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2 LEADERSHIP AND MANAGEMENT IN NURSING First Semester 2013

Jacqueline G. Polancos, RN, MSN Associate Professor, College of Nursing

Over the years, there has been one constant in the

changing health-care system, and that is that the RN is still expected to provide leadership and management skills to direct and ensure the high quality of the health care given to clients. Both leadership and management require sets of skills that can be learned. Nurses who learn these skills will become successful managers and the leaders of the health-care system in the future. Successful leaders and managers understand and often combine the best aspects of the many theories that deal with leadership and management. Knowledge of ones strengths and weakness provides the basis for successful management. Developing effective leadership and management skills is a lifelong, ongoing process. Learning from books and articles, as well as from other successful nurse managers, presents an opportunity for professional and personal growth.
In todays health-care system, even new graduates who have an RN after their name will be placed quickly in positions of leadership and management. MANAGEMENT VS. LEADERSHIP Leaders dont force people to follow they invite them on a journey. Charles S. Lauer

The terms management and leadership are frequently interchanged but they do not have the same meaning. A leader selects and assumes the role; a manager is assigned or appointed to the role. Managers have responsibility for organizational goals and the performance of organizational tasks such as budget preparation and scheduling. Although it is desirable for managers to be good leaders and to be effective at influencing others, there are leaders who are not managers and, more frequently, managers who are not leaders! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ THE TWENTY FIRST CENTURY: A DIFFERENT AGE FOR MANAGEMENT AND FOR LEADERSHIP For the first time in decades, there are four separate and distinct generations potentially working together in a stressful and competitive nursing workplace (Boychuck-Duchscher & Cowin, 2004,p.493). The leadership of health care in the twenty-first century is impacted by the diverse generations in todays workplace: the SILENT or VETERAN Generation (born between 1925 and 1942 account for 10% of the current workforce); the BABY BOOMERS (born between 1943 and 1960 account 45% of the current workforce); Generation X (born between 1961 and 1977 account for 30% of the current workforce); and the newest group to the job market, Generation Y (born between 2978 and 1995 account for 10% of the workforce). There are major differences in these groups in communication styles, what motivates them, what turns them off, and their workplace ideals (Martin, 2004).

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Who are the SILENT or VETERANS? This retiring group of nurses, as well as the oldest generation were taught to rely on tried, true and tested ways of doing things. Their early experience with economic hardship and their witness to the Great Depression of the 1920s and 1930s, World War II destruction and genocide, the eradication of p[olio, and the control of other diseases (e.g TB, whooping cough) via the development of antibiotics and immunizations, place value on loyalty, discipline, teamwork, and respect for authority. Who are the BABY BOOMERS ? They make up the largest group of nurse employees working today, with the majority of management positions filled by the Baby Boomers. This group has a multitude of family responsibilities - they have their own children and they are caring for aging parents thus, they are referred to as the sandwich generation. This group is very ambitious. They put long hours and have a strong sense of idealism, both in family and in work. They value what others think, and it is important that their achievements be recognized. They have set and maintained a grueling pace between their family and employment responsibilities. This group has embraced technology as a method for being more productive and to have more free time. Who are the GENERATION X? This group grew up in the information age. They are an energetic and innovative generation. They are hard workers, but unlike the Baby Boomers, they Gen X employees have little loyalty or confidence in leaders and institutions. They change jobs frequently and will stay in a position as long as it is good for them. Their independence and reliance grew out of their childhood experience of being alone, as both Baby Boomer parents worked. They are also called the Latchkey generation. They have no aspirations for retirement. The use of technology has initiated an expectation of instant response and satisfaction. Their learning style has been shaped by technology they want immediate answers from a variety of sources. They want different employment standards they want opportunities for self-building and responsibility for work outcomes. They want extensive learning and precepting, and they want their questions answered immediately. They value their free time; therefore, flexible scheduling and benefits (daycare centers, liberal vacations, working from home) are important. They claim to be motivated by work that agrees with their values and demands (Cordeniz, 2003). Who is GENERATION Y? They are also known as Generation Net, Nexter, or the Millenium Generation. They are the largest group, perhaps 3x the size of Generation X. This generation represents a large number of the children of the Baby Boomers. The impact of this generation remains to be seen, but research has several predictions. This generation is smart and believe education is the key to success, diversity is a given, technology is as transparent as air, and social responsibility is a business imperative (Martin, 2004). They are optimistic, and they are interactive. Traits in this group include individuality and uniqueness. They can multitask, think fast, as well as being extremely creative. Managing this group will require a totally different set of skills than what is in the market today. They are not team players. They are in the drivers seat, and work for them is there if they want it. Focusing on understanding their capabilities, treating them as colleagues, and putting them in roles to push their limits will help the manager to recognize the potential of this group to become the highest-producing workforce in history (Martin, 2004).

Note: The challenge to nursing will be to develop a workplace as well as a profession that will be attractive to all three generations who represent the mainstream of the workforce. Initially, there

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must be a focus on recruiting the younger generations into the health care fields, and specifically into nursing. There must also be an emphasis on retention of experienced nurses. They are necessary to mentor the younger generations, and their experience is invaluable. Motivational Strategies for Generation X and Y

1. Let them know that what they do matters

When was the last time a letter from a patient that was very pleased with the care on a unit was shared with the staff? When was the last time management sat down with all of the unit personnel to tell them what a good job they are doing? When was the last time the CEO complimented the staff on a job well done? Tell them the truth. When did the managers on a unit acknowledge to the staff exactly what was going on? For example, the surgery schedule is going to be heavy this next week, there are going to be a lot of new admissions as well as a lot of patients that will be going home. Acknowledge that that work level is going to increase, and see if any of the staff have suggestions for improving the coordination and workload assignments. Explain why you are asking them to do it. When a difficult time is anticipated, explain to the staff what is happening and why. Maybe a particular area of the hospital is overloaded and additional staff are being pulled from their regular units to help out. These patients must be accommodated and cared for this is why the hospital is there, and maintaining patient census is what pays the bills. Learn their Language. When was the last time the unit manager, head nurse, or other manager actually sat down with the staff (all levels) to find out who they are and what they like to do? What are their priorities, family situations, what they do on their off days? Be on the look out for rewarding opportunities. When did a staff member handle a particular difficult patient situation very well and the staff member was acknowledged at that time? Give positive feedback when opportunities arise, do not wait for a performance evaluation to do so. Praise them in front of their peers and other staff. Acknowledge a job well done at a staff meeting, or in the presence of people who are important to that person. Make the workplace fun. Making the hospital work environment fun can sometimes be a little difficult, but there are opportunities for humor if we just look at them. Clients share a lot of humor with the staff, is the staff encouraged to share that with the rest of the unit personnel? When something funny happens to staff, are they encouraged to laugh and share with others? Model Behavior. Does the behavior of the unit manager or head nurse model the behavior they are expecting others to exhibit? What about confidentiality it is expected of the personnel, does the manager practice it as well? Give them the tools to do the job. What about effective communication skills, or perhaps good customer service skills the health care industry is in the job of providing a service for the customer the client. Training is offered for the technical skills new equipment, procedures, policies, but what about training for the skills necessary in dealing with people? How about skills to deal effectively with the angry patient, the difficult doctor, the outraged family? (Verret, 2000).

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These strategies are from Eric Chester, as presented by Carol Verret in her article, Generation Y: Motivating and Training a New Generation of Employees.

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Key Points 1. Leadership: definition
Outstanding leaders go out of their way to boost the selfesteem of their personnel. If people believe in themselves, its amazing what they can accomplish. Sam Walton

A. Leadership is defined as a process of influence. B. Leadership is not limited to people in traditional positions of authority. Similarly, leadership is no automatic when a nurse is in an authoritative position. C. A leader influences others to move in the direction of achieving goals. D. Leadership an occur in a number of dynamics and settings. i. A leader can influence one person. ii. A leader can influence more than one person, including small and large groups, organizations, even entire communities or societies. 2. For leadership to be successful, the following characteristics must be present. A. There must be positive interactions between leaders and followers. B. The leaders and followers must have a reciprocal relationship ( communication, ideas, and respect must move back and forth, not just from the top-down). 3. True leadership is not based on traditional views of leadership as having authority, command, or power over others. A. Leaders can take charge of a situation, but taking charge and being responsible are not the only characteristics of leadership. B. Leadership and a position of authority are not equivalent. i. A person in a position of authority is not automatically a leader. ii. Ideally, nurses in positions of authority have highly developed leadership qualities. 4. Types of leadership A. Formal leader: A formal leader is a person in a position of influence or authority or who has a sanctioned role within an organization. B. Informal leader: An informal leader is a person who demonstrates leadership and has influence even though he or she is not in a formal leadership role in an organization. Informal leadership is marked by two key traits: i. Ability to influence others. ii. Other people in the group or organization recognize that ability and are influenced. 5. Core traits of leaders: Research on leadership does not reveal any absolute qualities that define a leader, but most experts agree that effective leaders have the following core values: A. A guiding vision i. A leader is able to see a picture of the desired future. ii. Such a picture allows the leader to set goals toward that desired future. B. Passion i. A leader is enthusiastic about the future possibilities. ii. He or she has the ability to inspire people and align them in a common effort to make those future possibilities in a reality. C. Integrity i. Leaders who have integrity possess a significant knowledge of the self or self-awareness, including knowledge of their strengths and weaknesses and the ability to receive feedback and learn from mistakes. ii. Integrity requires honesty and maturity iii. It is supported by the inner strength of the persons convictions and his or her ability to deal with conflict or obstacles that arise.

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A leaders integrity is developed through personal and professional experience and growth. v. Having integrity means that the person can be trusted. D. Curiosity and / or daring i. Leaders draw on these traits to enable them to take risks. ii. These traits facilitate change. iii. These traits also shorten the learning curve because leaders intuitively zero in on what works rather than wasting time on what doesnt work. iv. 6. Additional traits commonly found in leaders: A. Flexibility i. This trait allows leaders to adapt rapidly to changes in all aspects of the environment. In nursing, this can mean being able to manage six new admissions on the same shift ( small scale) to merging nursing units as part of a hospital-wide redesign (large scale). ii. Flexibility also allows leaders to deal effectively and creatively with uncertainty and even hostility that may come their way. B. Intelligence i. Subject-based intelligence includes knowledge and skills associated with the persons job functions, and the ability to use the knowledge and skills to solve problems and improve work processes. ii.People-based intelligence includes emotional intelligence the ability to use not only rational but also emotional perception in learning, problem-solving, and working with people effectively to achieve desired outcomes. Note that in nursing, this not only yields positive patient outcomes, but also results in the ongoing professional development and job satisfaction of the nurse. C. Ability to support others. This trait includes the following characteristics: i. Responsiveness to a wide range of situations and people. A person with this trait is likely to face situations head-on rather than withdrawing or procrastinating. ii. The leader who is able to support other practices open and effective communication iii. The leader who is able to support others possesses key social skills the ability to work effectively with and respect diverse constituents, to defuse conflict, and to generate trust and enthusiasm in others. D. Self-confidence i. A person who is self-confident is able to trust his or her abilities and decisions. ii. This person is also able to receive feedback and input from others without feeling threatened. E. Desire to lead. Accdg. to Kirkpatrick and Locke (1991), people who are effective leaders must be interested in and have a desire to influence change in people or organizations. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ What is LEADERSHIP? Leadership is the conception of a goal and a method of achieving it, the mobilization of the means necessary for attainment; and the adjustment of values and environmental factors. Some leadership theories try to explain why some people are leaders and others are not, but as yet none covers all the possibilities. That may be because leadership requirements differ depending on the situation. In the Intensive Care Unit (ICU), e.g. where quick decisions are a matter of life and death, the

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leader is the nurse with highly developed critical thinking and analytical skills and the confidence to make decisions under pressure. In quality management, where the problems are often long term and complicated, the leader tends to be a nurse who is well organized and can methodically sift through a mountain of information and statistics to develop a policy that covers the widest range of possibilities. Through the years, a number of researchers have developed theories about leadership. Be aware that older theories were developed based on the study of white men. These may or may apply to women and people of color. A. Behavioral theories Autocratic leadership/manager based on centralized decision making. The leader makes decisions and expects subordinates to obey. The leader uses his or her power to command others and to control them. If this type is used consistently, a great deal of hostility may develop between the leader and the followers. The autocratic manager may be most effective in crisis situations when structure and control are critical to success, as, for instance, during a cardiac arrest or code situation. Laissez-Faire leadership/manager (French for leave it alone) the leader defers decision making to her or his followers. There is a permissive climate with little direction or control exerted. This manager allows staff members to make and implement decisions independently and relinquishes most of his/her power and responsibility to them. Workers in this situation may wind up feeling frustrated (because the person who is supposed to make decisions does not), and efficiency may suffer as a result. Democratic leadership/manager the democratic manager encourages participation in decision making; and to share authority. He/she recognizes that there are situations in which such participation may not be appropriate and is willing to assume responsibility for a decision when it is necessary. The leaders power is derived from his or her expertise as well as the influence that results from close relationships with others. The goals of the group are identified, and the manager is perceived as a group member who is its organizer and who keeps it moving in the defined direction. The environment is open, and communication flows both ways. This type of group tends to perform well whether or not the leader is present, and leaders and followers tend to maintain positive relationships.
Degree of freedom Degree of control Decision making Leader activity level Responsibility Quality of output Efficiency Authoritarian Little freedom High control By the leader only High Leader High quality Very efficient Democratic Moderate freedom Moderate control Leader and group High Leader and group High quality / creative Moderately efficient Laissez-faire Much freedom Little control Group or no one Minimal Abdicated Variable Variable

Source: Tappen, RM, et al,: Essentials of Nursing Leadership and Management, ed. 2 FA Davis. Philadelphia, 2001. p.6

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Although these theories are discussed separately, they are a continuum of leadership style ranging from a mostly passive approach to a highly controlling one. Employee centered leadership - the focus is on the human needs of the employees. Employee-centered leadership is considered more effective than job-focused leadership, which is more concerned with schedules, tasks, or output than with the people who do the work. Although most agree that every individual leans toward one of these styles, it has been found that fluctuations from one to another can occur depending on the particular situation. In the health care setting, good leaders carefully balance job-centered and employee-centered behaviors to meet both staff and patient needs effectively. A good leader works toward established goals and has a sense of purpose and direction. A good leader must also be aware of how her/his behavior impacts the workplace. B. Contingency Theories Contingency approaches to leadership state that a variety of environmental factors affect the outcome as much as do leadership style or leader characteristics . In other words, the outcomes of leadership are determined by factors other than the leaders behavior. i. Fielders theory a leaders behavior depends on the interaction of the leaders personality and the particular needs of the situation. Leadership effectiveness depends on matching organizational structure with the best leadership style for that organization and situation. Effectiveness consists of the three following characteristics: a. Leader-member relations: includes the followers feelings about the leader, including trust, acceptance of the leader, and whether the leader is perceived as credible by his or her followers. b. Task structure: the extent to which work tasks are defined by specific procedures, directions, and goals. Tasks are classified as high structure (routine, clearly defined) or low structure ( not predictable, creative, working on the fly). This concept could also be applied to a work environment. For example, post partum is generally predictable with stable patients compared to the emergency departments complete lack of routine. c. Position power. This includes the amount of influence and/or the degree of formal authority that the leader has. In this model, high position power is considered favorable while low position power is considered less so. Hersey and Blanchards situation theory. According to this theory, the effectiveness of a persons leadership style depends not so much on the leader but on the follower the followers maturity should be assessed in order for the most appropriate leadership style to be implemented. With this leadership style, the effective leader also changes or adapts her or his leadership style to match the followers needs and attempts to increase the followers level o maturity. This leadership style can be categorized in 4 ways ( based on task and leadership levels): a. High task/low relationship behavior: telling leadership style b. High task/high relationship behavior: selling leadership style ( getting people to buy in to an approach, policy, or new staffing or management structure) c. Low task/high relationship behavior: participating leadership style d. Low task/low relationship behavior: delegating leadership style Houses path-goal theory: The effective leader makes the appropriate path easier for the worker to follow by using the appropriate leadership style. The effective leader also matches his or her leadership style to the situation or environment, for example, the type or

ii.

iii.

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complexity of tasks that need to be completed and the dynamics of work groups. When the leader aligns leadership style with followers needs and the particular situation, he or she enhances worker performance and satisfaction. In nursing, for example, a manager might need very different approaches: in a long-term care facility in which there is a predominance of non-RN staff, with many certified nurses aides, a manager may need to be more hands-on and delegate fewer tasks and responsibilities. On the other hand, an all-RN staff in a hightechnology, high acuity critical care setting may be able to function more independently, meaning the manager can delegate more and the staff can be active participants in management decisions. A mismatch in which independent nurse are given a hands-on manager, or a situation in which less skilled workers do not get enough direct supervision can lead to significant frustration among all nursing staff members and may affect the quality of patient care delivered. Kerr and Jermiers substitutes for leadership theory: Certain variables or factors may influence followers behaviors as much as or even more than the leaders behavior. Some of these identified substitutes for leader behavior include: a. amount of feedback provided by the task itself ( for example, the difference between taking care of a patient in a coma versus a patient who communicates and actively participates in care). b. Significant work group cohesion ( do experienced nurses make it difficult for less experienced nurses to be part of the group?) c. Groups rigid adherence to rules ( not only formal, but informal rules as well, such as whether nurses are expected to take personal responsibility for continuing education or if professional development is not valued). d. intrinsic satisfaction provided by the work or task For example, when critical care nurses are rotated out of critical care to a high-tech chronic care unit, nurses job satisfaction may drop because the nurses experience much less feedback from their work; patients conditions do not change rapidly in response to nursing interventions as they do in critical care. Rotation out of the original work environment can dilute group cohesion, and the nurses may not feel intrinsic satisfaction from this type of work compared to their usual fast-paced critical care work. iv. C. Current contemporary theories i. Charismatic theory: leaders who have the charisma ( leadership qualities that inspire followers allegiance and devotion) are able to make an emotional connection with their followers. Generally, these leaders display enormous self-confidence and are able to get others to have confidence in them. The positive aspect of the charismatic leader is his or her ability to communicate vision and use unconventional strategies effectively (especially in crisis). President John F. Kennedy used this type of leadership by showing his self-confidence in an unconventional strategy for the time by appearing on television. This was especially important during the Cuban missile crisis when the US faced the threat of nuclear war after the Soviet Union placed nuclear missiles in Cuba. On the other hand, some followers may assign a sort of superhuman quality or purpose to the charismatic leader, which has allowed some charismatic leaders such as Adolph Hitler and Charles Manson to do great harm. Transformational leadership theory: both leaders and followers act on one another to raise their motivation and performance to higher levels. This theory depends on the concept of

ii.

