care8. I & O9. Thoracentesis10.Lumbar Puncture

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 by developing and maintaining staffing patterns and distributing them in the various areas as needed.

• Includes developing job descriptions by defining the qualifications and functions of personnel.

OrganizationOrganization consists of structure and process which allow the agency to

enact its philosophy and utilize its conceptual framework to achieve its goals.It refers to a body of persons, methods, policies and procedures arranged

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

An organization is a collection of people working together under a defined structure for the purpose of achieving predetermined outcomes through the use of financial, human, and material resources. The justification for developing organizations is both rational and economic. Properly coordinated efforts capture more information and knowledge, purchase more technology, and produce more goods, services, opportunities, and securities than individual efforts (Anderson, 1992).

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

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

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

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

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

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

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 the hierarchyexample

Clinical & Administration

2. INFORMAL ORGANIZATION. – refers to horizontal relationships rather than vertical

- composed of small groups of worker with similar interests

3. STAFF ORGANIZATION. – purely advisory to the line structure with no authority to put recommendations into actionexample

Training & Research

4. FUNCTIONAL ORGANIZATION. – each unit is responsible for given part of the organization’s workload

- clear delineation of roles and responsibilities which are actually interrelatedexample

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 the lowest; proper definition and delegation of authority and responsibility facilitate the accomplishment of work.

Must observe the following:a. When responsibility for a particular job is delegated to a subordinate,

the latter should have authority over resources needed to accomplish the task;

Principle of Parity: authority delegation must be equal to the responsibility assigned

b. When a particular function is delegated to a subordinate, the superior’s own responsibility is in no way diminished;

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

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

-the conscientious nurse exhibits accountability toward her employing hospital, the patient, the government, her profession, & to God.

3. Homogenous Assignment or Departmentation – workers performing similar assignments are grouped together for a common purpose.

- promotes specialization of activities, simplifies the administrator’s work, & helps maintain effective control.

4. Span of Control – the number of workers that a supervisor can effectively manage should be limited.

- span of managerial responsibility and the number which one superior 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 a routine manner by lower-level managers whereas problems involving unusual matters should be referred to the higher level.

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

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

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

Definition of Terms

1. Authority – is the right to act. In legal sense, authority flows down in an organization, e.g., from the Board of Trustees to the Hospital Administrator 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 positions in the hierarchy in the accomplishment of the main operations of the organization.

b. Staff personnel provides advise, counsel or technical support that may be accepted, altered or rejected by the line officer.

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

Organizational Chart An 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 organizational relationships of people and departments.

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

5 MAJOR CHARACTERISTICS OF AN ORGANIZATIONAL CHART1. DIVISION OF WORK – each box represents the individual or sub-unit

responsible for a given task of the organization’s workload2. CHAIN OF COMMAND – lines indicate who reports to whom and by what

authority3. TYPE OF WORK TO BE PERFORMED – indicated by labels or

descriptions for the boxes4. GROUPING OF WORK SEGMENTS – shown by clusters of work groups

(departments or single units)5. LEVELS OF MANAGEMENT – indicate individual and entire management

hierarchy

VERTICAL CHART

Solid Line – Line Authority-depicts direct relationshipDashed Line – Staff Authority – advisory & service-oriented – shows coordinated relationship

TOP

MIDDLE

FIRST LEVEL

Administrator

Vice President

Patient Care Coordinator

RN LPN CNA

OPERATIONAL LEVEL

Organizational structure of a hospital Nursing Division/Service

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.

ORGANIZATIONAL STRUCTURE

The optimal organizational structure integrates organizational goals, size, technology, and environment. When the structure is not aligned with organizational needs, the organization’s response to environmental change diminishes; decisions are delayed; overlooked, or poor; conflict results; and performance deteriorates (Porter-O’Grady, 1994)

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

FUNCTIONAL STRUCTURE In functional structures, employees are grouped in departments by

specialty, with similar tasks being performed by the same group, similar group operating out of similar department, and similar departments reporting to the same manager. In a functional structure, all nursing tasks fall under nursing service; the same is true of other functional areas. Functional structures tend to centralize decision making because the functions converge at the top of the organization.

Weaknesses:Functional structures have several weaknesses. Coordination across

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

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

structure, all functions needed to produce a product or service are grouped together in self-contained units. A large health care institution that acquires a smaller clinic may operate it as a self-contained unit. The service-integrated structure is decentralized; units are based on product, service, geographical location, 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 and its outputs can be tailored to the situation, client satisfaction is high. Coordination across function occurs easily; work partners identify with their own service and can compromise or collaborate with other service functions to meet service goals and reduce conflict. Service goals receive priority under this organizational structure because employees see the service outcomes as the primary purpose of their organization.

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nursing

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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-depth training and specialization. Coordination across service categories (oncology, cardiology, and the burn unit, for example) is difficult; services operate independently and often compete. Each service category, which is independent and autonomous, has separate and often duplicate staff and competes with other service 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.