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empowerment, in which all parties are allowed to work together, to the best of their ability, to achieve a collective goal. This process transforms both the leader and the follower. The focus of transformational leadership is allowing innovation and change. According to this theory, there are two types of leaders: a. Transactional leader: the person responsible for day-to-day operations b. Transformational leader: the person responsible for maintaining the overall vision and motivating people to incorporate that vision in their work. C. Motivational theories: theories are sometimes called process theories because they are designed to do more than just explain behavior. They are designed to help us understand the processes involved in peoples behavior. The four key motivational theories are: i. Reinforcement theory: based on the research of Skinner (1953), views motivation as learning. Through this process, a person becomes conditioned to associate a behavior with a consequence (either a positive or a negative reinforcement). According to this theory, leaders are most effective when they can control or even manipulate the consequences of a followers behavior. This behavior modification approach works well when enough positive reinforcements exists and when leaders have a certain control over followers access to these rewards. This theory does not explain, however, why some reinforcements work for some people and not for others. In some cases, rewards can divide staff if the same people tend to get rewards over and over again, and some nurses are insulted by the concept of rewards, such as a free lunch coupon or other small tokens. The efficacy of this approach may also be affected by a persons educational background, age, and cultural experiences. Expectancy theory: peoples expectations about a situation also help determine their behavior. This theory emphasizes that people dont just respond passively to reinforcement or lack thereof; rather, they are actively and consciously interacting with their environment. Proponents of this theory often construct a matrix that helps quantify the following three motivational components: a. Expectancy: the perceived probability that a certain effort will lead to a desired action or behavior. b. Instrumentality: the belief that a given performance level will lead to an outcome. c. Valence: perceived value of that outcome. In nursing, the expectation is often one being taken for granted, being overworked and not receiving recognition for extra effort, or job well done. Thus, nurses may decide not to go extra mile if they expect that their efforts will not be acknowledged or appreciated. A true nursing leader can change these expectations by keeping the focus on the patient and family outcomes and the self-satisfaction that comes from prioritizing their needs. A nursing leader can help staff nurses develop the ability to achieve satisfaction from the intrinsic rewards of their work, altering their expectations for external rewards. iii. Equity theory: the degree of perceive fairness in the work situation is the key to job satisfaction and worker effort. Equity does not mean equality it is still possible, for

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example, for workers with different skills levels, different levels of educational preparation, or different levels of seniority in the workplace to receive different pay. What is important is that the workers perceive that they are receiving a fair and just reward for their efforts, and that their efforts are being rewarded proportionately to the efforts of the other workers. Workers who perceive that inequity exists will usually modify their work ( usually in terms of amount of work or difficulty of work) in order to restore equity themselves. iv. Goal setting theory: suggests that people dont expend effort for rewards or task outcomes, but to accomplish the goal itself. According to Locke (1968), three assumptions from the foundation of this theory: a. Specific goals are more effective than general goals for motivating higher performance b. More difficult or challenging goals lead to higher performance c. Incentives or rewards are effective only in that they encourage people to change their goals ( that is, its not the reward in itself that promotes improvement).

Keys to Leadership
Key Qualities Integrity Courage Initiative Energy Optimism Perseverance Well-roundedness Coping skills Self-knowledge Key Behaviors Critical thinking Problem Solving Acknowledgment of and respect for individual differences Active listening Skillful communication Establishment of clear goals and outcomes Continued personal and professional development
Source: Adapted from Tappen, RM, et al.: Essentials of Nursing Leadership and Management, ed. 2 FA Davis, Philadelphia, 2001, p.8

E. Wheatleys new leadership concept: Margaret Wheatley (1992), the leaders function in an organization is to: i. use his or her vision to guide followers ii. help followers make choices based on values shared by leaders and followers iii. provide meaning and coherence in the organization culture

This leadership concept draws strongly on the biological concept of organisms, contending that, like an organism, the organization is a living entity whose different parts are interdependent on each other for the entire organization to thrive. This theory sees the organization as being able to form strong internal connections and balances that promote the best functioning- an environment that provides optimal patient outcomes through collaboration in the workplace and maximizes worker satisfaction. Note: It is the responsibility of the leader to see the bigger picture and to be able to describe that vision or picture to others. This leader is the one who can stand on the balcony. From this position, the leader can monitor the ebb and flow of the organization and determine which direction the organization is moving. Seeing the big picture and communicating this vision are needed for a leader to be effective, because it helps to have a vision that can be put into words for others to understand. F. How do changes in organizations engender changes in leadership theory and practice? 1. Organizations today are more complex, and leadership styles and methods must keep pace with the complexities of people, the patient care they provide, and the technology they use.

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2. 3. The most effective leadership emerges from teams that are able to direct and organize themselves. Leaders must be able to lead teams that are diverse in terms of gender, race, culture, and age and deal effectively with the different needs and motivations of these groups.

CRITICAL THINKING Question # 1 1. A sudden storm struck at about 9:30 on a Thursday night. There were multiple motor vehicle crashes, and the community hospital emergency department was overwhelmed with injured patients. At the same time, two people having massive heart attacks arrived by ambulance for care. The evening shift staff was scheduled to go home at 11:30 pm. All staff, except for two people, stayed to help the night shift, not leaving until 3:00 a.m. The 2 people who left angered the rest of the staff because they did not pitch in to help, and offered no explanation for leaving. The following day, the evening staff arrived to see a memo posted in the staff lounge from the nurse manager thanking the staff for staying late, pitching in, and going the extra mile for the patients, their co-workers, and the department. However, the memo was addressed to the people who were on the staffing list for the evening shift, and included the 2 people who left early. Using one or more of the theories described, describe the positive and negative aspects of the nurse managers behavior. 2. An enthusiastic, 28 year old nurse is promoted to the nurse managers position on a different nursing unit within the same hospital. She worked on an oncology unit, and is now manager of a mixed medical-surgical unit that uses critical paths extensively for its orthopedic surgical patients. She is the third new manager in 3 years. Every nurse who works on the day shift is this unit has been there for 10 years or more. When the new manager spent more time on the unit observing the activities before taking the job, Mary, a nurse with 15 years of service to the hospital, stood out from the rest of the staff members. She told people what to do, and decided who went to break and lunch at what times. She called staff members together for report at the end of the shift. What challenges does this new nurse manager face?

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 1: Please encircle the letter of your choice.

1. Leadership is best described as a process of a. Coercion b. interpersonal dynamics

c. influence

d. passive learning

2. A person who is a leader but who does not have a sanctioned role within the organization is what kind of a leader? a. Formal b. informal c. situational d. traditional 3. The leadership trait defined as self-knowledge or self-awareness and the ability to receive feedback and learn from mistakes is called: a. passion b. vision c. curiosity d. integrity 4. The trait that allows leaders to adapt rapidly to changes in the organizations environment is called: a. support b. intelligence c. self-confidence d. flexibility 5. A leader who defers decision making to his or her followers is called what type of leader? a. autocratic b. laissez-faire c. contingency d. high task 6. Which group of leadership theories states that the leaders style has less impact on outcomes than on certain environmental and other factors? a. contingency theory c. charismatic theory b. democracy theory d. goal-setting theory 7. According to Houses path theory, which of the following is true? a. effectiveness of leadership style depends more on the follower than the leader b. the leaders effective leadership style helps the worker remain on the appropriate path c. the leaders charisma or personal appeal helps workers remain on the appropriate path d. workers are empowered to achieve a common purpose. 8. The theory that maintains that followers and leaders influence each other to increase their motivation and performance to higher levels is called: a. Reinforcement theory c. Goal-setting theory b. Equity theory d. Transformational leadership theory 9. The concept of valence is defined as a. the perceived probability that a certain effort will lead to a desired action or behavior b. the belief that a certain effort will lead to a desired action c. perceived value of an outcome d. behavior that is repeated because it is positively or negatively reinforced 10. The new leadership theory was proposed by a. Skinner b. Wheatley c. Locke

d. Bennis

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WHO NEEDS NURSING MANAGEMENT? All types of health-care organizations, including nursing homes, hospitals, home health-care agencies, ambulatory care centers, student infirmaries, and many others, need nursing management. Even the nurse working with one client and family needs management knowledge and skills to help people work together to accomplish a common goal. A primary nurse working with several clients prioritizes their care to assist time to improve health or, sometimes, peaceful death.

Nursing administration is the application of the art and science of management to the discipline of nursing. Nursing management is also the group of nurse managers who manage the nursing organization or enterprise. Nursing management is the process by which nurse managers practice their profession. Key Points 1. What is management? A. Management is the process of 1) coordinating actions, 2) directing actions 3) assigning resources B. The purpose of management is to perform these tasks in order to achieve the objectives (desired outcomes) of an organization. C. Management is a problem-oriented process with similarities to the nursing process. It is needed whenever two or more individuals work together toward a common goal. The manager coordinates the activities of the group to maintain balance and direction. D. The terms management and supervision sometimes are used interchangeably; however, management is a broader concept that includes The Essence of Leadership supervising people as well as other resources to accomplish organizational goals. A true leader has the confidence to E. Management often focuses on issues such as costs, stand alone, the courage to make productivity, staffing, and effectiveness. tough decisions, and the comparison F. These management issues may or may not have anything to listen to the needs of others. to do with leadership. Management does not equal He does not set out to be a leader, leadership, although leadership may play a role in but becomes one by the quality of management. his actions and the integrity of his 1. Management is often synonymous with constant intent. In the end, leaders are much activity and interaction like eagles they dont flock, you 2. In the course of a typical day, managers, usually find them one at a time. deal with many activities ranging from highly prioritized and crucial to routine (for example, from a downsizing decision that will send a nurse to a different unit, to making sure that a nurses employment anniversary is recognized) 3. The most common image of a manger is of a firefighter who responds to problems that emerge randomly, and are addressed in order of urgency 4. Most managers spend much of their time interacting with others Four (4) functions generally performed by a manager: planning (what is to be done), organizing ( how it is to be done), directing (who is to do it), and controlling (when and how it is done). G. Management functions consist of: 1. Planning: determining the objectives of an institution or organization and what needs to be done (both in the short term and long term) to achieve those objectives. Planning very often addresses the organizational questions of what, why, where, when, how, and by whom, and it usually consists of a four-stage process:

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a. Establish objectives b. Evaluate the present and predict future trends and events c. Formulate a planning statement d. Convert the plan into an action statement Staffing: selecting the people who are able to carry out the action plan. This selection is usually based on: a. The knowledge, skills, and experience of the nurse b. The number and type(s) of patients needing care c. Number and type of support staff available Organizing: based on the plan as well as knowledge about the structure of the institution or organization, organizing is the process of coordinating human and other resources to meet established goals. Effective organizing consists of: a. Knowledge of factors such as institution, environment, social structure, people, and technology. b. Ability to assign tasks appropriately to people who can accomplish the tasks successfully (delegation) c. Coordinating tasks that have been assigned and changing tasks or staff if goals are not being met d. Using appropriate and accepted types of authority to ensure that required tasks are completed. Depending on the organization and the manager, authority may derive from the managers position in the organization itself, or from the relationship between supervisor and staff member. For example, in a more rigid organizational structure such as a police or fire department, authority comes with rank. Directing: motivating and leading personnel to accomplish objectives. How a person directs others depends on that persons authority, power, and leadership style. Effective directing is achieved through strategies such as: a. Setting specific, clear expectations that are realistic and measurable b. Providing sufficient resources to accomplish the tasks c. Fostering a work environment that balances challenges and success d. Finding ways to recognize and reward work that meets or exceeds objectives in a way that is meaningful to workers Controlling: establishing standards of performance, comparing results with these benchmarks, correcting performance that differs from accepted standard. Frequently used means of control include: a. Management by objectives (MBO) devices: determining objectives, measuring to see if objectives are being met, and comparing objectives with standards (benchmarks) b. Socialization: often a key part of MBO, socialization means that nurses internalize professional values and standard codes of behavior. For nurses, socialization is a process of moving from the early stages of accepting perceived beliefs and values of the profession, through formal and informal education, to the final stage of full membership in the profession and commitment to its norms and values. c. Managerial surveillance: the direct observation of staff behavior by the manager as well as indirect observation, for example, through the managers review of records. A key concept of this function is span of control, which refers to the number of individuals for whom a supervisor is directly responsible. A narrow span of control means fewer numbers of directly supervised staff and thus higher degrees of direct observation and control. A wider span of control ( more than 10 supervised employees) means less opportunity for direct observation or control. A wide span of control can be effective as long as staff members are highly educated, tasks are relatively routine, and managers can effectively oversee such a group.

2.

3.

4.

5.

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d. Continuous quality improvement (CQI): in this formal quality improvement process, staff members participate in and lead the team. All team members are continuously involved in peer review, so that they can identify ways to improve processes or programs, and constantly enhance and improve the quality of care. 6. Decision making: key steps of this function include: a. Identifying problems b. Establishing criteria that can evaluate potential solutions to the problem(s) c. Seeking alternative solutions, including taking no action d. Evaluating all the alternatives that have been found e. Selecting the best alternative, based on organizational objectives, staff, environment, and other available resources. H. A variety of factors affect management roles and decisions. They include: i. The institutions structure ( for example, size how it handles authority, department size and structure, wide or narrow span of control, amount of centralization or decentralization, how it measures and controls outcomes, and how it selects, recruits, and rewards employees) ii. The organizations objectives: the service(s) it offers ( such as a hospital that specializes in cardiology or an outpatient surgical center that specializes in cataract surgery), how productive the organization is or how efficiently it meets objectives, the quality and amount of its human resources, and how employees participate in goal setting. iii. Environmental factors ( for example, the current economic, legal, technological, or social influences that the organization must consider) iv. Technology (for example, current state of medical or nursing science, process of technology, computer systems, and informatics) v. Tasks that are required or expected (for example, the nature of tasks that need to be completed, how work tasks are designed, and the impact of the organizations physical layout on the nature and design of tasks) vi. Social structure ( for example, the organizations internal culture, how it socializes employees, the rituals that it uses to conduct work or deal with conflict, perceptions of authority, and language and cultural issues. 2. Current management theories A. Scientific management a. Established by Engr. Frederick Taylor (Principles of Scientific Management,1911) but still in use b. Focused on maximizing worker production levels and efficiency. c. Relied on the view of work as systematic series of tasks that could be measured, predicted, and manipulated to increase efficiency d. Developed time and motion studies that resulted in one best way of carrying out a specific task or series of tasks e. One important medical application: this method revolutionized the field of surgery (Gilbreth,1912), as efficient surgical methods resulted in shorter operations and reduced risks to patients. f. This approach can also provide important feedback about workflow; where equipment, medications, and other items essential for patient care are stored and how they can be positioned to enhance nursing efficiency (so nurses dont waste time walking long distances to supply closets, for example) B. Bureaucratic theory a. Developed by Max Weber

17
b. Efficiency is achieved through impersonal relations within a formal structure ( bureaucracy) c. Focused on employee competence as the basis for hiring and promoting employees (rather than interpersonal relationships with superiors) d. Emphasized the orderly and rational, not the interpersonal e. Promoted strong top-down hierarchy with clear superior-subordinate communication and relationships. In this model, a persons power is assigned, based on the authority of his rank or position.

C. Administrative theory a. Originally developed by French mining Engr. Henri Fayol (1916) b. States that several principles are essential to the functioning of any organization: planning, organizing, coordinating, and controlling c. Additional component of management process is unity of command and direction (workers get orders from only one supervisor and related work tasks are grouped under one manager) d. Theory also recognizes the power of the informal structure in organizations (Barnard, 1939), which identifies the role of naturally forming social groups and the recognition that they are powerful forces in organizations. e. Barnard believed that managers must recognize and work with these informal structures to achieve the best outcomes for the organization D. Human relations theory ( later called organizational behavior) a. Focuses on the individual worker rather than processes and procedures as the key to organization motivation, productivity, and control. b. Studies in the 1930s showed that workers are motivated by other workers as much as by environmental factors. c. The Hawthorne effect, which was identified during these studies, says that when a person is observed or studied, his or her behavior changes. E. Motivational theory. This group of theories grew out of human relations theory, which emphasized that worker output was best when workers were treated humanely. According to the motivational theory: a. Motivation is interpreted from peoples behavior rather than explicitly demonstrated by their actions b. Motivation is an integral process that directs behavior to satisfy needs c. Understanding motivation is the key because it helps explain why people do what they do; understanding workers motivation can help managers create change. d. Most well-known motivation theories are those based on: 1. Maslows (1970) hierarchy of needs (physical needs must be satisfied before higher psychological needs) 2. Herzbergs (1968) theory (maintenance factors include adequate wages and safe workplace; motivations include meaningful work, recognition of accomplishments, and development opportunities) 3. McGregors (1960) theory ( Theory X: leaders must direct and control worker motivation and Theory Y: workers are self-controlled and self-disciplined and the leaders job is to remove obstacles from their work and help them meet their personal goals) 4. Ouchis (1981) theory (Theory Z: the best way to motivate is through collective decisionmaking, long-term job security, use of quality circles, and humanistic managements style. 3. The changing world of nursing and management A. Management often derives from a more rigid, hierarchical structure. In traditional organizations:

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i. A manager is an expert in management techniques, but not necessarily an expert in clinical realm. This can lead to a. Managers being targets of downsizing b. Managers becoming overseers of systems ( clinical, cost information, data) rather than of people. This means the manager has a vested interest in maintaining these systems even if redesign will be more efficient and will result in better patient outcomes. The disengaged manager is not a model that works well in nursing a. Nurses need clinical managers who have knowledge of the challenges beside caregivers face so as to be able to support staff and advocate for staff needs to superiors. b. Nurses tend to be put off by managers who could not participate in patient care is necessary during a crisis.

ii.

B. Ongoing dilemma for nursing: the combination of clinical and management skills i. Expert clinicians are often promoted to nurse manager positions based on their clinical expertise, and not their management skills. In many organizations, this is the only opportunity for advancement. ii. However, someone with great management skills may not be up-to-date clinically C. Management without leadership: according to S. Covey ( 1989) management without leadership is like straightening deck chairs on the Titanic. CRITICAL THINKING Question # 2 1. A nurses is working on a medical-surgical unit, and a physician has just given her an order to insert a Foley catheter into a patient and send a urine sample to the laboratory. The nurse manager has instructed her that it is time to go off the unit for her lunch break; if she doesnt leave the unit now, she will not be able to take her meal break when the cafeteria is open. Apply your knowledge of administrative theory to describe the problem in this situation. Choose another theory of management that could be applied in this situation, and explain how it would help the nurse solve her dilemma. 2. A hospital is building a new medical-surgical units as an addition to the building. Describe how scientific management theory can be used to help design the new unit to maximize nursing efficiency.
WINNER or WHINER Which One Are You?

A Winner Says.. We have a real challenge here. Ill do my best. Thats great! We can do it. Yes.

A Whiner Says This is a big problem. Do I have to do this? Thats nice, I guess. It cant be done, its impossible. Maybe, when I have some time.