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Cardiology

Burn Unitnsg dietary pharmacy storeroom

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

and managers. Managers often resent administrators’ intrusion into what they see as their own area of responsibility. Overtime, organizations tend to accumulate large corporate staff to oversee divisions in an attempt to provide functional 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 into a matrix. The unique defining characteristic of a matrix is that it integrates both product and functional structure into one overlapping structure. In a matrix structure, different managers are responsible for function and product. For example, the nurse manager for the oncology clinic may report to the vice president 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 a

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dietary admitting pharmacy billing

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highly uncertain environment that changes frequently but also requires organizational expertise.

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 matrix organization is time-consuming because frequent meetings are required to resolve problems and conflicts; the structure will not work unless participants can see beyond their own functional area to the big organizational picture. Finally, if one side of the matrix is more closely aligned with organizational objectives, that side 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 organization and the authority of its medical staff. In a parallel structure, the medical staff is separate and autonomous from the organization. The result is as organizational dilemma: two lines of authority. One line extends from governing body to CEO to managerial structure; the other line extends from governing body to medical staff. These two intersect in departments such as nursing, in which decision making involves both managerial and clinical elements.

Vice President outpatient services

Oncology Pediatrics Family medicine

Vice PresidentNursingServices

Nurse manager

Nurse managerNurse manager

Parallel structures are found in health care institutions with functional structure and separate medical governance structure. Parallel structures are becoming less successful as health care organizations integrate into newer models that incorporate physician practice under organizational umbrella. Purchased, allied, incorporated, and partnered physician practice arrangements are making parallel structures more untenable and difficult to maintain.

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 to registered professional nurse in provision of patient/client care activities as delegated by and under the supervision of the registered professional nurse” (ANA, 1994).

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

organizational tasks. This self-organizing (self-renewing) structure is flexible and able to respond to both internal and external change. The only requirement of

Chief executiveofficer

Chief nurseexecutive

Chief financeexecutive

Chief officer ofSupport acivities

Medicaldirector

Chief ofservice

Internalmedicine

Surgery

Pediatrics

Ob-Gyn

budget

housekeeping maintenance

finance

budget finance

CNS NM NM NM

RN UAP

LPN

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LPN

UAP

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this structure is self-reference; that is, future structures are consistent with previously established identity and its past. Rigid, permanent structures are avoided; 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 primary source of organizational creativity and success.

Staffing

• 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: to provide each nursing unit with an appropriate and acceptable number 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 of nursing personnel required to provide nursing care of 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 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 the

department 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- 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 or Minimal Care

1.50 55:45

Level II Moderate or Intermediate Care

3.0 60:40

Level III Total or Intensive Care

4.5 65:35

Level IV Highly Specialized orCritical Care

7.07 or up

70:3080:20

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

Type of Hospital Minimal Care Moderate Care

Intensive Care

Highly Specialized Care

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 <100 bed capacity or agencies in communities w/ <1M

population = 48 hrs. a week, 1 off-duty.

• Civil Service Commission, Memorandum Circular No.6 series of 1996 = 3-day special privilege:

birthdays, weddings, anniversaries, funerals (mourning), relocation, enrollment or graduation leave, hospitalization, & accident leaves.

Total # of working & non-working days & hrs of nsg. personnel per year

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

a. Vacation Leave – 10b. Sick Leave – 5

2. Holidays – 123. 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 48 hrs/wk.

• Multiply the computed reliever/person by the computed # of nursing personnel = 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:• 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 at each level of care (whether minimal, intermediate, intensive or highly specialized).

2. Find the total number of nursing care hours needed by the patients at each category level.a. Find the number of patients at each level by the average number of nursing 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 number of patients. Multiply the total nursing care hours needed/day by the total number of days in a year.

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

5. Find the total number of nursing personnel needed.a. Divide the total number of nursing care needed/year by the actual number of working hrs rendered by an employee per year.b. Find the number of relievers. Multiply the number of nursing personnel needed 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 of professionals 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.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 = 25c. Total Nursing Personnel needed 165 + 25 = 190

6. Categorize to professional and non-professional personnel. Ratio of professionals 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 nurses 66 Nsg attendats x .45 = 30 NA on AM shift

66 Nsg attendats x .37 = 24 NA on PM shift 66 Nsg attendats x .18 = 12 NA on NIGHT shift

Total = 66 Nursing Attendants

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

SCHEDULING

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

Objectives: - assign working days and days-off to the nursing personnel so that adequate patient 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 personnel’s 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 shifts on duty and off-duty.