Source: Tappen, RM, et al: Essentials of Nursing Leadership and Management, ed. 2. FA Davis.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 2: Please encircle the letter of your choice. 1. The purpose of management is to coordinate and direct actions and assign resources in order to: a. Achieve the organizations objectives c. Develop high quality staff b. Receive a promotion d. Keep staff turnover as low as possible 2. Which of the following statements about management is true? a. It focuses on clinical excellence b. It tends to attract people who like quiet, routine work without interruptions c. It focuses on issues such as cost, productivity, effectiveness, and staffing d. It is synonymous with leadership 3. The management function that involves determining the objectives of an organization and tasks needed to complete objectives is a. Staffing b. directing c. planning d. controlling 4. When a person internalizes a set of standards or codes of behavior, this is called: a. Decision making c. productivity b. Managerial surveillance d. socialization 5. A manager with a narrow span of control will a. Directly supervise more than 10 staff members b. Have greater opportunities for direct observation and control of staff c. Tend to oversee staff with high levels of training d. Be unable to motivate staff members 6. Identify problems, establishing criteria, seeking and evaluating alternatives, and selecting the best choice are steps in the management function of: a. Controlling b. Decision making c. Staffing d. Directing 7. MBO stands for management by a. Organization b. Opposition

c. Objectives

d. Oversight

8. The time and motion studies developed by ____ resulted in one best way of carrying out a specific task. a. Frederick Taylor c. Henri Fayol b. Max Weber d. Abraham Maslow 9. According to bureaucratic theory, which of the following is true? a. Efficiency is achieved through personal relations between an employee and superior b. There is no need for hierarchy, as all workers have a key role in the organization c. Employees should be hired based on their relationship with the owner d. Effective organizations are rational and orderly 10. Maslow, Herzberg, McGregor, and Ouchi developed theories about worker behavior, based on which school of thought? a. Scientific theory c. Administrative theory b. Motivational theory d. Socialization theory

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THREE BASIC SKILLS NEEDED BY ALL MANAGERS Technical Skill is the knowledge of and ability to use the processes, practices, techniques, or tools of a specialty responsibility area. The manager needs this skill enough to accomplish the job for which he or she is responsible. Ex: accountants, engineers, salespersons, and quality control specialists * Is most important for a manager at the first-line management level and becomes less important as the manager moves up in the organization structure. Human Skill is the ability to interact with other persons successfully. A manager must be able to understand, work with, and relate both individuals and groups in order to build a teamwork environment. The proper execution of ones human skills is often called human relations * Is important at every level in the organization. The need to be able to understand and work with people is important at all levels, but the first-line managers position places a premium on human skill requirements because of the great number of employee interactions required. Conceptual Skill it is the mental ability to view the organization as a whole and to see how the parts of the organization relate to and depend on one another. It is the ability to imagine the integration and coordination of the parts of an organization - all its processes and systems. It deals with ideas and abstract relationships.

Top Management Middle Management First Line Management

Proportions of Management skills needed at Different levels of management A manager needs conceptual skills to see how factors are interrelated, to understand the impact of any action on the other aspects of the organization, and to be able to plan long range. * Becomes increasingly important as a manager moves up the levels of management. First level manager focuses basically on her or his work group; therefore, the need for conceptual skill is at a minimum. Top level management is concerned with broad-based, long range decisions that affect the entire organization, therefore, conceptual skill is most important at that level. Leadership today is the preferred mode of getting things done in health care. Successful nurse leaders i. Respond flexibly to changes in the workplace ii. Disseminate information rapidly and effectively through their teams iii. Develop and maintain strong trust and interpersonal connections with staff, peers, patients, and other health care professionals iv. Build up and support team members skills and strengths, while dealing effectively with differences v. Do not avoid uncertainty or chaos but instead thrive on it

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Other characteristics of nurse leaders include: i. Specialists and generalists: effective leaders are experts in a particular field. In nursing, for example, this specialization could be in emergency care or community health practice. Nurse leaders are also generalists; they know enough about a wide range of areas so that they are able to communicate with and mediate between a variety of other specialist and specialty practice areas. Self- reliance: effective nurse leaders understand that they must rely on themselves (to listen, make good decisions, maintain clinical skills, etc) but they effectively balance this selfreliance against their value to and role within the organization Connectedness: effective nurse leaders are always excellent team players, and almost always key members of more than one team in an organization.

ii.

iii.

Roles and functions of nurse managers: The nurse manager is accountable for: i. Excellence in nursing clinical practice and delivery of patient care in a particular unit or area of an organization ii. Managing human, monetary, and other resources needed to provide excellent patient care and achieve expected outcomes iii. Facilitating the development of nursing and health care personnel ( both licensed and unlicensed) in a designated unit or department iv. Ensuring that all standards of care practiced in that area are in compliance with professional ( Nurse practice Act) regulatory, and government standards of care. v. Developing strategic planning that supports the departments or units and organizations overall mission vi. Facilitating relationships among different departments or disciplines to ensure the delivery of the highest quality patient care Key nurse management roles in the health care environment ( note that organizations have different names for these functional roles): i. First line manager. The nurse manager primarily supervises other managerial staff and monitors the quality of care that staff provide to patients. This manager is also responsible for motivating staff to meet organization goals. The remainder of the nurse managers time is usually spent in planning and coordination and staff evaluation. Key tasks that a first-line nurse manager may perform include: a. Preparing orientation schedule in collaboration with nurse educators b. Submitting time schedules for nursing shifts c. Making budget recommendations to nursing administration based on unit needs and patient acuity d. Calculating amount of staff needed and meeting challenges when staff members call out sick, or other situations disrupt the staffing schedule e. Making daily patient rounds f. Conducting meetings with staff g. Conducting employment reviews, including counseling reports and termination h. Setting goals for individual patient care areas i. Participating in quality assurance activities j. Maintaining clinical knowledge through reading journals, participating in continuing education activities, and other opportunities for learning

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ii. Middle-level manager. The nurse director supervises first-level managers, usually within a geographic or specialty area and is responsible for all people and activities in this area. The mid-level manager spends more time planning, coordinating, negotiating, and evaluating, and less time directly supervising staff. Increasingly, this level of responsibility requires graduate level education. Key tasks that a middle-level manager may perform include: a. Assessment: observe whether policies and objectives are meeting the needs of patients and the staff that provide care b. Planning: set short-term and long-term goals of patient care, revise policies if needed so that patient care objectives can be met and outcomes can be achieved most efficiently. c. Organization: put plans in action ( via delegation and committee work) by developing appropriate teaching strategies, organizing budget to meet planning needs, engaging in customer relations and communication to improves outcomes and manage risk effectively. d. Control. Analyze results of implementation, consider changes that need to be made, facilitate nurse managers in research and development, and communicate changes and opportunities to managers and staff Executive-level manager. The chief nurse executive or vice presidents of patient care services spends the lowest amount of time in supervision; most of the time is spent in planning and making policies. This person is less responsible for direct supervisory activities and more responsible for establishing overall organizational goals and strategic plans for a department, division, or entire organization oversight often includes non nursing areas. As with the middle-level manager, the responsibilities for this position usually require significant managerial experience and graduate level education. Key tasks that nursing executive might perform include: a. assessment: understand the organizations internal environment or culture and the external environment (bioethics, legislation, regulation, technology, community) in which it must function. b. planning: Forecast trends in health care, costs, reimbursement, and regulation, and developing responsive strategic plans c. organization: based on assessment and strategic planning, bring together the appropriate mix of staff, other resources, ongoing research, and education d. control: evaluate nursing policies, programs, and services, to ensure they are consistent with the organizations mission and objectives and the needs of the patients and of the staff.

iii.

Other managerial roles that have evolved: i. charge nurse ( also called resource nurse) a. expanded staff nurse role with some managerial responsibility on a given shift in a frontline role b. may be a permanent or rotating assignment c. usually functions as a liaison to the nurse manager, particularly on off-shifts d. tasks include assisting in shift coordination, promoting quality care, using resources efficiently, troubleshooting problems that occur, and helping staff members with making decisions and prioritizing care e. differs from first-level manager in that a charge nurse has more limited authority and limited scope of responsibility; depending on the organization, the charge nurse may or may not be involved in the staff evaluations (may be more involved in off-shifts in which the manager has less direct observation of staff members)

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ii. staff nurse a. this position may not have formal managerial rank but the nurse uses managerial and leadership skills to work with other nurses and assistive personnel. b. Management responsibilities include supervising to ensure quality patient care, delegating tasks appropriately, and motivating staff.

Mintzbers (1994) contemporary model of managerial work says that managerial functions occur at three levels information, people, and action. i. ii. iii. Information processing: the most abstract level including communicating ( sharing) information with others as well as controlling (using information to manage others work) People: at this level, the manager leads ( encourages and enables) people and links people ( establishes networks) to help them be effective Action: at this level, the manager is very involved in doing this includes supervisory actions such as directing change, handling disturbances, and negotiating.

Characteristics that distinguishes leaders and managers include: i. ii. Facilitator vs. director: leaders provide their staff resources that enable them to learn and solve problems, rather than giving directions on how tasks should be done Coordinating vs. controlling: effective leaders excel at stepping back and allowing people to use their initiative to solve problems with some support, but minimal guidance. Leaders then are free to work at higher level, coordinating a variety of able employees, rather than controlling or directing employees every move. Pull vs. push: effective leaders encourage and motivate people to act rather than ordering them to act Macromanagement vs. micromanagement: effective leaders tend to look at the big picture on a series of tasks. Micromanagement is often perceived by staff as indicating that they are incompetent or not to be trusted to act appropriately when independent. Peers/followers vs. subordinates: leaders tend to follow a less hierarchical approach to working with others, thus seeing staff members as part of a team rather than as located at higher or lower levels of an organization. This more open structure facilitates feedback and communication. Coaching/ challenging vs. blaming: effective leaders use mistakes or problems as learning opportunities that provide a chance for coaching in proper procedure or challenging them to increase their level of competence or performance rather than blaming, chastising, or punishing. Solving problems vs. just identifying them: effective leaders are active problem solvers, balancing the various needs of staff and the organization, matching resources appropriately with problems, and promoting both efficiency and care in an environment that is focused on patient care. These leaders may see problem solving as so effortless that they are not aware they are doing it; a problem-solving approach simply seems natural to them.

iii. iv.

v.

vi.

vii.

In many organizations, leaders and managers have very different roles: A. Leadership i. Key role is prioritizing and optimizing patient care ii. Focus is first on patient outcomes and then on bottom line outcomes B. Management i. Priority is the function of the organization ii. Particular focus on meeting financial or business goals

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 3: Please write the letter of your choice in the space before the number. ___1. Which of the following is a characteristic of an effective nurse leader? a. Following rules precisely c. Withholding strategic information for long periods of time b. Developing strong and trusting relationships with staff d. Focusing on the business of health care ___2. A nurse manager who spends 90% of his or her time submitting time schedules for nursing shifts and assigning teams and patients is at what level of management? a. First-line nurse manager c. chief nurse executive b. middle-level manager d. vice president of patient care services ___3. The advantage of a nurse leader being both a generalist and a specialist is that the nurse can: a. Delegate all tasks to others b. Operate effectively without input from other staff members c. Choose not to be part of a management team d. Be an expert on a topic as well as communicate with a variety of other specialists ___4. Which of the following is true about the nurse leaders trait of self-reliance? a. It prevents the nurse leader from working effectively in a team b. It is a characteristic only of nurse managers, not of nurse leaders. c. It balances the nurses personal abilities with the needs of the organization. d. It allows the nurse leader to accomplish multiple tasks without any assistance ___5. A focus on meeting an organizations financial or business goals is a function of: a. Management b. leadership c. problem-solving d. coaching ___6. The level of nursing manager that spends the least time directly supervising certified and noncertified nursing staff is: a. Nurse executive c. first-level manager b. Middle -level manager d. charge nurse ___7. A staff nurse with some increased managerial responsibilities is usually called a (n) a. Nurse executive c. nurse assistant b. Charge nurse d. associate director of nursing ___8. According to Mintzbergs model of managerial work, effective managers: a. Act first and then communicate b. Are seldom involved in leading people or forming networks c. Manage action by doing, for example, directing change or negotiating d. Lead at the first level, act at the second level, and communicate in summary form ___9. The ability to interact with other persons successfully. A manager must be able to understand, work with, and relate both individuals and groups in order to build a teamwork environment a. Human skill b. Conceptual skill c. Technical skill d. Human relations ___10. The effective nurse leaders understand that they must rely on themselves but they effectively balance against their value to and role within the organization a. Specialist b. connectedness c. Self- reliance d. generalist

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POWER AND AUTHORITY IN NURSING Power is having the ability to effect change and influence others to meet identified goals or the ability or capacity to act. In the minds of many people, this word elicits images of control and coercion the concept of power over. To empower nurses is to provide them with greater influence and decision making in their roles. The realization of greater power in the profession depends on the willingness of administrators to allocate this power and of nurses to accept it, along with the accompanying responsibility. Remember, power and responsibility go hand in hand. Key Points A. Having power means being able to make change, or to prevent change from happening. According to Miller (2003), for nurses, a positive definition of power means the ability to: i. Take resources by either creating them or acquiring them and ii. Use them to meet goals such as providing safe and competent care as well as meeting organizational goals B. Stephen Covey ( 1990) says that power is the vital energy to make choices and decisions. It is also the ability to overcome deeply embedded habits and to cultivate higher, more effective and productive habits. C. Leadership cannot exist without power according to Costello-Nickitas ( 1997) D. Power does not depend on the level at which a person sits in the hierarchy, but rather on how an individual perceives power, how others perceive the individual, and the extent to which an individual can influence events ( Miller, 2003, p. 348). E. People achieve power through influence: i. Influence is a skill used to gain power in interpersonal situations ii. A person who can influence (help change) another persons feelings, attitudes, or behavior is powerful Positive sources of power: The key sources of power are factors that help a person influence others to do what that person wishes ( Fisher and Koch ( 1996) More specifically, according to Wells (1998), most nurses are able to exert influence through using one or more of the following: A. Expertise i. skills and abilities the nurse possesses (can be clinical skills, communications skills, and problem-solving skills ii. knowledge the nurse possesses. This generally focuses more on clinical knowledge but can also include knowledge about information systems, political structures, sources of data, available opportunities, and other knowledge. For instance, the enterostomal therapist has expertise in the care of individuals who have had ostomies. Therefore, staff nurses seek out the therapist as a resource and use the experts knowledge to guide the care of these patients. C. Legitimacy, or power derived from the position a nurse holds in a group. Legitimacy equates with degree of authority.

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i. ii. Focuses on personal authority that the nurse holds rather than authority designated by an organization The group recognized legitimate leaders and generally follows those with whom the group members agree. Leaders with whom the group significantly disagrees often lose their legitimacy. Legitimacy as the sole source of a persons power may not be sufficient in some settings, and may not be recognized in others. For example, a nursing administrator without an educational background equal or higher than her contemporaries in other departments may not be perceived as having legitimate power. A nurse who is seen as legitimate in one setting or culture may not be seen in the same way in another setting; for example, a nurse who is an administrator in a small long-term care facility may not make an automatic transition to the same administrative position in a medium-sized community hospital. Men in nursing have struggled to achieve legitimacy in a predominantly female profession.

iii.

C. Admiration and trust, sometimes called referent power or charismatic power. This type of power is characterized by: i. a high level of respect for and trust in the charismatic individual ii. a significant amount of loyalty to the person who possesses referent power This can explain the fact that followers sometimes rationalizes or try to explain away any of the leaders behavior that is inconsistent. iii. a high level of confidence in followers, which depends on the trust in the charismatic leader. A leader with charismatic or referent power can be extremely influential, especially in difficult or stressful times ( Miller, 2003). This power can be easily abused. Franklin D. Roosevelt and John F. Kennedy are considered charismatic leaders, as were Charles Manson and David Koresh. iv. Among the most important characteristics of ethical charismatic leaders is the ability to develop creative, critical thinking in their followers and to stimulate followers to think independently and to question the leaders view to reduce the risk of blind loyalty that may ultimately be harmful to followers. D. Information power. This type of leader has characteristically i. has significantly knowledge or understanding that is useful, accurate, or timely ii. readily shares this knowledge with others iii. does not rely on the organization to bestow power; the power comes from the persons own internal know-how and his or her willingness to share that power with others E. Connection power. The nurse who exercises this power is aware that: i. all people are connected in some way to all other people. This is especially true in health care organizations and nursing communities in which people are connected through schools, professional organizations, and community affiliations. ii. people are attracted to making connections to people with power or their associates. No one, in nursing or elsewhere, likes to feel detached from sources of influence. For nurse leaders, this can be as simple as a verbal recognition of, staff excellence or as complex as an award banquet. iii. people at all levels of an organization are connected, and those connections must be acknowledged and respected. As Miller (2003) notes, effective leaders recognize, for example, that workers at all levels of organization have a complex web of relationships with more and less powerful people. If you are disrespectful of the hospital vice presidents clerical staff, you can easily damage any relationship with the vice president as well. F. Honesty, integrity, and ethical practice also called principled-centered power have these

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characteristics: i. Based on principles of honor, respect, loyalty, honesty, and integrity ii. How leaders choose what to do in any situation is based on these principles; all decisions made are measured against these principles. According to Sullivan and Decker (2001), nurses must understand and select behaviors that are in accord with principle-centered leadership, including: a. Getting to know people and learning what they want and need b. Being open: to keeping others informed, and to use trust and respect instead of fear and suspicion c. Knowing ones own values and visions d. Increasing interpersonal skills such as listening and expressing ideas clearly e. Using personal power to enable others f. Increasing connections between people and enlarging ones own sphere of influence. g. Understanding that in order to win one does not have to lose and that a w in-win outcome can be the key to building ongoing, successful relationships. Note: Leaders and managers need to understand the concept of power and how it can be used and abused in working with others. Graduate nurses need to be aware of and willing to implement methods and resources to increase their personal power. As they gain experience in the staff nurse role, they can develop expert power by increasing competency in their roles and clinical skills. Guidelines for using power positively in organizations. Effective ways for using the different types of power: 1. Expert power a. Preserve credibility ( for example, by avoiding speculation or careless discussions) b. Stay up-to-date with technology and other changes that affect peoples work c. Act with confidence and decisiveness in crises d. Show respect and avoid arrogance; avoid damaging peoples self-esteem e. Show concern for the perspectives of all people at all organizational levels; attempt to show how changes minimize risk to people. 2. Authority/legitimacy power a. Ask, dont demand b. Make sure staff understands directions or questions c. Explain why you are asking for something to be done d. Follow up to ensure compliance 3. Referent/charismatic power a. Be considerate, show concern for people, treat people fairly, and defend their interests to supervisors or outsiders b. Avoid expressing (verbally or in action) hostility, rejection, distrust, or indifference toward people c. Make requests that are reasonable d. Be a positive role model 4. Connection power a. Use relationships correctly and appropriately b. Avoid name dropping c. Be ready to reciprocate if someone does a favor for you, offer to return the favor in a spirit of give and take, not keeping score d. Recognize that all connections have limits, and abide by them

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Power influences choices, and choices affect behaviors and feelings. A clear vision unites power and choices by: a. Building consensus b. Identifying capabilities c. Determining factors needed for success d. Identifying resources: people, time, and money Other (less positive) sources of power A. Punishment or coercive. Most experts recognize that the power to punish or give negative incentives (dock someones pay, issue a reprimand, termination) is sometimes necessary, as these penalties can discourage certain behaviors. However, as Miller ( 2003) notes, this type of power is perceived as i. humiliating by the person on the receiving end of the coercive power and thus ii. much less desirable for use by people in authority positions iii. however, some people who enjoy holding power over others may actually enjoy using punishment or coercive power, just to show they can. B. Reward power. This can encourage certain behaviors, and people may be motivated by monetary and other reward systems. However, Miller (2003) states: i. Rewards that assigned and distributed unfairly can have the opposite effect ii. Rewards do not provide long-term changes in behavior or attitudes iii. withholding rewards can produce resentments iv. rewards dont motivate as effectively or as consistently as a clear, unifying vision v. If reward is used, the leader should remember to a. Avoid overdoing incentives, emphasize the intrinsic reward of teamwork and loyalty instead b. Reinforce actual behavior rather than future performance c. Ensure rewards reflect total, not partial, performance d. Recognize that monetary awards may be the least effective e. Carefully match the reward to the person; a reward for a unit secretary that is valued and appreciated may not have value for a registered nurse on the same unit. Empowerment the process by which we facilitate the participation of others in decision making and take action within an environment where there is equitable distribution of power. Empowerment is built: a. Through a commitment to the well-being of all concerned, from the lowest to the highest levels of an organization b. By providing an atmosphere in which risk taking is valued and encouraged to lead to or provide insights c. With flexibility to adapt to changing priorities, needs, and situations d. From diversity i. In styles of thinking, communication, and problem solving ii. In accepting and encouraging culturally different points of view e. With cooperation rather than competition f. Though the ability to compromise (finding as many win-win solutions as possible) g. With empathy for patients, other staff, management, and people in the community Empowerment is demonstrated through: 1. An increased ability to solve problems creatively and effectively 2. Improved communication a. Between nurses and patients

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b. Between nursing team members ( RN, LPN, nurses aides, unit secretaries, and other assistive personnel) c. Between nurses and other health team members (respiratory, physical and occupational therapists; pharmacists; and physicians, for example) d. Between nurses and management e. Throughout the organization f. Between the organization and the community through community outreach programs 3. Increased satisfaction with work, including less stress and lower levels of burnout 4. Improvements in peoples a. Levels of self-esteem b. Ability to function with autonomy c. Levels of accountability and responsibility

Critical thinking Questions # 3 1. Using your knowledge of the entities of power, describe the powers that interact between an organization and a collective bargaining unit that represents workers in the organization. 2. When patients are empowered, are they more independent? Does that threaten established lines of power between the patient and the nurse or between the patient and the physician? What are the benefits and downsides of patient empowerment?