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

3. Cyclical – covers a designated number of weeks called the cycle length and is repeated thereon. It assigns the required number of nursing personnel to each nursing unit consistent with the unit’s patient care

requirements, the staff’s preference, their education, training, and experience.Advantages: Fair to all, Saves time, Enables employee to plan ahead for

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

Other types of schedulinga. Self-scheduling – personnel are scheduled to work their

preferred shifts as much as possible, as long as their preferred shifts meet the needs of the unit and balance with the needs of coworkers. Self-scheduling is an activity that may make the staff happier, more cohesive, and more committed. It should be planned carefully on a unit (cost center) 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

PERSONNEL S M T W TH F S S M T W TH F S S M T W TH F S S M T W TH F S

7-3 Head/Sr.Nurse X X X X X X X X

Staff Nurse X X X X X X X X X

Nsg. Att. 1 X X X X X X X X

Nsg. Att. 2 X X X X X X X X

3-11 Staff Nurse X X X X X X X X

Ns. Att. X X X X X X X X

11-7 Staff Nurse X X X X X X X X

Nsg. Att. X X X X X X X X

Gen.Rel. 3-11;11-7

Staff Nurse 3-11 3-11 11-7 X X 3-11 11-7 11-7 X 7-3 3-11 3-11 11-7 X X 7-3 3-11 3-11 11-7 11-7 X X 3-11 11-7 11-7 X 7-3 3-11

Nsg. Att. 3-11 11-7 X 7-3 3-11 11-7 X 7-3 3-11 X 11-7 11-7 X 3-11 X 7-3 11-7 X 3-11 3-11 11-7 11-7 X 7-3 3-11 3-11 11-7 X

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

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

- an important management tool to make certain that responsibilities are wisely 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

Directing is the issuance of orders, assignments, and instructions that enable the nursing personnel to understand what are expected of them. It includes supervision and guidance so that in doing their job well, nurses can maximally contribute to the organization’s goals in general and to the nursing service objectives in particular.

Directing actuates efforts to accomplish goals. It is the connecting link between 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 policies and 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 must be able to defend his or her point of view with confidence and enthusiasm. The manager learns continuously and educates people at all levels for access in their assigned task.

Fayol stated that command occurs when the manager gets the “optimum return from all employees of his unit in the interest of the whole concern.” To do this, the manager must know the personnel, eliminate the incompetent; understand binding agreements with employees; set a good example; conduct periodic 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 loyalty among employees. Fayol defines coordination as creating harmony among all activities to facilitate the work and success of the unit. In modern management, command and coordination are often labeled directing or leading.

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

Rowland and Rowland state that directing “initiates and maintains action toward desired objectives” and is “closely related to leadership.” These authors suggest that a manager’s choice of leadership style will be the major factor in directing. Among the activities of directing are delegation, communication, training, and motivation.

Elements of Directing

DelegationDelegating is the process by which a manager assigns specific

tasks/duties to workers with commensurate authority to perform the job. The worker in return assumes responsibility for its satisfactory performance and is held accountable for its results.

By delegating well defined tasks and responsibilities, nurse manager can be freed of valuable time that can be well spent on planning and evaluating nursing programs and activities. Delegation also trains and develops staff members who desire greater opportunities and challenges in their work making them 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 for delegation. 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, based on outcomes)

know yourself (barriers, benefits) know your delegate (competency, motivation)

Reasons for DelegatingThe 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 manager’s own job emphasis.5. Capability building.

The nurse manager must be careful not to misuse the clinical nurse by delegating 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 the accountability and authority to do the job.

2. Delegate both interesting and uninteresting tasks. – uninteresting jobs can be used to challenge, motivate & increase a person’s performance and commitment. Interesting jobs draw out the best among employees and inspire them to a higher achievement.

3. Provide subordinates with enough time to learn. – Expertise can be achieved through training and experience.

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

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

6. Consult before delegating. – Clarification minimizes problems and promote 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 have responsibility 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 objectives

9. 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

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 of practice 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 be evaluated?Is a written report required?What constraints or risks apply?

Seek agreement

Monitor performance and provide feedback

Identifying and Defining the Task and Level of Delegation

The first step in delegation is determining what can be delegated. You can delegate only an aspect of your own work for which you have responsibility and authority. These include: (a) routine tasks, (b) tasks for which you do not have time, (c) tasks that have moved down in priority, (d) problem solving, and (e) staff building. In addition, Morrison (1993) suggests you should delegate only what you know best. She contends this is important in providing guidance and feedback. Clearly, lack of expertise in the task hinders delegator’s ability to define the task and associated requirements. Therefore, know well the task to be delegated.

What Cannot Be Delegated

1. Overall responsibility, authority and accountability for satisfactory completion of all activities in the unit. – Nurse Managers cannot be absolved of poor performance of subordinates by blaming them.

2. Authority to sign one’s name is never delegated. – The worker who performed the task should be the one to sign it.

3. Evaluating the staff and/or taking necessary corrective or disciplinary action.

4. Responsibility for maintaining morale or the opportunity to say a few words of encouragement to the staff especially the new ones. – showing confidence 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 free to ask questions or seek clarifications regarding a delegated task which to them may be too difficult to understand.