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 4: Please write the letter of your choice in the space before the number. ___1. A nurse who has power is able to a. Make staff do anything the nurse wants b. Make or prevent change

c. Avoid engaging in organizing politics d. Avoid decision making

___2. According to this author, power includes the capacity to culture more effective habits. a. Nicolo Machiavelli c. Stephen Covey b. Warren Bennis d. Eleanor Sullivan ___3. A characteristic of power over strategy is that it makes the receiver feel a. Empowered b. Collaborative c. Incompetent d. Secure ___4. A nurses clinical abilities, education, and knowledge of systems are part of the power source known as: a. legitimacy b. charismas c. connection d. expertise ___5. The source of power known as connection power is the best described as a. Power that equates with the degree of the nurses personal or organizational authority b. Power that is based on peoples respect for or trust in a particular person c. Power based on honor, respect, loyalty, and integrity d. Power that derives from an awareness of the networks that exist between people in an organization ___6. Leaders who make all their decisions based on their own ethical values (honesty, integrity, respect, etc) are engaged in what kind of power? a. Expertise b. principle-centered c. legitimacy d. charisma ___7. An effective use of reward power would include a. Giving bonuses for future performance b. Using money as the primary reward system c. Rewarding total performance d. Giving incentives every day ____ 8. Preserving credibility, staying current with technology, and acting decisively in crises are positive ways of using what type of power? a. Expert b. Reward c. Authoritative d. Charismatic ____9. A person who effectively uses connection power would: a. Do a lot of name dropping to emphasize connections b. Continually return to the same people for favors to build a network c. Build a group of networks based on different affiliations d. Understand that reciprocity is unimportant ___10. Which of the following is true about punishment or coercive power? a. Penalties do not change peoples behaviors b. People appreciate being the recipient of this type of power c. This type of power can include docking a persons pay, reprimands, or termination d. This type of power should never be used in an organization

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FUNCTIONS OF NURSING MANAGEMENT

A nurse manager performs these management functions to deliver health care to patients. Nurse managers or administrators work at all levels to put into practice the concepts, principles and theories of nursing management. They manage the organizational environment to provide a climate optimal to provision of nursing care by the clinical nurses. PLANNING o is pre-determining a course of action in order to arrive at a desired result. o the continuous process of assessing, establishing goals and objectives and implementing and evaluating them, which is subject to change as new facts are known. o primary to all other activities or functions of management o o o a thinking or conceptual act that is frequently committed to writing if plan is not written down, they probably wont be implemented. the forecasting of events the building of an operational plan an important management function that helps reduce the risks of decision making problem solving, and effecting planned change.

While planning is largely conceptual, its results are clearly visible. Note: nursing managers who learns to plan will aim for maximum utilization of all resources money, supplies, equipment, and personnel.
Importance of Planning : It 1. leads to the achievement of goals & objectives 2. gives meaning to work 3. provides for effective use of available resources & facilities 4. helps in coping with crises 5. is cost-effective 6. is based on the past & future activities 7. discovers the need for change 8. necessary for effective control 9. orients people to action, instead of reaction 10. increases the chances of success by focusing on results, not on activities 11. increases employee involvement & improves communication Scope of Planning Top Management ( Nursing Directors, Chief Nurses, Directors of Nursing & their assistants) Set the over-all goals and policies of the organization. - Scope of responsibility is the over-all management of the organization. Middle Management ( Nursing Supervisors) -Direct the activities that actually implement the broad operating policies such as staffing and delivery of services to the units headed by the Senior or head Nurses. Without good advice everything goes wrong--it takes careful planning for things to go right. Proverbs 15:22

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- Formulation of policies, rules and regulations, methods and procedures for personnel for intermediate level planning for ongoing activities and projects are done in coordination with top management and those in the lower level. Lower or first level management (Head Nurses or Senior Nurses (including Charge Nurses or team leaders) - do the daily schedules, or weekly plans for the administration of direct patient care in their respective units Major Aspects of Planning 1. Plans should contribute to objectives (actions without plans often result to chaos) 2. Planning precedes all other processes of management (organizing, directing, controlling) (Planning and control are as inseparable as Siamese twins) 3. It pervades all levels. ( from higher to lower echelons and vice versa, horizontally or across.) 4. It should be efficient (it should contribute to the attainment of objectives not only in terms of pesos, man-hours, units or products but also include values as individuals and group satisfaction) Elements of Planning 1. 2. 3. 4. 5. Forecasting Setting the Vision, Mission, Philosophy, Goals and Objectives Developing & Scheduling Program Preparing the Budget Establishing Nursing Standards, Policies and Procedures

1. Forecasting - estimates the future, including the environment in which the plan will operate. It includes who the patients are their customs, beliefs, language/dialect barriers, public attitude and behavior, the acuity of their conditions/illnesses, the kind of care they will receive; the number and kind of personnel (professional and nonprofessional); and the resources-equipment, facilities, supplies needed. 2. Setting the Vision, Mission, Philosophy, Goals & Objectives Vision outlines the organizations future role and function that gives the agency something to strive for. Mission outlines the purposes the agency is in (whether hospital or health care), who clients are (the poor, the needy, the middle or upper class), what services are provided (in-patient, out-patient, emergency) and why it exists. Philosophy describes vision. It is a statement of beliefs and values that direct ones life or ones practice. In an organization, it is the sense of purpose of the organization & the reason behind its structure and goals. A written statement of philosophy explains the beliefs that determine how the mission or purpose is achieved, it gives direction to achieving the goals and objectives set. Goals (general) and Objectives (more specific) - they are action commitments through which its mission and purpose will be achieved and the philosophy or belief sustained.

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They are stated in terms of results to be achieved and should focus on the production of health care services to the patients * Philosophy states beliefs and values while objectives state specific and measurable goals to be accomplished. 3. Development & Scheduling Program - programs are determined, developed and targeted within a time frame to reach the goals and objectives set. 4. Preparing the Budget Components of Budget Cash Budget estimating the amount of money received form patients and allocating it to cash disbursement required to meet obligations promptly as they come. Operating Budget salaries, supplies, drugs & pharmaceuticals, etc Capital Expenditure Budget consists of accumulated data for fixed assets that are expected to be acquired during the budgeted period 5. Establishing Nursing Standards, Policies and Procedures 1. Nursing Standards this can supply professionally desirable norms against which the departments performance can be measured. Areas for improvement are identified, and a plan of action to correct be made and implemented. Ex: Structure, Criteria, and Standards Proverbs 28:2 In time of civil war there are many leaders, but a sensible leader restores law and order. this

2. Nursing Service Policies are broad guidelines for the managerial decisions that are necessary in organizational and departmental planning. - they govern the action of workers and supervisors at all levels and are intended to achieve predetermined 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. Three General Areas in Nursing that requires policy formulation 1. Areas in which confusion about the locus of responsibility might result in neglect or malperformance of an act necessary to a patients welfare, 2. areas pertaining to the protection of patients and families rights e.g right to privacy, property rights, 3) areas involving personnel management and welfare Characteristics of Good Policies 1. written and understandable and known by those who will be affected by them. 2. comprehensive in scope, stable, flexible so they can be applied to different conditions that are not so diverse that they require different set of policies. 3. consistent to prevent uncertainty, feelings of bias, preferential treatment and unfairness. 4. realistic and prescribe limits 5. should allow for discretion and interpretation by those responsible for it.

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Example of Nursing Service Policies 1. Admissions Receiving, consent, notifying doctor, care of patients 2. Doctors Orders written, verbal, telephone 3. Reporting On or Off-Duty Information given in leaving unit 3. Nursing Procedures are specific directions for implementing written policies 2 Areas procedures are needed: a) related to job situations such as reporting complaints or disciplinaryinstances, b) involves patient care

II ORGANIZING
the grouping of activities for the purpose of achieving objectives. it shows the part each person will play in the general social pattern as well as the responsibilities, relationships and standards of performance.

Elements of Organizing 1. Setting up the Organizational Structure 2. Staffing 3. Scheduling 4. Developing a Job Description 1. Setting up the ORGANIZATIONAL STRUCTURE - process or way a group is formed, its channels of authority, span of control and lines of communication mechanism through which work is arranged & distributed among the members of the organization so that the goals can be logically achieved. Organizational Chart a line drawing that shows how the parts of an organization are linked. Characteristics of Organizational Chart 1. Division of Work each box represents an individual or sub-unit responsible for a given task of the organizations workload 2. Chain of Command lines indicate who reports to whom & by what authority 3. Type of work to be Performed indicated labels or descriptions for the boxes 4. Grouping of Work Segment shown by the clusters of work groups 5. The level of Management, which indicate individual & entire management hierarchy, regardless of where an individual appears on the chart. Organizing Principles 1. Unity of Command responsible to only one Superior 2. Scalar principle authority & responsibility should flow in clear unbroken lines from the highest to the lowest executive. 3. Homogenous Assignment or Departmentation - workers performing similar assignment are grouped together for a common purpose 4. Span of Control the # of workers that a supervisor can effectively manage should be limited depending upon the pace & pattern of the working area 5. Exception Principle recurring decisions should be handled in a routine manner by a lowerlevel manager. Unusual matters/problem should be referred to higher levels.

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Forms of Organizational Structure 1. Hierarchical / line organization - oldest and simplest form - associated with the principle of chain of command, bureaucracy, vertical control and coordination, levels differentiated by function & authority & downward communications - has authority for direct supervision of employees 2. Staff organization - assists the line in accomplishing the primary objectives of the unit - provides advice and counsel - includes clerical, personnel, budgeting & finance, staff development, research & specialized clinical consulting 3. Free Form/ Matrix - super imposes a horizontal program over the traditional vertical hierarchy. personnel from functional depts. are assigned to a specific program or project & become responsible to 2 bosses a program manager & the functional dept. head. - actually an interdisciplinary team of core & extended members - e.g. task force, ad hoc committee - the expert is the authority that leads the team ________________________________________________________________________________ To identify staffing and scheduling in nursing management a patient has to be classified accordingly: Patient Classification System (PCS) - method of grouping patients according to the amount and complexity of their nursing care requirements, of nursing time & skill they require. This assessment can serve in determining the amount of nursing care required, generally within 24 hours, as well as the category of nursing personnel who should provide that care. Purposes for classifying patients: For/ to 1. staffing. Perceived patient needs can be matched with available nursing resources 2. program costing & formulation of the nursing budget 3. tracking changes in patient care needs 4. determine values for the productivity equation: output divided by input. 5. determine quality Classification Categories Level I Self Care or Minimal Care Patient can bathe, feed and perform ADL. Level II Moderate Care or Intermediate Care Patient needs some assistance in ADL, ambulating up and about for short periods of time, Level III Total, Complete or Intensive Care Patients are completely dependent upon the nursing personnel. Level IV Highly Specialized Critical Care - Patients maximum nursing care, they need continuous treatment, observation, many medications, IV piggy backs, vital signs q 15-30 mins. hourly output; significant changes in doctors orders more than care hours/patient/day may range from 6-9 or more. The number of categories in a patient classification may range from 3 to 4, which is the most popular, to 5 or 6. These classes relate to the acuity of illness and care requirements, such as minimal, moderate, or intensive care. Other factors affecting the classification system would relate to the patients capability to meet his physical needs to ambulate, bathe, feed himself, instructional needs including emotional support. Patient care classifications have been developed primarily for medical, surgical, pediatrics, and obstetrical patients in acute care facilities.

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Levels of Care Level I Self Care or Minimal Care Level II Moderate or Intermediate Level III Total or Intensive Care Level IV Highly Specialized or Critical Care

NCH Needed Per Patient/ Day 1.5

Ratio of Prof. to Non-Prof

55:45

60:40

4.5 6 7 or higher

65:35 70:30 80:20

Percentage of Nursing Care Hours The percentage of nursing care hours at each level of care also depends on the setting in which the care is being given. Percentage of Patients in Various Levels of Care Minimal Moderate Intensive Care Care Care 70 65 30 Tertiary Hospital 10 Special Tertiary Hospital * The Forty-Hour Week Law, Republic Act 5901, provides that employees working in 100 bed capacity and up will work only 40 hours a week. * This also applies to employees working in agencies with at least one million population. * Employees working in agencies located in communities with less than one million population, will work 48 hours/week and therefore will get only one off-duty a week Personnel Policies that have to be enjoyed by each personnel regardless of the working hours / week. 3 day special privilege to government employees by the Civil Service Commission as per Memorandum Circular No. 6 series of 1996 which may be spent for birthdays, weddings, anniversaries, funerals (mourning), paternity leave, relocation and enrollment or graduation leave, hospitalization and accident leaves. 25 45 20 25 30 45 5 5 15

Types of Hospital

Highly Specialize Care 10

Primary Hospital Secondary Hospital

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CLASSIFICATION OF HOSPITALS AND OTHER HEALTH FACILITIES 1. Government or Private 1.1. Government operated and maintained partially or wholly by the national, provincial, city or municipal government, or other political unit; or by any department, division, board or agency thereof. 1.2. Private privately owned, established and operated with funds through donation, principal, investment, or other means, by any individual, corporation, association, or organization. 2. General or Special 2.1. General provides services for all types of deformity, disease, illness or injury. 2.2. Special primarily engaged in the provision of specific clinical care and management. A primary care hospital, secondary care hospital, tertiary care hospital, or infirmary, may provide special clinical service(s). 3. Service Capability 3.1. Primary Care Hospital 3.1.1. Non-departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality 3.1.2. Clinical services include general medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia 3.1.3. Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) 3.1.4. Provides nursing care for patients who require intermediate, moderate and partial category of supervised care for 24 hours or longer 3.2. Secondary Care Hospital 3.2.1. Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care 3.2.2. Clinical services provided in the Primary Care Hospital, as well as specialty clinical care 3.2.3. Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) 3.2.4. Nursing care provided in the Primary Care Hospital, as well as total and intensive skilled care 3.3. Tertiary Care Hospital 3.3.1. Teaching and training hospital that provides clinical care and management on the prevalent diseases in the locality, as well as specialized and sub-specialized forms of treatment, surgical procedure and intensive care 3.3.2. Clinical services provided in the Secondary Care Hospital, as well as sub-specialty clinical care 3.3.3. Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) 3.3.4. Nursing care provided in the Secondary Care Hospital, as well as continuous and highly specialized critical care 3.4. Infirmary a health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and management to mothers and newborn babies. 3.5. Birthing Home a health facility that provides maternity service on pre-natal and post-natal care, normal spontaneous delivery, and care of newborn babies.