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

4 Methods:1. Functional Nursing

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

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

- this method divides the work to be done with each person being responsible 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 a group 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 best advantage. An RN gives medications while others give baths, make beds, take vital signs, administer treatments, and so forth.

The advantage of this system is that all employees, even UAPs, become very 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 in acute care facilities and only occasionally in long-term care facilities.

Advantages:1. Allows most work to be accomplished in the shortest time possible.2. Workers learn to work fast.3. Because tasks are repetitive, they gain skill faster in that particular task.

There is also greater control over work activities and it is aimed conservation of workers and cost.

Disadvantages:• Fragmentation of nursing care and therefore holistic care is not achieved.• Nurses’ accountability and responsibility are diminished.• Patients cannot identify who their “real nurse” is.• Nurse-patient relationship is not fully developed.• Evaluation of nursing care is poor and outcomes are rarely documented.• Difficult to find a specific person who can answer the patient’s or relatives’

questions.

2. Total Care or Case NursingIn the total or case method of nursing care, one nurse is assigned to one

or more patient/s for the delivery of total care.

Charge Nurse

Medication nurse

Treatment nurse

UAP with bath duty

UAP responsible for vital signs

UAP responsible for transportation

Patients

- the nurse plans, coordinates, implements, evaluates and documents the nursing care she has given during her shift. Her entry point is anytime of the patient’s illness.

Examples:PDN,Nurses in special care units such as critical care units or those in isolation,Nursing students

- the nurse is accountable for her own actions.- provides holistic care to her patient, who in turn can relate well with her.- works best when there are plenty of nurses and patients are few.- nurses may not be familiar with patients in other areas.

Advantages:

1. Continuous holistic care, expert nursing care;2. Total accountability for the nursing care assigned patient for

that shift; and3. Continuity of communication with the patient, family,

physician(s), staff from other departments.

Disadvantage:The disadvantage of this system is that RNs spend some time doing tasks

that could be done more cost-effectively by less skilled staff. This inefficiency adds to the expense of using total patient care delivery system.

3. Team NursingTeam nursing is a decentralized system of care in which a qualified

professional nurse leads a group of nursing personnel in providing for the nursing needs of a group of patients/clients through participative effort.

The team leader assigns patients and tasks to team members according to job descriptions.

Head or Senior Nurse

Staff Nurse

Patient

- team leader is responsible for coordinating the total care of a group of patients.

-intent: provide patient-centered care

Team nursing remains the most common nursing care delivery system in the United States in acute as well as long-term care settings. Historically, team nursing evolved from functional nursing and has remained popular since the mid- to late 1940s. Under this system, a “team” of nursing personnel provides total patient care to a group of patients. In some instances, a team may be assigned a certain number of patients; in others, the assigned patients may be grouped by diagnoses or provider services.

4. Primary Nursing- an extension of the principle of decentralization of authority.- each RN is responsible for total care of a small group of patients from

admission to discharge.- primary nurse assesses the patient’s needs for care, sets care goals,

writes a nursing care plan, evaluates the outcomes of care, and makes the necessary changes or adjustments as necessary.

Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team nursing, primary nursing was designed to place the registered nurse back at the patient’s bedside.

Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility and authority for nursing care allocated to staff nurses at bedside. Primary nursing recognized that nursing was a knowledge-based professional practice, not just a task-based activity. The RN maintains a patient load of “primary” patients. A primary nurse designs,

Charge Nurse

Team/module leader Team/module leader Team/module leader

RN, LPN, UAP RN, LPN, UAP RN, LPN, UAP

Patients Patients Patients

implements, and is accountable for the nursing care of patients in the patient load for the duration of the patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses.

Primary nursing advanced the professional practice of nursing significantly because it provided (a) a knowledge-based practice model; (b) decentralization of nursing care decisions, authority, and responsibility to the staff nurse; (c) 24-hour accountability for nursing care activities by one nurse; (d) improved continuity and coordination of care; and (e) increased nurse, patient and physician satisfaction.

Disadvantages also exist. Primary nursing requires excellent communication between the primary nurse and associate nurses.

Other Nursing Assignments: Modular Method – modification of team and primary nursing.

- differs from team nursing in that the RN provides direct nursing care with the assistance of aides.

- the professional nurse provides leadership, support, and instruction to the non-professional nursing personnel.

- similar to primary nursing in that each pair or trio of nursing personnel is responsible for the care of pts from admission to discharge, following discharge, and throughout and subsequent admissions to the same institution.

- greatest responsibility falls on the RN who assesses the patient’s needs, plans and implements care, and assesses outcomes including guiding and instructing her partners.

Physician Head Nurse Hospital & Community Resources

Primary NursePatient/Client

Secondary/Ass. Nurse PM

Secondary/Ass. Nurse Night

Secondary/Ass. Nurse Relief

Case Management – system of pt care delivery that focuses on the achievement of outcomes within effective and appropriate time frames and resources. - focuses on an entire episode of illness, crossing all settings in which the patient receives care. - care is directed by a case manager who ideally is involved in a group practice.- in institutions these activities are done prior to admission and continues to about 2-3 weeks after discharge. - in communities, activities occur in any setting – home, clinic or hospital.

Utilizing/Revising/Updating Nursing Service Policies & Procedures:

Policies, Procedures, Rules & Regulations: standing plans of an organization.

Advantages:- promote consistency of action and stability.- Speed up decision making.- Conserve time by setting standards.

Procedure Manuals – outline a standard technique or method in performing duties.

- serve as a guide for action- contain detailed plans for nursing skills and include steps in proper

sequence.

Supervision – (supervise)- to inspect, to guide, evaluate, and improve work performance of employees through a criteria against which the quality and quantity of work production and utilization of time and resources are made.

Case Manager

Patient caseload

Caregivers Caregivers Caregivers

Supervisory Techniques – include observation of the worker while making her rounds

- spot checking of charts through nursing audits- asking the patients about the care they receive- looking into the general condition of the units- getting feedback from co-workers or other supervisor or relatives- asking questions discretely to find out the problems they encounter in the

wards or drawing out suggestions from the workers for improvement of their work or work situation.

Purposes: - to facilitate work- Increase motivation- Effect change- Optimize care- Increase worker satisfaction- Facilitate coordination- Binds the organization to ensure common understanding

Principles of Effective Communication1. Clear lines of communication serve as the linking process by which parts

of the organization are unified toward goal achievement. Synchronization of efforts is facilitated when proper lines of communication are identified and utilized.

2. Simple, exact and concise messages ensure understanding of the message to be conveyed. Since it starts with the perception of the recipient, overloading or underloading of messages should be avoided to prevent distortion and misunderstanding.

3. Feedback is essential to effective comm. Mutual interaction is required. There is little or no communication when there is no feedback. Listening, openness to the other person’s point of view and being supportive provide the means to effective feedback.

4. Communication thrives best in a supportive environment which encourages positive values among its personnel. Communication is used to support the vision, mission and goals of the organization and the nursing service.

5. A manager’s communication skill is vital to the attainment of the goals of the organization. Successful managers utilize various modes of comm. It may be formal or informal, written or verbal. - Written Communication: Meetings, interviews, counseling, turn-of-the-shift reports, memos, charts, and official publications• Body language affects the effectivity of communication.

6. Adequate & timely communication of work-related issues or changes that may affect jobs enhance compliance. People resist change if they do not understand the reason for it.

4-Dimensional Flow of Communication

Downward Communication:- Traditional.- Primarily directive and activities are coordinated at various levels of the

organization.- Aims to impart what the personnel need to know, what they are to do and

why they are to do these.- Includes policies, rules and regulations, memoranda, handbooks,

interviews, job descriptions, and performance appraisal.

NURSES

UPWARD To superior

HORIZONTAL To Peers, Members of Health Team

DOWNWARD To

subordinates

OUTWARD To Patient, Family, & CommunityTo Workers’ Family & Friends

Upward Communication:- emanates from the subordinates and goes upward.- In the form of feedback to show the extent to which downward

communication has been received, accepted, and implemented.- Does not flow easily as downward communication.- examples: discussions between subordinates and superiors, grievance

procedures, written reports, incident reports, and statistical reports.

Horizontal Communication:- flows between peers, personnel or departments on the same level.- Used most frequently in the form of endorsements, between shifts, nursing

rounds, journal meetings and conferences, or referral between departments or services.

Outward Communication:- deals with info that flows from the caregivers to the patients, their families,

relatives, visitors and the community.- Involves how employees value their work: may be directly or indirectly

communicated to their families.

COORDINATION

- unites personnel and services toward a common objective.- Synchronization of activities among various services and departments

enhances collaborative efforts resulting in efficient, smooth and harmonious flow of work.

- Prevents overlapping of functions, promotes good working relationships and work schedules are accomplished as targeted.

Coordination with the Medical Service:Nurses should:

- know the medical staff in their respective units, their services and scheduled time of medical rounds.

- Know the pts in the units, their diagnosis, actual conditions, and the programmed medical plan of care and treatment so that they can participate intelligently in planning the care of each individual patient.

- Not be mere “implementers of care” (exercise reasonable judgment and care to avoid errors and misinterpretations.)

- Adequate feedback on the progress of the patient’s condition, patient’s response to meds and treatment and the prescribed therapies and nursing care.

With the Administrative Service:- pertains to both human and material resources- Unit level: budget planning for staffing, adequate facilities, and material

resources.- Layout of work areas- Need for repair and maintenance - Preventive maintenance of all equipment- Requisitions for supplies, linen and equipment - Monthly inventories- Prevent overstocking of supplies

Coordination with:Laboratory, Radiology, Pharmacy, Dietary, Medical Social, Medical Records, Community Agencies, other Institutions and Civic Organizations.