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3.6. Acute-Chronic Psychiatric Care Facility a health facility that provides medical service, nursing care, pharmacological treatment and psychosocial intervention for mentally ill patients. 3.7. Custodial Psychiatric Care Facility a health facility that provides long-term care, including basic human services such as food and shelter, to chronic mentally ill patients. http://www2.doh.gov.ph/BHFS/classification.pdf
2. STAFFING the process of determining & providing the acceptable # & mix or personnel to produce a desired level of care to meet patients demand for care. Methods of Staffing Pattern 1. Conventional centralized- decentralized combination; oldest and most common 2. Cyclical staffing pattern repeats itself every 4 6 wks or 7 -12 wks, etc. 2.a 40 hrs/4 days 40 hrs a wk is worked in 4 days, followed by a block of off duty time 2.b Seven days off, 7 on a 10 hr day is worked for 7 days, followed by 7 days off Criteria for staffing patterns depends on: 1. Existing organizational structure & Standards 2. Availability of job descriptions or performance responsibilities which spell out precise job content, including duties, activities to be performed, responsibilities & results expected from the various roles by the organization. 3. SCHEDULING a timetable showing planned work days and shift for nursing personnel Types of Scheduling: 1. Centralized Chief Nurse or designate do assigns the personnel to the hospital units 2. Decentralized Chief Nurse or designate assigns personnel but supervising Nurse/ Head or Senior arranged the shift and off duties 3. Cyclical Covers designated number of wks. (cycle length) it assigns required number of nursing personnel to each nursing unit consistent with the units patient care requirements, the staff preference, then, education, training and experience. The following scheduling variables should be considered: a. Length of scheduling period whether 2 or 4 weeks b. Shift rotation c. Week-ends off d. Holiday offs e. Vacation leaves f. Special days ( birthdays, wedding anniversaries, etc.) g. Scheduled events in the hospital training programs, meetings, etc. h. Job categories i. Continuing Professional Education (CPE) programs

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Advantages of Cyclical Schedule 1. It is fair to all 2. It saves time as the schedule does not have to be redone every week or two 3. It enables the employees to plan ahead for their personal needs preventing frequent changes in the schedule. 4.Scheduled leave coverage such as vacation, holidays and sick leaves are more stable 5. Productivity is improved Factors Considered in Making Schedules a. the different levels of the nursing staff - adequate mix of nurses and nursing attendants should be observed so that they only assume duties they are legally responsible for, according to their positions, education, training and experiences. b. adequate coverage for 24 hours, seven days a week c. staggered vacations and holidays - not everybody can enjoy the holiday off on exactly the same day that these occur; schedules for holidays are staggered at least once a month. Vacations (whether forced or requested) are likewise staggered to ensure adequate coverage at all times. d. weekends Weekends are scheduled in such a way that everyone gets a fair share of at least one week-end off a month. Saturdays and Sundays tend to have lower requirements since there are lesser medical rounds, fewer medical orders and lower patient census. e. long stretches of consecutive working days are to be avoided as much as possible because it might affect the health of the nursing personnel. Afternoon and night shifts are more difficult than the day shifts. Nursing personnel should get their fair share of these things including the relief duty for the three shifts periods. f. evening and night shifts requirements for staff are usually lower than in the morning shift g. floating Some problems that occur in the schedules: * busy units may require additional help * unscheduled absences may occur and suddenly a staff may be pulled out from her regular area of assignment to cover for another unit. - in order to minimize problems as a result of emergency assignments cross training and/ or orientation to complementary units is advised. 4. Developing JOB DESCRIPTION a statement that sets the duties and responsibilities of a specific job.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 5: Please write the letter of your choice in the space before the number. ___1.A function of management that helps reduce the risks of decision making, problem solving, and effecting planned change. a. Controlling b. Planning c. Directing d. Organizing ___2. The level of management where the Nurse Director is, that sets the over-all goals and policies of the organization. a. Middle Mgt. b. Lower/first level mgt. c. Top level mgt. d. Operating level ___3. It describes the vision. It is the organizations sense of purpose: a. Vision b. Mission c. Goals

d. Philosophy

___4. Programs are determined, developed and targeted within the time frame to reach goals/objectives. a. Development and scheduling b. Staffing c. Budgeting d. Planning ___5. Broad guidelines for the managerial decisions that necessary in organizational and departmental planning. a. Nursing Standards b. Nursing Service Policies c. Nursing law d. Rules ___6. This can supply professionally desirable norms against which the departments performance can be measured. a. Nursing Standards b. Nursing Service Policies c. Nursing law d. Rules ___7. They are specific directions for implementing written policies. a. Nursing Standards b. Nursing Policies c. Nursing Procedures

d. Nursing law

___8. The number of workers that a supervisor can effectively handle should be limited depending upon the pace & pattern of the working area. a. Unity of command b. Exception Principle c. Span of Control d. Scalar Principle ___9. The method of grouping patients according to the amount of care requirements, nursing time & skill they require. a. Modalities of nursing care b. Patient Classification System c. Patients level of acuity ___10. The process of determining & providing the acceptable #& mix of personnel to produce a desired level of care to meet patients demand for care. a. Scheduling b. Planning c. Staffing d. Development ___11. A timetable showing planned work days and shift for nursing personnel. a. Scheduling b. Planning c. Staffing d. Budgeting ___12. A statement that sets the duties and responsibilities of a specific job. a. Nursing Service Policies b. Job description

c. Guidelines

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III DIRECTING
- the issuance of orders, assignments and instructions that enables the nursing personnel to understand what are expected of them. Elements of Directing 1. Delegating /Delegation 2. Utilizing / Revising / Updating Nursing Service & Procedures 3. Supervision 4. Communication 5. Coordination 6. Staff Development 7. Decision Making 8. Motivating / Motivation Delegate! 1. DELEGATING - getting the work done through subordinates assigning specific tasks/duties to workers with commensurate authority to perform the job With the increased use of less-educated and unlicensed personnel in todays health-care system, it is essential that the nurse develop effective delegation, and supervision skills. The nurse needs to be mindful that the tasks that can be delegated can change on the basis of working setting, client needs, position descriptions, institutional training of personnel, and the ever changing requirements of nurse practice acts and professional standards. Nurses also need to know when delegation is inappropriate. DELEGATION and SUPERVISION IN NURSING In todays health-care system, delegation has become an essential component of client care and management of nursing units. It allows health-care managers to maximize the use of caregivers who are educated at multiple levels in a variety of programs. Delegation, if performed properly, permits nurses to meet the requirements of quality care for all client and has become a basic skill that registered nurses (RN) must learn. The goal of delegation is to meet the cost restraints of limited health-care budgets by using less-expensive personnel that maximize the use of time by RNs and to promote team building. Although delegation and supervision are closely related concepts, they are different. Delegation is recognized as assigning or designating a competent individual the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients . Delegation includes the understanding that the authorized person is acting in the place of the RN and may be carrying out tasks that generally fall under the RNs scope of practice. This includes more than asking someone to do something. Delegation has been defined by the American Nurses Association (ANA) as the transfer of responsibility for the performance of an activity from one individual to another, with the former retaining accountability for the outcome Let whoever is in charge keep this simple (ANA, 1995). This definition emphasizes that delegation question in her head (NOT how can I increases the responsibility and accountability of the always do the right thing myself but) how RN. Be sure you know the delegation rules and can I provide for this right thing always to regulations of your states nursing practice act. be done? - Florence Nightingale Additionally, you will also need to know that delegation policies and job descriptions of nursing team members in your employing agency.

Policies

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Supervision is the initial direction and periodic evaluation of a person performing an assigned task to ensure that he or she is meeting the standards of care. Although delegation almost always requires supervision, it is possible to have supervision without delegation. Supervision: the provision of guidance or direction, evaluation and follow-up by the licenses nurse for accomplishment of a nursing task delegated to unlicensed assistive personnel. Nurses need to recognize when to delegate. Nurses are often confused regarding supervision. This responsibility does not belong to only the one with the title of manager or house supervisor; rather, the expectation by law is that any time you delegate a task to someone else, you will be held accountable for the initial direction you give and the timely follow-up (periodic inspection) to evaluate the performance of that task. When nurses delegate nursing tasks to non-nurses, the RNs are always legally responsible for supervising those people to ensure that the care given meets the standards of care. Legally, the power to delegate is restricted to professionals who are licensed and governed by a statutory practice act. RNs are considered professionals with state-sanctioned licenses governed by a nurse practice act and therefore are authorized to delegate independent nursing functions to other personnel. The stresses the belief that even though the leader or manager delegates a task to another employee, he or she remains responsible and accountable for the care that is provided. When nurses delegate nursing tasks to non-nurses, the RNs are always legally responsible for supervising those people to ensure that the care given meets the standards of care. Delegation and supervision are integrated processes: Once you delegate, you must supervise. To increase delegation skills, it is sometimes necessary to overcome the myth of perfection. In teaching or training someone else to do a delegated task, initially they may or may not be able to perform the activity as well as you can; however, it is not important that they do this perfectly, in the way you do it, or even as well as you do. What is important is that they meet the standards required to complete the task adequately. As long as safety is not compromised, it is more effective time

management to delegate to others. With experience, most people will improve (and may even surpass you).
The Nurses Responsibilities Assess the Client. Prior to delegating any task, RN should give careful consideration to the condition of the clients health care needs. Assessing clients is a designated responsibility of RNs. Without a thorough assessment, it is likely that critical needs will remain unidentified by less trained personnel, leading to potential errors in care. Clients who are relatively stable and not likely to experience drastic changes in health-care status are the most suitable for delegation. Also, the tasks being delegated must be relatively uncomplicated, routine, performed without varying from policy or procedure, and should nor require the use of nursing judgment while being performed.

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Know Staff Availability. The delegating nurse needs to know the availability the availability of staff, the education, and competency levels of the personnel to be assigned. These factors must be matched with the level of care required by the client. Key information to obtain in relation delegation is how often the delegates has performed the required tasks o cared for this type of client, what units the delegate has worked on and feels comfortable in, and his or her organizational abilities. Know the Job Description. The RN needs to know both the institutions official position description for the unlicensed assistive personnel (UAP) (nursing aide) as well as the individual UAPs abilities. For example, the position description may state that the UAO can care for postoperative clients who have multiple wound drains. However, when the RN assigns a specific UAP to such a postoperative client, the nurse discovers that UAP has has worked only in the newborn nursery for the pas 5 years and has no knowledge of how to care for adult postoperative clients. If the RN assigns this UAP anyway and a major complication develops as a result of the UAPs lack of competence (even though the position description states that this is an appropriate function for the UAP), the RN will be held legally responsible for the poor outcome. When the RN determines that the clients need match the skills and abilities of the UAP or the licensed practical nurse (LPN), only then should that person be assigned. Educate the Staff Member. RNs who delegate are also responsible for educating the UAP (nursing aide) about the task to be done. If the UAP is unfamiliar with the task, the RN is required to demonstrate how the task or procedure is performed and then document the training. Education also includes telling the UAP what is expected in the completion of the tasks and what complications to watch for and report to the RN. The ANA suggests that the RN watch the UAP perform the designated task at least initially, and then make periodic observation throughout the shift to ensure safe and competent care for the client. Furthermore, the RN must always be available to answer questions and help the UAP whenever assistance is required. Consider the following situations: Elsie Humber, RN, is the evening charge nurse on a busy oncology unit of the country hospital. On one particularly busy evening, she discovered during shift report that one of the scheduled LPNs has called in sick and no other LPNs are available to take her place. Ms. Humber assigns the LPNs duties and clients, including a heat lamp treatment for a decubitus ulcer, to a UAP who has worked in the unit for several months. The UAP protests the assignment, but Ms. Humber rebukes him by saying I have no one else. If you dont care for these clients, they wont get any care this shift. In setting up the heat lamp treatment, the UAP knocks the lamp over and burns the client. Because of his suppressed immune system chemotherapy and generally debilitated condition, the burn doesnt heal and develops into infection. The client later sues the hospital for malpractice. The hospital in turn attempts to shift the legal responsibility for the burn to Ms. Humber. Who is legally responsible for the incident? Does the client have grounds for a successful case? Predictable and Uncomplicated When a nurse delegates a task, the outcomes of task should be expected and predictable. For example, when a UAP (or nursing aide) is assigned the task of feeding a client who has suffered a stroke and has hemiplegia, the predicted outcome will be that the client will eat and not choke on the food. The task should not require excessive supervision, complex decision making, or detailed assessment during its performance. If any of these elements are required, then it needs to be re assigned to an RN. It is important to remember that when nurses delegate nursing tasks, they are not delegating nursing.

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It is important to remember that when nurses delegate nursing tasks, they are not delegating nursing. Professional nursing practice are both a science, on a unique body of knowledge, and an art guided by the nursing process. It is not merely a collection of task. Of all health-care workers, professional workers are the most qualified to provide holistic care of the client by promoting health and treating disease. Nurses education and experience provide them with the skill s and knowledge to coordinate and supervise nursing care and to delegate specific tasks to others.

How Do I Know What And When I Can Delegate? Knowing the nurse practice act of your state or country, in addition to the policies for each institution, is critical in delegating appropriately and safely. Once that has been established, consider some general guidelines regarding what and when to delegate. You should not delegate to anyone other than another RN the task of assessment to determine changes in a patients condition. Licensed practical nurses or vocational nurses perform patient assessment (gathering data), but it is the RN who must confirm and interpret these findings. Assessment should not be delegated when a decision needs to be made regarding patient care, the patients condition is changing, or there is a new patient the RN has not previously assessed. According to the nursing process, after assessment and analyzing comes planning. This is another role of the RN. Data can be gathered from a number of sources including input from a nursing assistant, etc. Ultimately it is the responsibility of the RN to determine the immediate plan of care and the comprehensive plan of care for the patient. Many nurses suffer from supernurse syndrome Another area of the nursing process that is reserved for the RN is the area of evaluations. It is the RNs responsibility to determine the patients response to procedures, medications, nursing care, and so forth. Nursing judgment based on the assessment and evaluation of the patient must also remain the responsibility of the RN. It all comes down to the RNs responsibility in implementing the nursing process. Time management with delegation can help the RN more effectively implement the nursing process. Determine which patients are the most stable and whose positive progress can be anticipated. The stable patients with predictable progress should be the first to be delegated. The unstable, unpredictable patient should only be delegated to an RN. An RN should be assigned to any patient who is undergoing a procedure or treatment that may cause them to become unstable. When you are dealing with unlicensed assistive personnel, you can delegate them those activities that are standard with specific guidelines that are unchanging. For example, feeding, dressing, bathing, obtaining equipment for the nursing staff, picking up meal trays, refilling water containers, straightening up cluttered rooms all of these activities should have guidelines according to the institution policies, fit within the job description, and be followed by the unlicensed assistive personnel. Patient teaching and discharge planning are also the responsibility of the RN. It is the RNs responsibility to determine the patients learning needs and to establish a teaching plan. It is also the RNs responsibility to coordinate and implement the discharge planning. The RN should request input from all nursing personnel who have assisted to provide care for this patient or who are involved (.eg. dietary, physical therapy) in the care of the patient. It is important that once the RN implements the teaching plan, the other RNs, licensed practical nurses, vocational nurses, and unlicensed assistive personnel are aware of what the patient has been taught so they may follow-up and report any pertinent observations to the RN. >

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Nursing care makes a difference in patient outcomes. This care is more than providing tasks. It incorporates assessment, care planning, initiation of interventions, interdisciplinary collaboration, and outcome evaluations. It includes patient and family teaching, therapeutic communication, counseling, discharge planning, and teaching. To maximize the impact nursing care can have on patient outcomes, nurses must develop and integrate multiple strategies to promote effective time management. Critical Thinking: Determine how and to whom patients are delegated on your current clinical unit. What guidelines are implemented? NO Critical Thinking : In Your Organization, Can You Delegate The Following Tasks? YES Bladder retention catheter insertion Taking vital signs Feeding a patient Hygienic care Medication administration Discontinuing an IV line Teaching insulin administration

Nursing is a knowledge-based process discipline and cannot be reduced solely to list of tasks. The licensed nurses specialized education, professional judgment and discretion are essential for quality nursing care while nursing tasks may be delegated, the licensed nurses generalist knowledge of patient care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated. According to nurse-attorney Joanne P. Sheehan, nurses cannot delegate the following: Assessments that identify needs and problems and diagnose human responses. o Any aspect of planning, including the development of comprehensive approaches to the total care plan. o Any provision of health counseling, teaching, or referrals to other health care providers. o Therapeutic nursing techniques and comprehensive care planning. DEVELOPING DELEGATION SKILLS Clear Communication. In the process of developing delegation skills, students should try to emulate the good delegators. Develop good communication and interpersonal relationship skills. Make eye contact with the other person, be pleasant, and asks for suggestions. However avoid allowing the person to whom the tasks are being delegated to control the exchange by intimidation or resistance. Careful Monitoring. Effective delegation includes monitoring the delegates while they are giving care. Are they doing what they should be doing? Do they understand the responsibilities involved in the clients care? Help them if they need help. Effective delegation also presumes that the delegator will teach the delegates who demonstrate a lack of knowledge. Most important, at the end of the shift, say Thank you. I appreciate the hard work (good job) youve done today. Certain delegation situations may place the RN at an increased risk for liability. Try to avoid the following when delegating: * Assigning tasks that are highly invasive or have the potential to cause significant physical harm to clients. * Assigning tasks that are designated under the scope of practice or standards of care as belonging exclusively to RN (admission assessments, care plan development)

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* Assigning tasks that the person is not trained for or lacks the knowledge to safely complete * Assigning tasks when there is inadequate time to safely monitor or evaluate the practice of the person performing the tasks.

Client Care Needs

RN
Admission Assessment IV Meds Blood Products Care Plan Client Teaching Unstable Clients Acute Diseases

LPN
Vital Signs Uncomplicated Skills Stable Clients Chronic Diseases Oral and IM Medications

UAP
Feeding Basic Hygiene Basic Skills Stable Clients Chronic Diseases Ambulation

WHO IS ACCOUNTABLE HERE? One of the biggest questions concerning teamwork and delegation is the issue of personal accountability. The definition of delegation already notes that the nurse is accountable for the total nursing care of the individuals. What does this really mean? Accountability: being answerable for what one has done, and standing behind that decision and/or action. Accountability has gotten a lot of bad press, and many nurses feel that being accountable means I am the one to blame. With that kind of attitude, no wonder there is reluctance to delegate! What is the point if someone else is going to make a mistake and you are going to be taking the blame? (Notice how e focus on the negative and forget that accountability also means taking the credit for the

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positive results we achieve through the actions and decisions we make, and our freedom to act because of our licensure.) Here is an important reminder about accountability before you take the weight of the world on your shoulders: The delegate is accountable for accepting the delegation and for his/her own actions in carrying out the task It is important to focus on what you are accountable for in this process and to let the delegate also assume his or her own level of accountability. Remember, you are accountable for the following: Making the decision to delegate in the first place Assessing the patients needs Planning the desired outcome Assessing the competency of the delegate Giving clear directions and obtaining acceptance from the delegate Following up on the completion of the task, providing feedback to the delegate. What if the delegate makes a mistake doing the task? What are you accountable for? Let us consider the following example: It is 7 AM on your busy medical-surgical unit. You scan your assignment quickly, reviewing the high points with your nursing assistant before going into report. With trays coming at 7:30, you remind your assistant that your patient in room 210 will be going to surgery this morning and is to have nothing to eat or drink. Coming out of report, you make brief rounds, only to find that ( you guessed it) your patient in room 210 is happily drinking her morning coffee and eating a bagel. What are you accountable for? Did you delegate correctly? What do you do now? In your review of the previous guidelines, you identified that you did indeed delegate appropriately. Your communication may or may not have been as complete as it needed to be. You are accountable for correcting the clinical effects of this error: Did the patient eat or drink too much, requiring that surgery be canceled or delayed? You will call the operating room and make the appropriate adjustments in this patients care on the basis of the decis ion regarding her surgery time. What about the nursing assistant? You are also accountable for following up with her regarding her performance, giving the appropriate feedback so that the understands her level of personal accountability as well. THE FIVE RIGHTS OF CLINICAL DELEGATION Right Task Right Communication Right Person Right Feedback Right Circumstance The RIGHT TASK The first part of any decision regarding delegation is the determination of what needs to be done and then the assessment of whether this is a task that can be delegated to someone else. Many nurses, unfortunately, suffer from super nurse syndrome and believe that no task should be delegated because no one can do it better, faster, or easier than they can. In comparison, other nurses may be all too eager to delegate the least desirable tasks to someone else. A word of caution is necessary here: If we focus only

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on making task lists for people to do, we eliminate the very core of our purpose. Remember, your role as RN on the team involves the coordination and planning of care, with your primary focus on identifying with the patient and the physician the desired outcomes for your patients. Once determined, interventions will be readily apparent, and the decision regarding possible delegation of these tasks must be made. What Can I Delegate? Fortunately, there are several references to assist you in making this determination. The first place is looking into the nurse practice act of your state. The scope of practice for each level of care provider usually includes a description of the tasks that may be performed at that level. The next place to look is in your organization, getting a copy of the job description and the skills checklist for each care provider. This will give you a very specific lists of tasks to work from, but remember, there are other considerations. Simply because the skills checklist includes ambulation of patients, it may not be advisable to delegate the first ambulation of a postoperative total hip replacement patient to the new patient care assistant. Is There Anything I Cannot Delegate? Again, your first resource is the law. Many states are very specific in their description of what cannot be delegated and therefore belongs only to the RNs scope of practice. The National council of State Boards of Nursing ( CSBN) reminds us that nursing is a knowledge-based process discipline and cannot be reduced solely to list of tasks. The licensed nurses specialized education, professional judgment and discretion are essential for quality nursing care while nursing tasks may be d elegated, the licensed nurses generalist knowledge of patient care indicates that the practice -pervasive functions of assessment, evaluation and nursing judgment must not be delegated. According to nurse-attorney Joanne P. Sheehan, nurses cannot delegate the following: Assessments that identify needs and problems and diagnose human responses. Any aspect of planning, including the development of comprehensive approaches to the total care plan. Any provision of health counseling, teaching, or referrals to other health care providers. Therapeutic nursing techniques and comprehensive care planning. Beyond the law, your employer will have job descriptions and skills checklists that should clearly define the role of the caregiver. As many organizations develop creative assistant roles to leverage the professional judgment of scarce registered nursing personnel, the scope of practice of each role is defined first by the law. If the organization extends the role of a patient care technician to include preoperative teaching, you want to be aware that this is clearly an RN function and not allowed by law to be delegated to the technician. A job description and a policy would not override the legal limits of the scope of practice. Where To Look For Determination of the Right Task Nurse practice act Employee job description Skills checklist Demonstrated competency With the right task selected according to the scope of practice, the policies in your agency, and your assessment of the situation, there is still work to be done. Who will do the task? The RIGHT PERSON Matching a task that can be delegated to the right person involves that definition of delegation once again. Nurses must select the right task for a competent person in a selected situation. How do we select the right person in the right situation?