Decision Making A course of action that is consciously chosen from available alternatives

for the purpose of achieving a desired result.- involves a choice utilizing mental processes to the conscious level and is

aimed at facilitating defined objective.

Steps in Decision Making Process:1. Definition of the Problem –

“Does the problem occur in all units or only in one specific unit?”“Why did the problem occur?”

2. Analysis of the Problem – getting to the cause of the problem3. Development of an Alternative Solution – focuses on the search of and

analysis of alternatives and their possible consequences.“If we do this, the result will be….”

Factors: time, available resources, labor, cost of tools and equipment to be used, and the moral and legal implications.

4. Selection of a Solution – ranking of preferences- narrows down the choice to 2 or 3 alternatives, while weighing the advantages and disadvantages of each.

5. Implementation and Follow-up – Major Management Functions:

a. Planningb. Organizingc. Staffing

d. Controlling

Conflict Management – (conflict)- a clash between 2 opposing and oftentimes hostile parties.

- a warning to managers that something is wrong and needs solution thru problem solving and clarification of objectives, establishment of group norms, and determination of group boundaries.

Sources of Conflict: 1. Human Interactions – competition, domination, provocation 2. Stress – evidenced by confrontation, disagreements, and anger3. Differences in position in the hierarchy – (short-term / long-tem solutions

Types of Conflict:Covert, Overt, Vertical or Horizontal Conflict, Horizontal or Line & Staff, Intrapersonal, Interpersonal, Intragroup, Intergroup.

Conflict Resolution:1. Avoidance – don’t want to do something that may interfere with their

relationships.- neutrality is maintained at all costs

2. Accommodation – self-sacrifice- used to preserve harmony and gain social credits that can be used later

3. Collaboration – inspires mutual attention to the problem and utilizes the talents of all parties.- focuses on problem-solving to find mutually satisfying solutions.

Compromise – both parties seek expedient, acceptable answers for short periods when the goals are only moderately important and the parties have equivalent power.

Competition – supervisor or nurse manager exerts power at the subordinate’s expense. Enforces the rule of discipline.

Smoothing – disagreements are ignored so that surface harmony is maintained in a state of peaceful co-existence.

Withdrawing – one party is removed thereby making it possible to resolve the issue.

Forcing – yields an immediate end to the conflict but leaves the cause of the conflict unresolved

Some basic rules on mediating a conflict between 2 or more parties:1. Establish clear guidelines and make them known to all.2. Do not postpone indefinitely.

3. Create an environment that makes people comfortable to make suggestions.

4. Keep a two-way communication.5. Stress a peaceful resolution rather than confrontation.6. Emphasize shared interests.7. Follow-up on the progress of the plan.

CONTROLLING (Evaluating)

- an on-going function of management which occurs during planning, organizing, and directing activities.

- Includes assessing and regulating performance in accordance w/ the plans that have been adopted.

- Means of determining success or failure- Not an end in itself; it is implemented throughout all phases.

Reasons for Conducting Evaluation:1. It ensures that quality nursing care is provided.2. It allows for the setting of sensible objectives and ensures compliance with

them.3. It provides standards for establishing comparisons.4. It promotes visibility and a means for employees to monitor their own

performance.5. It highlights problems related to quality care and determines the areas that

require priority attention.6. It provides an indication of the costs of poor quality.7. It justifies the use of resources.8. It provides feedback for improvement.

Evaluation Principles:1. Based on the behavioral standards of performance which the position

requires.2. There should be enough time to observe employee’s behavior.3. The employee should be given a copy of the job description, performance

standards and evaluation form before the scheduled evaluation conference.

4. The employee’s performance appraisal should include both satisfactory and unsatisfactory results w/ specific behavioral instances to exemplify these evaluative comments.

5. Areas needing improvement must be prioritized to help the worker upgrade his/her performance.

6. The evaluation conference should be scheduled and conducted at a convenient time for the rater and the employee under evaluation, in a pleasant surrounding and with ample time for discussion.

7. The evaluation report and conference should be structured in such a way that it is perceived and accepted positively as a means of improving job performance.

Characteristics of an Evaluation Tool1. Objective – free from bias2. Reliable – accurate or precise such that it will produce the same results if

administered twice.3. Valid – relevant measurement to the performance of the employee.4. Sensitive – instrument can measure fine lines of differences among the

criteria being measured.

Basic Components of the Control System:1. Establishment of standards, objectives, and methods for measuring

performance.2. Measurement of actual performance.3. Comparison of results of performance with standards and objectives and

identifying strengths and areas for correction and/or improvement.4. Action to reinforce strengths or successes.5. Implementation of corrective action as necessary.

Standards – desirable sets of conditions and performance necessary to ensure the

quality of nursing care services which are acceptable to those instrumental to or responsible for setting and maintaining them.

Types:1. Standards on structure – focus on the structure or management system

used by the agency to deliver care. Include the number and categories of nursing personnel, their education, personal and professional qualities and proficiencies, their function, physical facilities, and equipment.

2. Process standards – decisions and actions of the nurse relative to the nursing process which are necessary to provide good nursing care.

3. Outcome standards – designed to measure the results of care provided in terms of changes in the health status of clients served, changes in the

level of their knowledge, skills, and attitudes, and satisfaction of those served including the members of the nursing and health team.

Performance Appraisal – control process in which employee’s performance is evaluated against standards.

- most valuable tool in controlling human resources and productivity.- reflects how well the nursing personnel have performed during a specific

period of time.

Purposes:1. Determine salary standards and merit increases;2. Select qualified individuals for promotion or transfer;3. Identify unsatisfactory employees for demotion or termination;4. Make inventories of talents within the institution;5. Determine training and development needs of employees;6. Improve the performance of work groups by examining, improving,

correcting interrelationships between members;7. Improve communication between supervisors and employees and reach

an understanding on the objectives of the job;8. Establish standards of supervisory performance;9. Discover the aspirations of employees & reconcile these w/ the goals of

the institution;10.Provide “employee recognition” for accomplishments; and11. Inform employees “where they stand.”

Factors Contributing to an Effective Performance Appraisal System1. Compatibility between the criteria for individual evaluation and

organization goals.2. Direct application of the rated performance to performance standards and

objectives expected of the worker. 3. Development of behavioral expectations which have been mutually agreed

upon by both the rater and the worker.4. Understanding the process and effective utilization of procedure by the

rater.5. Rating of each individual by the immediate supervisor.6. Concentration on the strengths and weaknesses to improve individual

performance.7. Encouragement of feedback from the rated employees about their

performance needs and interests.8. Provision for initiating preventive and corrective action and making

adjustments to improve performance.

Methods of Measuring Performance

Formal Appraisal – accomplished regularly and methodically by collecting objective facts that can demonstrate the difference between what is expected and what was done.

Informal Appraisal – consist of incidental observation of performance while the worker is engaged in performing nursing care or by responses made by worker during conferences.*Include: essay, checklist, ranking, rating scales, forced-choice comparison, and anecdotal records.

Quality Assurance : Quality assurance is the estimation of the degree of excellence in patient

health outcomes and in activity and other resource outcomes.(Williamson) – Quality assurance is the measurement of the actual level of

service provided plus the efforts to modify when necessary the provision of these services in light of the results of such measurements.

Purpose – to assure the consumer of a specified degree of excellence through continuous measurement and evaluation.

Quality – the “degree of excellence”Assurance – means “formal guarantee of a degree of excellence”; assures patients that an acceptable standard of care will be provided them.

Principles Underlying QA Efforts:1. All health professionals should collaborate in the effort to measure and

improve care.2. Coordination is essential in planning a comprehensive quality assurance

program.3. Resource expenditure for quality assurance activities is appropriate.4. There should be focus on critical factors such as functions and activities

that promise to yield the greatest health and financial benefit to reveal significant findings.

5. Quality patient care is accurately evaluated through adequate documentation.

6. The ability to achieve nursing objectives depends upon the optimal functioning of the entire nursing process and its effective monitoring.

7. Feedback to practitioners is essential to improve practice.8. Peer pressure provides the impetus to effect prescribed changes based

on the results of assessment and needed improvements on the quality of care.

9. Reorganization in the formal organizational structure may be required if assessment reveals the need for a different pattern of health care.

10.Collection and analysis of data should be utilized to motivate remedial action.

TOTAL QUALITY MANAGEMENT (TQM)

Total Quality Management (TQM) is a management philosophy that emphasizes a commitment to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was adopted by the Japanese and helped transform their industrial development after World War II. Dr. Deming developed 14 points that provide the foundation for the Deming management method (Koch & Fairly, 1993). These principles of quality management were originally applied to improve quality and performance in the manufacturing industry. They are now widely used to improve quality and costumer satisfaction in a number of service industries, including health care.

TQM CharacteristicsFour care characteristics of Total Quality Management are customer/client

focus; use of quality tools and statistics for measurement, and the identification of key processes for improvement.

Deming 14 points1. Create constancy of purpose for improvement of product and service. A

company must develop a plan to become competitive and to stay in business through research, innovation, continuous improvement, and maintenance of improvement.

2. Adopt the new philosophy. We must not tolerate poor service and

workmanship and must religiously reject mistakes and negativism.

3. Cease dependence on mass inspection. Companies must eliminate need for inspection after the product is produced. When products are defective, the company pays for workers who made the products that must be either reworked or discarded. Quality comes from improving the production process, enlisting the workers involved when properly trained, rather than from inspection.

4. End the practice of awarding business on the basis of price tag. Instead, industry leaders should depend on meaningful measures of quality; along with price. Seek the best quality supplier and build a long-term relationship to improve the quality.