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How Can I Use Outcomes In Delegating? USING OUTCOMES IN DELEGATING Patient Outcome Mr. Peterson Patient will be clean Patient & caregivers will know how to perform skin assessment and range of motion Bath

Task/Process

Who will perform it? Nursing assistant other care associate or

Ms. Ibutu

Bath with education regarding home care

RN: teaching plan; OT, PT, or rehabilitation aide may also assist RN: assessment and interpretation of data LPN: data-gathering and reporting RN: initial plan for comfort measures and pain assessment

Mr. Handelsky

1.Patient will maintain Initial baseline vital cardiorespiratory homeostasis signs and assessment, and continue on care path day close monitoring 1 2.Patient will be free of pain and comfortable for this shift. Long-term outcome, pain free death Pain assessment and treatment, comfort measures ( repositioning skin care)

Assistant: comfort measures, report of progress LPN, Licensed practical nurse; OT, occupational therapist; PT, physical therapist; RN, Registered Nurse. TALKING ABOUT OUTCOMES: WHATS IN IT FOR ME? Provides a method to decide appropriate assignments: who should be doing what task Gives you a sense of purpose for the shift ( short term) and long term Enhances your ability to motivate co-workers along a track to achieving the outcomes Clarifies your role as leader of the team Verifies and clarifies patient/ family expectations when outcomes are discussed and planned with them Promotes job satisfaction for the whole team In planning for the right person to do a task, focusing on outcomes is essential . For example, two patients can be admitted to a hospital. Each of these individuals will need a bath today ( task), but who will do the bath is related to the outcome you are trying to achieve. For Mr. Peterson who has been homeless and is in dire need of hygienic care so that you can perform a complete and accurate skin assessment, the priority outcome you and your patient desire is that Mr. Peterson will be clean. With Ms. Ibutu, who is a paraplegic, today is the day that her caregivers and she will demonstrate how they will assess the skin for areas of breakdown and how to perform range of motion to her lower extremities. The RNs decision about who will do the task is dependent on the plan of care and the goals that the team has established in the discussion with the patient or family. This same logic applies when you have heard in report that a patient is unstable. In your current care-delivery system on your unit, the LPN may carry out the initial vital sign data-gathering in your postoperative ICU. Suppose, for example, that the report you received stated that there had been increasing cherry red drainage in the chest tube and that the patients cardiac monitor showed

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supraventricular tachycardia, with increasing respiratory rate. On the basis of the outcome for the shift, Mr. Handelsky will maintain cardiorespiratory homeostasis and continue on critical path for first day post-thoracotomy. Using your insight that his condition may be deteriorating, you may make a different decision regarding who will be there for initial patient contact. If the assistant working with you today is an experienced team member, you may choose to send him in to see the patient immediately while you check on another critical patient. Or if the assistant is a float from an agency, known to you only by initial questioning, you may immediately make a visit to see Mr. Handelsky and begin to set up the plan for the data-gathering and schedule for reporting that you will expect from your assistant. This would be a very different process if the outcome you wanted to achieve was pain relief and comfort for a terminal patient. Focusing on outcomes takes time. But, as many have often said, If you fail to plan, you plan to fail. Why should an RN focus on outcomes? Discussion of goals not only establishes who should be doing what task, but also allows RN to motivate others. How many of us jump on a train if we do not know where it is going? A purpose and destination allow all the team members to function more effectively. When assistive personnel are given the same assignment daily, without variation, without any understanding of why they are doing what they are doing, it is similar to being an assembly line worker putting widgets in a machine. Satisfaction and motivation of co-workers generally come from the feeling that they are making a difference in the lives of their patients. In a similar manner, you as the leader of the team would feel much better at the end of your shift or assignment if you could feel comfortable with the outcomes you have assisted the patient In achieving. You could actually verify the outcomes and plan with the patients, much as you were always told to do by the teachers in your nursing program! Much time is saved by streamlining the care to the patients expectations. Again, the RN is accountable for the patient, for determining the situation in which delegation will be used, and for the selection of the right person to do the right task, in addition to the periodic inspection and follow-up of those they supervise.

The RIGHT CIRCUMSTANCES

The National Council of State Boards of Nursing discussed the right circumstance as an additional consideration for the nurse. Right Circumstances - appropriate client setting, available resources, and consideration of other relevant factors, suggests that the staffing mix, community needs, teaching obligations, and the type of patients being cared for should be considered. (NCSBN, 1995). Different rules for delegation may apply regarding what and how an RN must delegate in home care, long-term care, or in community homes for the developmentally disabled or group boarding homes for assisted living. How Can I Determine The Strengths And Weakness Of Team Members? Often motivated by the fear that a delegate may make a mistake in an assigned task, nurses focus on the potential weakness of their team members. As nurse, we are educated to anticipate the worst so that we can prevent accidents, adverse drug reactions, and negative sequelae to disease processes and treatments alike. Prudent as this approach may be for the safety of all concerned, it is worthwhile to discuss the need to be clear on the strengths of the team members as well. Assigning tasks on the basis of the strengths of the person will allow the individual and the patient to experience the very best care. Now, as a supervising RN, you are in a new position with respect to the long-term performance of delegates. If assistive personnel are assigned only those tasks they are good at, they may not grow in their abilities and skills. This mistake is exemplified by a hospital that had created a new multiskilled patient care assistant (PCA) role with certified nursing assistants (CNAs). These CNAs had been trained to do phlebotomies as well, as authorized by the state board. Phlebotomists had been eliminated but were given the option of training for the new PCA role. When all of the PCAs worked together, the lab tests were drawn by those who had been phlebotomists were off on vacation and

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maternity leave. None of the PCAs who were formerly CNAs had become proficient at this skill! Recognize strengths, and encourage the best patient care possible by using them, but challenge delegates to grow too. The dreaded weaknesses in performance of team members can often be prevented by asking the right questions before delegation. Nurses can be reserved about asking personnel such as float or agency replacement staff about whether they feel comfortable in completing the assignment they have received. Float and temporary personnel tell us that they would prefer being asked about their competency at the beginning of a shift or assignment, with the offer of help and clarification, rather than having to locate an RN to request information. The American Nurses Association (ANA) Code of Ethics states, The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care (ANA, 2001). Be assured that although it is the responsibility of the RN to assess the competency of those they supervise, the delegate must be accountable for accepting the delegation and for his/her own actions in carrying out the task (NCSBN, 1995). The RN who is familiar with the situation, however, must ask the correct questions to determine whether the person is competent. For example, if an RN were planning to ask a nursing assistant to feed a baby with respiratory difficulties, based on the outcome that the baby would be able to ingest 12 ounces of formula this shift, what questions might the RN ask to determine the potential strengths and weaknesses? If the individual has not had experience in this procedure, how could the nurse ensure future competency? In this situation, an RN would certainly ask questions about past experiences with feeding babies with difficulty swallowing. If the delegate assures the RN that she is competent, the RN may go further in asking what the CNA would do if coughing or choking occurred. Depending on the situation, the RN would probably want to demonstrate feeding techniques and observe skills to ensure the competency of the delegate. What Are The Causes Of Performance Weaknesses? Let us take a look at an example of a performance weakness and try to determine what the potential causes may be. In this scenario, you are an RN working as night shift on a hematology-oncology unit, and an agency nursing assistant, Pam, comes to work with you this shift. Pam is excited about the possibilities of interviewing for a regular night shift position and would love to work extra on holidays and weekends. As you begin to discuss her assignment for the night, she states, Oh, I forgot to tell you, I do not ever take patients who are HIV-positive! Ever! There are some potential costs and benefits to your response to this statement. As the charge nurse, you could ignore this statement and continue with your work. You may decide this person has problems, and you may elect to deny her request for an interview. Or you may determine there is something behind her refusal. How you respond may cost you a potentially valuable staff member and could upset the other members of your staff and the patients. Avoiding the problem or accommodating her refusal could become a terrible headache for making assignments and would be contrary to the mission of your organization. Experience has shown that there are several potential causes of performance inadequacies. POTENTIAL SOURCES OF PERFORMANCE WEAKNESSES Unclear expectations Lack of performance feedback Educational needs Need for additional supervision and direction Individual characteristics: past experiences, motivational or personal issues

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One of the most common causes is that the employee is not aware of what is expected of him or her. Does Pam know that at this facility it is part of your policy that everyone takes care of all patients, whether or not they are known to be HIV-positive? Perhaps being aware of this expectation would assist Pam in making her decision about whether to apply for work on this unit. Often being clear about expectations is not enough. Each of us has some blind spots in his or her own performance. Perhaps we think we are doing just fine, meeting performance competencies and beyond, but colleagues have noted that we are not performing procedure according to policy. If these observations are not shared, we will blithely believe we are doing great. Another common cause of performance difficulties is that no one has shared their perceptions of our performance with us. Pam may have adopted this attitude regarding other patients in other work settings, and because of the desperation for help, no one had shared the fact that this behavior falls short of competencies in her job description. Another common origin of performance weakness is an educational need. Does Pam need more education about how HIV infection is transmitted and how it is prevented? Surely she had to complete some content regarding this in her CAN certificate course, but it seems she did not internalize this content. Or is there a personal problem? She may have just witnessed the death of a loved one from AIDS and feel unable to cope with seeing others with this disease for the short term. The amount of supervision needed can be another source of performance problems. As an RN, you must determine the degree of periodic inspection needed by the delegate. Some people require additional direction but are still able to do the job competently. In the absence of that direction, they will be unable to create positive patient outcomes. Nurses tell us they wish that the assistive personnel on their staff would be self-directed and take initiative without being told. We question whether an RNs hope that all will do their jobs without interaction or supervision on his or her part fits with the definition of supervision! Again, as a leader, the RN must determine how much supervision is needed for the individual delegate, just as we determine the degree of observation needed for each patient on the basis of our assessment of their needs. In Pams case, her reluctance to work with patients with HIV may have nothing to do with supervision but may reflect a need for guidance, education, or a frank discussion of expectations. As the RN who is supervising Pam, what steps would you take to determine the cause of Pams performance weakness, the assertion she refused to care for patients with HIV? What question would you ask? How would you respond so that you could continue to use Pams services this s hift, maintain the integrity of your mission, and preserve to use Pams services for hiring a new employee? Matching the right person with the right task is the second step in the circular process of delegation. This process includes planning and articulating priority patient outcomes, assessing the competency of the delegate to perform the task, determining the potential strengths and weakness of the assistive personnel, and planning how much supervision is needed. To ensure that the right task will be done by the right person, additional clarification of expectations, performance feedback, and planning for education needs may be necessary; these steps will promote the long-term success of the team. The right communication will begin that clarification process, bringing us to the next step in the four rights of delegation. The RIGHT COMMUNICATION How Can I Get The Delegate To Understand And What I Want? No matter what, it always comes back to communication. How clear you make your initial direction will be the cornerstone in determining the success of your delegated task and, ultimately, the performance of your team. The bottom line, whether the patient outcome was achieved, hinges on your ability to give initial direction that clearly defines your expectations of the delegate in performing the assigned task. It is not surprising that this is a step that is often done poorly or left out entirely because the assumption is made that the individual knows what the job is and should just do it.

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The first component of supervision, according to its definition, is the provision of initial direction. Achieving a balance in which we provide enough information for the person to understand the request without overstating the case and risking confusion or condescension requires that we tread a fine line. The use of the four Cs of initial direction will help you to plan your communication The FOUR Cs of INITIAL DIRECTION CLEAR: Does the team members understand what I am saying? CONCISE: Have I confused the direction by giving too much unnecessary information? CORRECT: Is the direction according to policy, procedure, job description, and the law? COMPLETE: Does the delegate have all the information necessary to complete the task?

Situation: Let us assume that you are working in a home health agency and you are planning the care for a patient with congestive heart failure. You have made your initial visit, assessing the patient and planning the outcomes you and the team will work toward in the next 3 weeks. Your patient is taking diuretics and antihypertensives, in addition to potassium supplements and being on a restricted diet. She is frequently short of breath and requires an assistant three times/week for hygienic care. In addition to providing hygienic care, you would like that assistant to monitor BP on the days you are not making a visit and to notify you if the BP is outside of the range of 120 to 170 systolic and 50 and 90 diastolic. Using the four Cs listed, you can evaluate your communication. Mrs. Jones has a heart condition and high BP that requires medication and constant monitoring. One of our goals is to help Mrs. Jones have a stable BP, in a range that isnormal for her. On the days that you are visiting and giving the patient her bath, I would also like you to take her BP. If it is outside the range of 120 to 170 systolic and 50 to 90 diastolic, I would like you to let me know. We may need to adjust her medication, change her diet, or call her physician for different orders. Clear: Does the home health aide understand what is being asked of her? This direction is fairly straightforward: an easily understood instruction of taking the blood pressure. Concise: Have you confused the assistant by giving too much information? Or is it enough for her to complete the task? Only the assistant can help you with this determination. You will need to ask directly, Am I confusing you, or do you have enough information to do the job? Every individual has different needs. However, you will want to make certain to check this out; some people will not be honest or accurate in their assessments of their understanding or abilities, leading to trouble later. Many of us are reluctant to ask questions, being afraid to admit our need for additional information. (We do not want to look like we do not know what we are doing!) This reluctance can ultimately result in harm to the patient because assumptions are made that the direction was understood when, in fact, it was not. Correct: Can a home health aide monitor BP? Where would you look for additional information if you were not sure? Complete: Does the assistant have enough information to fulfill your expectations? Once again, you will need to ask the delegate for clarification of his or her understanding of what you are asking. If you expect this assistant to also note the respirations and alert you to increased effort of breathing, have you shared that in your initial direction? Or did you assume she would naturally observe all vital signs because you alerted her to the patients condition ( and besides, she is a good assistant)? In our attempts not to appear condescending ( I do not want to insult this assistant by reminding her to note

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the respirations she might think I do not trust her to think!), we may often choose not to be as complete as we should be in giving initial direction. Another common pitfall is the rationale that comes from working with someone over a period of time. A working relationship develops, and a routine or pattern of performance is established. When this happens, we start talking less and less to the other individual, believing that she knows what I expect her to do. Consider the following situation: You are working on a surgical unit in a partnership with Sam, an LPN you have been working with for the past year. Your easygoing style had led to a comfortable reliance on each other and the feeling that each knows what other expects. On this particular evening shift, you are traveling down the hall, intent on medicating one of your patients. You also see a post anesthesia care unit (PACU) nurse bring one of your patients back to surgery. Seeing Sam coming your way, you state, Sam, the post-op is back in room 103. Evaluate your initial direction. Did you believe that Sam just knew you wanted him to check on the patient, get the first set of vital signs, position the patient, check the dressing and the drains, and note the status of the intravenous tube? Thirty minutes later, you are standing at the nurses station, noting an order. Sam is charting. You ask him, Sam, hows the patient in room 103 doing? Expecting a brief report, you are surprised when Sam says, I dont know. I thought you were going to take him. What went wrong? No matter how long you have been working with someone, the right communication is essential to ensure the success teamwork. Sam did not accept the delegated task ( remember what the delegate is accountable for?) because he did not understand what you meant. Be sure that you check the delegates understanding of what you are saying. Failing to do this may result in unmet expectations, which lead to anger and frustration. More importantly, the patient will not receive the optimal care that both of you want to provide. You have carefully assessed the patient, determined your plan on the basis of outcomes, and selected the right task to delegate to the right person. You have even given clear initial direction as part of the right communication. Now what? The final right of delegation is also a part of supervision: the periodic inspection of the actual act. Read on as we continue with a discussion of the right feedback. THE RIGHT FEEDBACK How Can I Effectively Give And Receive Feedback? Many nurses have shared their discomfort with giving and receiving feedback from co-workers. Few of us enjoy telling co-workers how they are doing or hearing about how we may have missed the mark! When supervising others, it is absolutely necessary to give feedback during your periodic inspection. By following a formula for giving and receiving feedback and practicing it daily, RNs are assisted in the difficult job of correcting the performance of others. The reciprocal feedback process also permits you, as supervising RN, to hear how your own supervisory performance and communication affected the outcomes of the team.

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FEEDBACK FORMULA Ask for the other individuals input first! Give credit for effort. Share your perceptions with each other. Explore differing points of view, focusing on shared outcomes. Ask for the other individuals input to determine what steps may be necessary to make certain desired outcomes are achieved. Agree on a plan for the future, including timeline for follow up. Revisit the plan and results achieved.
Modified from Hansen R, Jackson M: Clinical delegation skills: a handbook for nurses, ed 3, Sudbury, Mass 2004, Jones & Bartlett.