5. Improve constantly and forever the system of production and service. It is management’s job to work continuously on the system to reduce waste and improve quality. Quality improvement is not one=time effort or “program.”

6. Institute training. Management must invest in training and not ask another worker who has never been trained to be the trainer. The worker cannot do the job because they have not been promptly trained.

7. Institute leadership. The role of the supervisor is to lead, not tell workers what to do. Leading means the supervisor helps the worker do better and objectively evaluates who is in need of individual assistance.

8. Drive out fear. Fear has a great economic loss. When people are afraid to ask questions or express their thoughts, the job may continue to be done wrong. To improve quality and productivity, the people must feel secure with management.

9. Break down barriers between staff areas. When departments, units, or areas have conflicting goals, competition may occur. This stops any teamwork toward finding opportunities for improvement.

10.Eliminate slogans, exhortations, and targets for the workforce. Quality is not a program with management-defined slogans. Let the people write their own slogans.

11.Eliminate numerical quotas. Quotas are only numbers and do not take quality or process methods into account. Quotas may be counterproductive because people will meet quotas to maintain a job although the company may suffer damage.

12.Remove barriers to pride of workmanship. People are eager to do a good job and want to do so. Management must remove barriers such as faulty equipment and defective materials, so the people can improve the quality of the product and process.

13. Institute a vigorous program of education and retraining. Management and workers must be educated and retrained in statistical techniques and teamwork for quality improvement to take place.

14.Take action to accomplish the transformation. It takes a dedicated team of top management with a defined action plan to lead the quality mission.

Control of Resources

Part of the control process is the periodic review of the utilization of materials and supplies in the various nursing units. Consumption of supplies and materials should be proportionate to the number of patients served, be these in the form of dressings, treatments done, injections given, and other materials.

Requisitions of and/or stocking a large number of supplies and materials should be avoided to prevent pilferage, misuse or spoilage.

An equipment utilization report should be made including frequency of breakdown. Preventive maintenance requires the regular inspection of equipment to prevent breakdown and/or detect needed repairs.

Absences due to leaves, whether scheduled or not, should be analyzed as these may have implications for staffing. Provision for relievers should be included in the staffing pattern to maintain quality service.

Discipline (past) – rigid obedience to rules and regulations, the violation of which

resulted to punitive actions.(today) – constructive and effective means by which employees take

personal responsibility for their own performance and behavior (self-discipline).

Factors that Influence Discipline:1. A strong commitment to the vision, philosophy, goals and objectives of the

institution.2. Laws that govern the practice of all professionals and their respective

Codes of Conduct. – P.D. 807: Civil Service Rules and Regulations / R.A. 6713: Code of Conduct for Public Officials

3. Understanding the rules and regulations of the agency.4. An atmosphere of mutual trust and confidence.5. Pressure from peers and organization.

Disciplinary Approaches:- A set of disciplinary policies and procedures- A uniform application of discipline rules- A disciplinary committee- An orientation program for all new employees

Characterized by:- Promptness, Fairness, Impartiality, Non-punitive, Advance Warning, Follow-through.

Problem Solving

Effective supervision aids supervisors in analyzing the work problems of their subordinates. Counseling becomes part of an oral warning session before resorting to a disciplinary action.

Disciplinary Action

An employee charged for breach of the rules and regulations, policies, norms of conduct shall be given due process. There must be existing rules of conduct governing his behavior and a documentation of actual violation of such rule must support charges. The employee charged must be notified in writing about the violation and given the right to counsel.

Disciplinary action should be progressive in nature such as counseling and oral warning, written warning, suspension, and dismissal.

Counseling and Oral Warning

Counseling and oral warning are best given in private and in an informal atmosphere. The employee is given fair chance to air his side. The relevant facts are analyzed and evaluated against his past performance. The employee is then counseled regarding expectations of improved behavior/performance, ways of correcting the problem and a warning that a repetition of the same offense may warrant further disciplinary action. The employee must commit to correct the behavior. He should be informed of any follow-up action that may be taken.

Written Warning

A written warning is the second step in disciplinary action. It is preceded by an interview similar to the oral warning. The employee must be told after the interview that he will be given a written warning. This includes the statement of the problem, identification of the rule which was violated, consequences of continued deviant behavior, the employee’s commitment to take corrective action, and any follow-up action to be taken.

Suspension

Suspension over minor violation is given after an evidence of oral and written warnings. Although a violation is a major infraction, suspension, rather than dismissal is applied when management feels that the employee can still be rehabilitated. Accurate documentation of oral and written warnings including suspension, if done, are necessary evidences of due process.

Dismissal

Dismissal is invoked only when all other disciplinary efforts have failed. The Disciplinary Committee should be very sure that the cause for dismissal conforms with the criteria of a major discipline violation as contained in the policy manual, and for government employees, those contained in the Civil Service Rules and the codes of conduct. A review is usually done by higher

management. In the case of government employees this is further reviewed by their respective departments and final affirmation is done by the Civil Service commission,