Lets look at how this process can be used in a situation in which positive feedback is intended. An RN (Pat) is working with a float RN ( Julia) for the first time. Julia is new in the pool but is an experience nurse. Pat is so pleased with Julias experience and performance that she has gone off to have a nice break and lunch with an old friend from the third floor. She has also taken time to meet with a colleague from the evening shift regarding a unit problem. Unfortunately, she has not been present on the unit much today. When Pat is having lunch with her friend, she exclaims, That new float Julia is just excellent! If it werent for her, I couldnt be here having lunch with you. I hope that she knows how organized and valuable she is! Her friend, Alex, states, Well, you know you should tell her, not just me, about this. When Pat returns to the floor, flushed with good intentions of making Julias day with effusive praise, she tells Julia about how lucky she has been to work with her today. Because all of us crave positive feedback, and Julia is new to your organization, will Julia tell Pat that shes been trying to find her for hours? Probably not. But she may tell others that Pat is one of those dump and run nurses. I dont want to work on that floor again! What if Pat asked first, How have things been going for you today, Julia? I know this is your first day on the unit. Julia may have determined it was possible ( and expected) to give reciprocal feedback: Ive have been trying to find you! I have completed everything, but it hasnt been easy. Where have you been? The best intentions can be destroyed by not asking the other individual for input first. If you plan to give some negative feedback to an individual, you will also need to ask for her/his input first. For example: You have just noted that the night shift CAN did not chart the intakes and outputs (I & Os) on three patients on your telemetry unit. You have called him and are thinking about how o discuss this with him in a positive manner, yet you know that he is not going to want to chat because it is about time for him to get some rest. If you said, Why didnt you put the I & Os on the charts!? the CAN would react defensively. If you state, How was your night? I noted that the I & Os are not on the charts, you have allowed the person to respond with what happened. If this CAN went home early with the flu or the unit experienced three codes, it would not be an effective or popular action to pounce on the team member for missing data. This brings us to the next step in the process giving credit for what has been accomplished. Let us turn to Pat and Julia. At this point, Julias input has been received. Pat can state, Well, I can see I did not help you as much as I should have and I forgot to give you my beeper number. But I do want you to know that Ive checked on all of our patients, and they are very happy with their care today.

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After hearing input and giving credit where it is due, exploration of the gaps in the relationships and their communication and initial direction at the beginning of the shift can now be undertaken with open and frank discussion. The discussion of differences will progress most smoothly if each party recognizes that they share common objectives: safe, effective care of the patients on their unit, as reflected in the fulfillment of shared, planned outcomes or goals determined by collaborative discussion among patients and care team members. When difficulties or conflicts occur, remember the reason you are both there: the patients. Julia and Pat may clarify what happened and what actions each may take to ensure that the missed communication does not happen again in the future. Do not try to fix the situation for the other individual or prescribe what you will do for them. The other individual will know what he or she needs to do to achieve your shared outcomes. For example, Pat may have decided that what would fix it for Julia would be to convene an hour before shift tomorrow and go through the unit manuals and read procedures. However, the most Julia may need is a beeper number and some more discussion and planning about assignments at the beginning of the shift. Why wait for the other individual to come up with ideas when we can solve it for them? RNs who lead teams throughout the nation tell us that their work lives would be much better if everyone were behaving in an accountable manner. When we ask others for their step-by-step plan to prevent the problem in the future, it helps them determine that they are accountable for their own performance. In our scene with the missing I & O data, the RN will ask, How can you make sure those I & Os are charted before you leave in the future? What will work for you? This type of statement confess the necessary respect for the delegates ability to determine how to adapt his work performance. Do not miss the final steps in the formula. The individuals must agree on how they will proceed in the future and when they will revisit the problem or issue again. Julia may determine that shell remind Pat in the future when she gets to the unit that she will need her beeper number and a plan for the day. When the next shift is completed, they will want to compare notes about how the shift has proceeded and whether patient outcomes have been achieved. The CAN may decide to ask the RN next week whether she has noted any missing I & Os. The pair will be able to evaluate whether the CNAs charting plan has been effective and can proceed to celebrate the success of the plan or to try other interventions.
ASSESSING YOUR DELEGATION SKILLS Assemble these documents: Your state nurse practice act Your job description and those co-workers and delegates Skills checklists The patient list or assignment form from your unit A list of the usual staffing complement for your shift 1. Using the above, determine the short-term outcomes for an average patient assignment based on the information you have been given in a report. What tasks could be delegated to the individuals you have on staff? When will you complete further assessment of the patient situations? 2. Based on the outcomes and job descriptions, how will you determine the competency of individuals to complete the tasks you have determined could be delegated? 3. How will you communicate the teams plan using outcomes in your discussion? 4. How often will you communicate with the delegates, based on their need for supervision and patient complexity and dynamics? Have you used the four Cs? 5. How will you evaluate the effectiveness of your plan? How will you give positive feedback to the team? 6. A mistake was made by a delegate. You determined the person was competent, but the procedure was done improperly. For what are your accountable? How will you give feedback to the individual, encouraging his or her growth and accountability? 7. Have you implemented the Four Rights of Delegation?

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Practice using the feedback formula. Remember the following three most important points: Ask for the other persons input first. Give credit for the accomplishments and efforts. Ask the other individuals to come up with steps for resolving the issue. How would you use this formula to tell a supervisor that you are concerned about how long it has been since you have heard about your intershift transfer and you are getting worried about whether it will take place? How would you give positive feedback to an individual on your team who has been improving his ability to get out on time? What about a delegate who is missing in action, the person you cannot seem to locate when you need her?
Barriers to Effective Delegation A. Internal Barriers (person delegating): 1.Lack of experience delegating 2.Lack of confidence in others 3.Personal insecurity 4.Demanding perfectionism 5.Poor organizational skills 6.Indecision 7.Poor communication skills 8.Lack of confidence in self 9.Fear of not being liked by everyone 10.Micromanaging management style B. External barriers ( circumstances or person being delegated to): 1.Unclear policies about delegation 2.Policies that do not tolerate mistakes 3.Management-by-crisis model for facility 4.Unclear delineation of authority and responsibilities 5.Poor staffing 6.Lack of competence 7.Overdependence on the person delegating 8.Unwillingness to accept responsibility for ones own practice 9.Immersion in trivia and gossip 10.Work overload
Sources: Fisher, M: do you have delegation savvy? Nursing 2000 (9): 58-59, 2000 Tappen, RM: Nursing Leadership and Management, ed. 4. FA Davis, Philadelphia, 2001heeler, J: How to delegate your way to a better working life. Nursing Times 97 (36):34-35, 2001

As a leader: What Cannot Be Delegated? o Overall responsibility, authority, accountability o Authority to sign ones name is never delegated o Evaluating the Staff/or taking necessary corrective/ disciplinary action o Responsibility for maintaining morale/encouragement of staff o Too technical jobs and those that involves trust and confidence Conclusion We often hope for an exact prescription for what to delegate, when and how. Because nursing assessment and professional judgment are necessary for clinical delegation, each situation will be different. Whether you work in an intensive care unit in a large tertiary hospital or a rural long-term care facility, the template of the delegation process matching the right task with the right delegate, communicating effectively, and offering and receiving feedback will be similar.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 6: Please write the letter of your choice in the space before the number. ___1. It is getting the work done through subordinates. a. Supervision b. Delegating c. Coordination

d. Motivating

___2. It is designating a competent individual the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients. a. Supervision b. Delegating c. Coordination d. Delegation ___3. They are considered professionals with state-sanctioned licenses governed by a nurse practice act. a. BSN b. RN c. Staff Nurses d. Graduate Nurses ___4. This means, being answerable for what one has done, & standing behind that decision &/or action:. a. Responsibility b. Liability c. Accountability d. Answerable ___5. The determination of what needs to be done & then the assessment if the task can be delegated to someone. a. Right Feedback c. Right Task b. Right Circumstance d. Right Assignment ___ 6. The first source of information to know of what can and what cannot be delegated to someone. a. Policies b. Law c. Job description d. Operating Guidelines ___7. This refers to appropriate client setting, available resources, and consideration of other relevant factors. a. Right Feedback c. Right Task b. Right Circumstance d. Right Assignment ___8. The RN who is familiar with the situation must ask the correct questions to determine whether the person is____________. a. Committed b. Excellent c. Efficient d. Competent

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PATTERNS OF NURSING CARE DELIVERY (Modalities of Nursing Care, Systems of Nursing Care, Care Delivery Models) Every patient needs a nurse.
American Nurses Association

What Are The Effects Of Various Patterns Of Nursing Care Delivery? Over the years, nursing care has been delivered in many ways, including total patient (private duty model), functional, team, primary, and relationshipbased care. TOTAL PATIENT CARE OR PRIVATE DUTY MODEL Originally nursing was organized around the total patient care or private duty model. Registered nurses were hired by the patient and provided care to one patient, typically in their home. This approach was used in which one nurse assumes responsibilities for the complete are of the a group of patients on a 1:1 basis, providing total patient care during the shift. The quality of care in the total patient care model is Evolving patterns of nursing care delivery. considered to be high, because all activities are carried out by RNs, who can focus their complete attention on one patient. This model is efficient because it (1) decreases communication time between staff caring for a patient, (2) reduces the need for supervision, and (3) allows one person to perform more than one task simultaneously. Patient satisfaction tends to be high with this model if continuity of care and communication are maintained among nurses. FUNCTIONAL NURSING The movement to use RN as employees of hospitals came with the outbreak of World War II. RNs took over the work in the hospital and that, coupled with the war effort, stimulated the nursing shortage of that period. This forced hospitals to develop alternative models of nursing. The positions of aides and licensed vocational/practical nurses came into being, and in some states, they allowed to perform functions such as administration of medications and treatments. This functional kind of nursing, which broke nursing into a series of tasks performed by many people, resulted in a fragmented, impersonal kind of care.

Lines of Authority: Functional nursing

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Fragmentation of care caused patient problems to be overlooked, because they did not fit into a defined assignment. This assembly- line approach provided little time for the nurse to address psychosocial or spiritual needs. They cite a number of studies, which found that errors and omissions increased when functional nursing was used. This approach would seem to be cost efficient, because it can be implemented with fewer RNs. However, there are studies that suggest that the functional method in fact, costs more than primary nursing care. In addition, patients, nurses, and physicians have been critical of this approach because of the fragmentation and the lack of accountability for the total patient. TEAM NURSING In the 1950s, team nursing evolved as a way to address the problems with the functional approach. In this type of nursing, groups of patients were assigned to a tram headed by a tram leader, usually an RN, who coordinated the care for a designated group of patients. ( see figure below). The team leader determines work assignments for the team on the basis of the acuity level of the group of patients and the ability of the individual team members. The following is an example of the components of a team: An RN who is the team leader Two licensed vocational nurses/practical nurses assigned to patient care Two unlicensed assistive personnel (UAP)

Lines of authority: team nursing The success of team nursing centers on good communication among the team members. It is imperative that the team leader continuously evaluates and communicates changes in the patients condition to the team members. The team conference is a vital part of this approach, allowing the tram to assess the needs of their patients and revise their individual plans of care on an ongoing basis. The team model allows the nurse to know patients well enough to make assignments that best match patient needs with staff strengths. Patient needs are coordinated, and continuity of care may improve, depending on the length of time and each member stays on the team. However, care can be fragmented and the model ineffective when staff is limited. In addition, the amount of time required to communicate among team members may decrease productivity. PRIMARY NURSING In this system, a nurse plans and directs the care of a patient over a 24-hour period. This approach is designed to reduce or eliminate the fragmentation of care between shifts and nurses, because one nurse is accountable for planning the care of the patient around the clock. Progress reports, referrals, and

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discharge planning are usually the responsibility of the primary nurse. When the primary nurse is off duty, an associate nurse continues the plan of care. An RN maybe the primary caregiver for some of the assigned patients and an associate nurse to others. Some forms of primary nursing evolved into an all-RN staff (see figure below).

Lines of authority: Primary-care nursing You may also find primary nursing being mixed and modified with nurse extenders, such as paired partners, or partners in care. Although team nursing took the RN away from bedside care, primary and modified primary care puts the nurse back in close contact with the patient. Relationship-based practice is the new name for primary nursing. The RN, who may be called the care coordinator, the responsible nurse, the principal responsible nurse, the case manager, or the care manager, manages and coordinates patients care in the hospital and the discharge plan. This nurse develops a relationship and can be identified by the patient, their families, and the health care team as having the responsibility and authority for planning the nursing care the patient is to receive. PATIENT-FOCUSED CARE This is another delivery system that has evolved during the last 15 years. In this system, the patient comes into contact with fewer people, and the RN, who is familiar with the patients plan of care, supervises the delivery of care. This model also moves RNs to a higher level of functioning, because they are now accountable for a fuller range of services for the patient. Tasks that do not require an RN can be delegated to UAP under the supervision of the RN. What is the Most Effective Model of Nursing Care? There has been a great deal of literature about models of care delivery. However, there is lack of systematic evaluation regarding the use of the various models, often because of the lack of similarity in staffing and patient populations on comparison units. As a result, it is impossible to determine the impact models of nursing care have on patient outcomes, costs, or job satisfaction. It may be that model of nursing care delivery is less important than the other factors, including the nurse-to-patient ratios, use of overtime, and the organizational structure in which the nurse works, in influencing outcomes. ? Critical Thinking ?: What factors influence the patterns of nursing care delivery? In todays health care system, nurse managers continue to follow the trend of moving away from the close supervision of the staff nurses work to a role of helping them complete their work safely and effectively. As this role continue to evolve, the emphasis to highly supportive functions as are seen in the leadership role.

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Comparison of Common Client Care Models Model Nurses Are Called Charge Nurse Medical Nurse Treatment Nurse Team Leader Team member Description Where Model is Used Hospitals Nursing Homes Nursing Consultants Operating Rooms Hospitals Nursing Homes Home care Hospice Hospitals Specialty units Dialysis Home Care Hospitals Home health care Transport team

Functional

Nurses are assigned to specific tasks rather than specific clients Nursing staff members are divided into small groups responsible for the total care of a given number of clients Nurses are designated either as the primary nurse responsible for clients care or as the associate nurse who assists in carrying out the care. Nurses are paired with other lesstrained caregivers. Generally involves cross training of personnel.

Team

Primary Care

Primary nurse Associate nurse

Modular

Care Pair

What is the Impact of Staffing Patterns on the Quality of Care? In 2004, the AHRQ released a report that summarized the latest findings of AHRQ funded and other research on the relationship between nurse staffing levels and adverse patient outcomes. This report concluded that: Lower levels of hospital nurse staffing are associated with more adverse outcomes. Patients in hospitals today are more acutely ill than in the past, but the skill levels of the nursing staff have declined. Higher acuity patients have added responsibilities that have increased the nurse workload. Avoidable adverse outcomes, such as pneumonia, can raise treatment costs by up to $28,000. Hiring more RNs does not decrease profit Higher levels of nurse staffing could have positive impact on both quality of care and nurse satisfaction The largest of these studies found significant associations between too few nurse on a unit and higher rates of pneumonia, upper gastrointestinal bleeding, shock/cardiac arrest, urinary tract infections, and failure to rescue. Other studies in the review found associations between lower staffing levels and pneumonia, lung collapse, falls, pressure ulcers, thrombosis after major survey, pulmonary compromise after surgery, longer hospital stays, and 30-day mortalities. JCAHO data confirm the effect of insufficient staffing on the outcomes of nursing care. As of September 2004, insufficient staffing levels were listed as a cause in 64% of the sentinel vents that were entered into the JCAHO database. Sentinel events are any unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. Serious injuries specifically include a loss of limb or function. The phrase risk thereof includes any variation in the process of care for which a recurrence would carry a significant chance of a serious adverse outcome.

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Determination of the number of nursing staff needed relative to the number and acuity of patients on a unit is the challenge of staffing. In the past 20 years, patient classification systems (acuity systems) have been used to determine the number of nurses needed on a unit at any one time. Patient acuity is the measure of a patients need for nursing care in a 24-hour period, considering the extent of each patients illness. Patient classification systems, particularly with increased computerization and the ability to access the system online, provide many benefits. Not only do they determine acuity (patient mix) and workload for patient care units or specific clinical populations, they also (1) help managers determine how and where staff spend time; (2) identify trends in patient population; (3) document staffing patterns and workload and care practices; (4) effectively allocate limited resources; and (5) benchmark units to support financial decisions. How Are Nursing Work Assignments Determined? Once appropriate staffing levels for a unit are determined, specific nurse must be scheduled. How work assignments are given vary with individual institutions. A major problem in scheduling nurses is the fact that patient acuity fluctuates dramatically from day to day and from season to season. For example, over the Christmas holidays there is often a significant decrease in the number of elective surgeries. In response, some hospitals may close units or reduce the number of staff on any given unit. By contrasts, in the middle of the influenza season, the hospital unit might be full and understaffed. Nursing has tried a variety of approaches to anticipate the number and qualifications of nurses that will be needed for a specific period of time for a specific group of patients. Regulatory agencies as JCAHO require staffing be based on some sort of organized system. Staffing in organizations may be based on budgeted nursing hours per day. Hours per patient per day are calculated by the number of patient care staff working during a 24-hour period and divided by the number of patients served in a day. Whether nursing resource requirements are defined by nursing hours per patient days or as nursepatient ratios, the underlying assumption is that all patients, patient days, and nursing staff are equal. However, the need for nursing care varies significantly among patients and over the length of each patients stay in the hospital. As the intensity of patient care increases and length of stay decreases, hours per patient day or nurse-patient ratio may not adequately express the resources needed. The competencies of the staff also influence the numbers and types of staff needed. The most accurate way of determining optimal staffing is through the judgment of an experienced nurse who is knowledgeable about quality and fiscal management. There were two approaches to document that the organization has a minimum number of nurses to ensure safety in any given acute care unit: (1) establishment of a hospital-specific written staffing plan, which typically uses computerized patient acuity systems as a basis and (2) identifying and mandating fixed staffing ratios. A written plan should include the following factors: Establishing initial staffing levels that are recalculated at least annually or more often as necessary Setting staffing levels on a unit by unit basis Identifying ways to adjust staffing levels from shift to shift, based on intensity of patient care Using outcomes and nurse-sensitive indicators to evaluate the adequacy of the plan

Written staffing plans should be developed by an advisory committee composed of a number of registered nurses, a significant portion of whom are involved in direct patient care at least part of the time.

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WHAT ABOUT SCHEDULING PATTERNS? Nursing also always been concerned about scheduling practices and options because in many health care environments, nursing care must be provided 24 hours a day, 365 days per year. That is why there are numerous scheduling patterns other than the typical 8-hour shift 5 days a week. From working 10 hour days 4 days a week to the weekend alternative (known as the Baylor plan) of two 12-hour weekend shifts for 36 hours of pay, nurses have tried numerous patterns and combinations of shifts. WHAT ABOUT THE USE OF OVERTIME? With the current shortage of health professionals, employees are also encouraged and sometimes required to work overtime. According to the National Sleep Foundation (NSF), a deficit of sleep can result in decreased alertness, problems with completing tasks, reduced concentration, irritability, and unsafe action and decision making. These problems known as the fatigue factor have an impact on the care delivered by health care providers. Lack of sleep can also result in slower response times, altered mood and motivation, and reduced morale and initiative. The review of sleep studies in nurses found that self-reported alertness, performance, and job satisfaction lessen with longer shifts. The risk for making an error greatly increased when nurses had to work shifts that were longer than 12 hours, when they worked significant overtime, or when they worked more than 40 hours per week. The likelihood of making an error was three times greater when nurses worked that lasted 12.5 hours. Working overtime also increased the odds of making at least one error, regardless of how long the shift was originally scheduled. JCAHO has recognized problems associated with overtime, and in the 2002 white paper on the nursing shortage, stated that mandatory overtime should only be used in emergency situations. 2. UTILIZING / REVISING/ UPDATING NURSING SERVICE POLICIES AND PROCEDURES 3. SUPERVISION to inspect, guide, evaluate, improve work performance of employees Managers at different levels of institutional hierarchy are referred to in different terms:

Top
Middle First Line Operating Level

----------- Administrator ----------- Supervisors ----------- Head Nurses/ Senior Nurses ----------- Staff Nurses/ Nursing Attendant

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 7: Please write the letter of your choice in the space before the number ___1. An approach used in which one nurse assumes responsibilities for the complete care of the group of patients on a 1:1 basis. a. Functional nursing c. Modular nursing b. Primary Nursing d. Total Patient Care or Private Duty Model ___2. Approach designed to reduce or eliminate the fragmentation of care between shifts and nurses, because one nurse is accountable for planning the care of the patient around the clock. a. Functional nursing c. Modular nursing b. Primary Nursing d. Total Patient Care or Private Duty Model ___3. It is broke nursing into a series to tasks performed by many people, resulted in a fragmented, impersonal kind of care. a. Functional nursing c. Modular nursing b. Primary Nursing d. Total Patient Care or Private Duty Model ___4. The new name for primary nursing. a. Relationship-based practice b. Patient-focused care

c. Primary nursing d. Private Duty Model

___5. _____ in organizations may be based on budgeted nursing hours per day. a. Scheduling b. Staffing c. Development d. Vacancy ___6. It is calculated by the number of patient care staff working during 24-hour period and divided by the number of patients served in a day. a. Nursing time needs c. Hours per patient per day b. Nursing care d. Staffing and scheduling ___7. The _____ of the staff also influence the numbers & types of staff needed. a. Education preparation c. Areas of assignment b. Years of work experience d. Competencies ___8. This can result in decreased alertness, problems with completing tasks, reduced concentration, irritability, and unsafe action and decision making. a. Drug use b. Smoking c. Caffeine intake d. Deficit of sleep ___9. An element of directing that inspects, guide, evaluate, improve work performance of employees. a. Communication b. Delegation c. Supervision d. Coordination ___10. The risk for making an error greatly increased when nurses had to work shifts that were longer than _____ hours, when they worked significantly overtime, or when they worked more than ___ hours per week. a. 8, 72 b. 12, 40 c. 12, 72 d. 8, 40

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4. COMMUNICATION - the transmission of information, opinions, and intentions between and among individuals. - It binds the organization together to ensure common under-standing Purposes: * facilitate work * increase motivation * effect change * optimize care * increase worker satisfaction and facilitate coordination Lines of Communication Downward from superior to the subordinate which may pass through various levels. e.g policies, rules and regulations, memos, handbooks, interviews, job descriptions, and performance appraisal Upward emanates from subordinates to superior, usually in the form of feedback and does not flow as easily as downward communication. e.g. discussions between subordinates and superiors, grievance procedures written reports, incident reports and statistical reports. Horizontal or lateral flows from between peers, personnel or departments on the same level. e.g. endorsements, between shifts, nursing rounds, journal meetings and conferences, or referrals between departments or services Outward deals with information that flows from the care-givers to the patients, his family, relative, visitors and the community. e.g. information about the nature of their illness, medical and nursing plans of care Communication can be enhanced by carefully choosing the words or information you wish to convey, by creating an environment that promotes its acceptance, by avoiding preconceived opinions and biases about a person, by listening to and understanding the other persons point of view and by being open and supportive. Most people learn to communicate through example. Nurse managers should promote a responsive communication climate in their units. EFFECTIVE COMMUNICATION AND TEAM BUILDING To effectively communicate, we must realize that we are all different in the way we perceive the world and us this understanding as a guide to our communication with others. - Anthony Robbins If you can laugh together; you can work together. - Robert Orben Communication is like breathing we do it all the time, and the better we do it the better we feel. At times communication can be so subtle; others are not able to comprehend the sender. Communication between people in everyday life is an exercise in subtleties and interpretations. The more personal the information, the more indirect and obscure the messages becomes. In nursing, indirect communications and obscure terminology can be the difference between life and death. When you say, I want to be clear when I communicate to others, it is not different from washing windows. The clearer the window, the better we see. Communicating what we see, what needs to be done, and teaching a client what they need to know is part of the foundation of nursing care.

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THE COMMUNICATION PROCESS What Are the parts of the Communication Process? Communication begins with a person who creates a message on the basis of his or her own perception of a situation. This person is the sender, who transmits the message using words, actions, body language, tone of voice, and facial expression. The message goes to a receiver , who has to interpret and evaluate the message, including all the words and the signals. When the receiver sends a message back to the sender to let the sender know what to he or she heard or saw, that is called feedback. So communication is basically the giving and receiving of information that involves responding with meaning. Much of the skill involved in effective communication involves how clear the message is. The actual words that are used are known as the messages content. Sometimes the words are very clear and the message is easily understood. But at other times, the words might mean different things to different people. The way in which the words are said may also change how they are interpreted.
Different Ways Information can be Interpreted TRY THIS 1. How many different ways can you communicate this sentence to change its meaning? I do not care how youve done that procedure before; do it my way now. 2. When the instructor says to you: Come to my office at 2:00. Theres something I want to talk to you about. What are some of the possible interpretations of the message? 3. When a patients spouse says to you: I do not need your help when we go home. How many possible explanations can you come up with regarding the meaning of the communication?

We all know that spoken words make up what we call verbal communication. When we
include body movements, facial expressions, and tone of voice, we are adding the nonverbal communication components that make up nearly 90% of the message. An angry voice and crossed arms can change a friendly, supportive message to a hostile and critical one. The way we choose to communicate is known as process. The process may clarify the message or confuse the receiver. Consider the following one-pact play as an example: Scene # 1 Susan has been working on a very busy surgical unit for 6 weeks since she graduated from nursing school. She is approached by the dietitian, who says to her, I was so relieved when I got to the unit and saw that you had already requested a dietary modification for Mr. Smith following his surgery. Imagine that; I didnt even have to tell you to do it. Scene # 2 Susan: Can you believe the arrogance of that dietitian? Just because shes been here forever and Im new, does that give her the right to treat me like Im a stupid third-grader? Nancy (another recent graduate): How do you know thats what she meant? Susan: I could just tell by the frustration in her voice and how she moved away from me so quickly. It was as if she couldnt stand to talk to me anymore,

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Scene # 3 Dietitian: Susan, I wanted to thank you again for your initiative yesterday with Mr. smith. I was having a particularly stressful day, and the thought of having to do one more task just seemed to overwhelm me. You really helped me out. Susan: Im glad you said something about it. I wasnt sure what you meant then, and I feel much better. Huber ( 2000) suggests several reasons why communication fails to be effective that can be applied to our one-act play. Nonverbal signals may mean different things to different people and can easily be misinterpreted; so can the words we use. In addition, if we are short of time, it is hard to hear clearly and remember pieces of important information. Finally, the personalities of the sender and the receiver may create a bias or distortion of the message. What Are The Basic Principles Of Effective Communication? Here are some suggestions for improving our communication with others. 1. Communication is a process involving interaction between at least two people. Merely giving information is not communication unless the opportunity for a response is given. 2. The sender has a responsibility to make the message as clear as possible. You can verify what has been received by asking Would you share with me how you interpreted what I just said? 3. Whenever possible, use the simplest, most precise words you can. Your words must be understood by the listener. 4. Encourage the receiver of your message to provide feedback so you can verify that the message has been interpreted in the way it was intended. The receiver might say so, what youre saying is. Or Let me make sure I understand you.. 5. Remember that nonverbal behavior communicates a message even when words are not used. Try to match your nonverbal behaviors to the feeling or tone of the message you want to send to others. 6. Your reputation and credibility will make easier for you to communicate during difficult situations. When you are trustworthy, reliable, and competent, people will listen more carefully and be more likely to interpret your messages in a positive way. 7. Because communication is an interactive process, it is much more successful within the context of a sound relationship. To create and maintain that positive relationship with others, you need to acknowledge the needs, feelings, and contributions of others. This helps create a climate more open to communication. 8. Whenever possible, communicate directly with the person you want to receive your message. This allows for immediate feedback and verification and can reduce the chances of misunderstanding. 9. Concentrate on the communication happening in the present. Avoid the temptation to daydream or plan ahead what you might say or do next. 10. Be aware of your personal values and biases, and try to keep them from interfering with your ability to communicate. 11. When you are caring for a patient in his or her home, be especially respectfully of the personal nature of the surroundings.

69 What Does My Image Communicate To Others?

Remember that old saying Do not judge a book by its cover? Unfortunately, we know that most people do not follow that suggestion. People get impressions about us from the way we look, sound, talk, and act. Often we are less careful about the messages we send with our appearance and behavior than we are when we choose our words. But our image may speak louder than our words. Think about it. Would you feel comfortable accepting nutrition advice from a 300-pound nurse? How would you like it if your instructor criticized your professionalism while wearing dirty shoes, a wrinkled uniform, bright red nail polish, and four earrings in each earlobe? What would you think about a physician whose progress notes contain man misspelled words and poor grammar? Communication is enhanced by your credibility. And people listen more to people they respect. Your image will help you communicate your professional credibility. The place to start projecting a positive image is with the first impression your appearances creates ( Vengel, 2000). Good personal hygiene is a must. Each day you must pay attention to your grooming. This means a flattering, neat haircut; clean, well-fitting clothes; reasonable makeup and perfume; minimal jewelry; and clean, sensible shoes. Your image is improved greatly if your weight is appropriate for your height and bone structure. Your appearance at work should conform to the norms for professionals in your work setting; save your individuality for your personal time away from work. Another aspect of your image is your depth and breadth of knowledge. You need to know your particular area of nursing thoroughly if you want the respect of others. However, you also need to know something about a wide variety of subjects so that you can have conversations with people beyond nursing. This means keeping up with current events, learning things about art or sports, and reading books. When people discover common interests, they are more willing to communicate with you. Flexibility is necessary for effective communication with different kinds of people. This means that you are willing and able to adapt your behavior to relate more comfortably or effectively with others. Flexibility is part of a positive image because it says to people that you are willing to accept responsibility for changing your behavior to meet the professional needs or requirements of others. People who achieve success in their professional careers are enthusiastic. They let others know they are happy to be at work. They work harder, longer, and more accurately. They are pleasant to be around. They are sincere in their efforts to create a professional image that can be trusted. Take an inventory of your appearance, knowledge, and attitude. If you are not sure what kind of image you are communicating, ask several trusted friends. What Are Facilitative Messages? Two types of messages: facilitative and obstructive. Facilitative messages create a positive outcome in which the people communicating with each other feel good about their interaction. It takes self-awareness and practice to send facilitative messages, but it is worth it. Your relationships with other health care workers will be satisfying and, ultimately, the patients you care for will benefit. Strayhorn (1977, p. 7) summarizes the benefits of learning to use facilitative messages: If I can avoid antagonizing the other person, make my wishes known, find out the other persons wishes, explore various options, and make decisions accordingly, then I am much better equipped to bring happiness to others and to allow them to bring happiness to me.

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Facilitative Messages Type Definition 1.I want statement Asks for a specific behavior Shares your feeling in response to the other persons specific behavior Indicates your pleasure or displeasure with a specific behavior Tells the other person what you think you heard so he or she can verify or deny your interpretation Indicates general area of interest, but leaves specifics to other person Refuses to argue by agreeing or sympathizing with some part of the others statement Allows you to ask what behaviors the critic didnt like, what behavior he or she would like in the future Names specific behaviors and events and describes them without drawing conclusions about meaning Asks the other persons reaction to what you have just said

2.I feel statement

Example I want you to let me practice this skill by myself and then check me in 3 days. I felt irritated jus then when you told me to clean the nurses station. I like it when you told me I did a good job with that patient. Sounds like that really upset you. Tell me your reactions to the new medication cart.

Effect Simplest way to communicate what you want within a relationship. Allows you to get in touch with and share your feelings in a way undistorted by assumptions Helps define what would make you happier; positive reinforcement most effective in changing anothers behavior. Helps increase listening skills, reduces distorted messages, acknowledges feelings. Offers attention and encourages communication to begin.

3.I like and I do not like statements

4.Reflection

5.Open-ended statement

6. Agreeing with part of a criticism or argument

7. Asking for more specific criticism

The head nurse has just said to you, You do not have any sense. You say, Its true that I could be smarter than I am. The patients family says, Youre doing that all wrong. You reply, what would you like me to be doing instead? I noticed during the meeting that you werent saying much, werent smiling. Im wondering what was going on? Im interested in how you react to that idea. Youve really grown in your ability to handle complex situations. That was good. I intend to be more careful about my charting. Im feeling hurt and angry right now and would like some time to think before we talk more

Avoids wasting time arguing; allows you to remember that you do not have to be perfect; focuses energy on negotiation of wants Turns an argument into an opportunity for productive negotiation; keeps anger at a minimum Allows the other person to hear about his or her behavior and clarify what specific behaviors mean; reduces misperception

8. Citing specific behaviors and observations

9. Asking for feedback 10.You are good, You did something good, your something is good statement 11.I intend statement

Conveys something was worthwhile

Allows the sender to be sure the message was received as it was intended; allows further clarification Draws attention to positive aspects of the other person and makes the other person feel good, appreciated Indicates the person accepts responsibility for his or her behavior Allows you to be in emotional control

12.Communication postponement

Conveys independent action the person plans to take Asks for postponement of a discussion until a more favorable time

Modified from Strayhorn JM Jr: Talking it out: a guide to effective communication and problem solving, Champaign, Ill, 1977, Research press, pp. 53 76.

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How Do Sex Differences Influence Communication Styles? Men and women view their work environments from different perspectives ( Vengel, 2000; Mindell, 2001). Men often see the world from a logical, sequential, focused perspective. Women often tend to see the big picture and to seek solutions based on what makes people feel comfortable rather than on logic. Subtle communication differences can create barriers to open, healthy communication between men and women in the workplace. Men may ask fewer questions in a public situation, especially if they feel that their questions might suggests ignorance. Women seem to be more comfortable asking questions ( Mindell, 2001). In fact, there are times when a person can benefit from remaining silent and looking up information later in private so that others do not conclude that the asker lacks sufficient knowledge. At other times, a person must be assertive and ask questions so that he or she does not threaten the health of patients. Within the workplace, the dominant communication style is direct, confident, and assertive. This style may be more familiar to men because they are often raised hearing more aggressive, direct language from their parents, whereas many women may be more used to a soft, supportive tone of voice and choice of words. Cultural values learned in childhood also play a role in the communication style a person chooses. This style may have to be modified to make interactions more successful. A woman who is communicating with a man may need to be more direct and assertive than usual, whereas a man may need to learn to be less aggressive in many situations. Another sex difference in communication is related to childhood experiences with sports. Men often grow up with participation in team sports. They have worked toward a goal and have learned to strategize together for the good of the team, building a network of allies. Women have tended to be less involved with team sports than men. Women are more likely to have spent more time interacting with a few people they really like who share similar values and behaviors. Women are generally taught to be polite and to say nice things about and to others, whereas men are encouraged to do whatever it takes to help the team win. In the workplace, men and women need to understand their different points of view so that they can be team players and value cooperation and respectful relationships with each other. To summarize, men and women have innately different communication styles. Often developed from childhood experiences. To be successful in the workplace, we all have to learn as much as we can about communication differences, identify our own styles, and have the flexibility to use other communication techniques that call for it. How Can You Improve Communications In Group Meetings? Nurses participate in many meetings, from patient are conferences to more formal committee meetings. Communication within a group of people can be an opportunity to influence the quality of care given to patients. When you participate as a member of a group, the following are positive behaviors that will help you to communicate effectively and will also help the group to accomplish its tasks more efficiently:

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Come prepared. Bring all the stuff you need. Listen. Be open to other viewpoints. Keep on track. Do not visit or chit-chat. Present your ideas or opinions. Ask other members for theirs. State disagreements. Be able to back them up. Clarify when needed. Do not assume.

What Are The Responsibilities Of A Group Leader? If you are the leader of a group meeting, you have additional responsibilities. If you are organized and able to communicate effectively, the meeting is as much more likely to run smoothly. This is especially important when you and your group members are busy. You cannot afford to waste time sitting in an unproductive meeting. Nothing is as irritating as time spent arguing with others when you know your work is piling up on your desk. If the irritation continues to build, you and the other group members will be less committed to the goals of the group and some will even stop coming. The key to effective meetings is the planning and organization that occurs before the meeting is actually held. Planning should allow the leader to think through what the meeting is for, who should be there, and how it would run ( Huber, 2000). There should be a clear purpose for every meeting and every item on the agenda. Every item should require some action by the group. If the purpose could be achieved in another way, such as by making a telephone call or sending a memo, there should be no meeting. It is the leaders responsibility to send out an agenda ahead of time and to indicate any preparations that members need to make or materials they need to bring. The leader must also be concerned with the room where the meeting will be held. If you are making a formal presentation, some audiovisual equipment will be necessary, and chairs will need to be arranged so that everyone can see the presenter and the audiovisuals. If the meeting if for discussion and decision making, a table at which everyone can sit face-to-face is more effective. Look at the figure below. This type of note-taking clarifies who is responsible for what activities. Ask for a volunteer to keep track of the timeline information. At the conclusion of the meeting, summarize the decisions, and identify the plan of action. Review the timeline information for clarity and understanding regarding group member responsibilities. At the end of the meeting, the time should be established for the next meeting. All members should receive a copy of the timeline information.

What Schedule inservice on glucometer Revise suction procedure

Who Janet & Linda

When 8/28/05 4/23/05

Completed

5/8/05 5/16/05

Sue & Bill Review charting, and report back to next unit meeting. 4/1/05 Jom & Amy

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COMMUNICATION IN THE WORKPLACE Sharing information with the members of the health care team requires different approaches. This communication in a daily basis may involve delegation of a nursing procedure, clarification of a physicians orders, reevaluation of a patient care assignment of another health care team member, or coordination of various hospital departments ( e.g radiology, dietary, pharmacy) to provide nursing care. How Can I Communicate Effectively With My Supervisor? Upward communication with supervisor takes on a formal nature. It is important to learn and then use the channels of communication. If you are a team member, this means you share information with your team leader. The team leader shares information with the supervisor, the assistant vice president of nursing, and the vice president of nursing, and so on. You can see that there are many levels of nursing between the bedside nurse and the people with major decision-making responsibility. Remember the point that messages can get very distorted when they travel through many people in the upward flow of communication. Arrendo (2000) says it is important in communicating with superiors to state needs clearly, explain the rationales for requests, and suggest the benefits to the larger unit. It is also important to listen objectively to the response of the supervisor because there may be good reasons for granting or not granting the request. Arrendo ( 2000) gives the following tips for talking to your supervisor: 1. Keep your supervisor informed 2. If a problem is developing, make an appointment to talk it over. Have a specific information available, especially written documentation of facts. Focus on problem solving, not just the problems. 3. Show that you have important information to share and a sense of responsibility. 4. Be careful which words you use. Avoid blaming others, exaggeration, and overly dramatic expressions. 5. Do not talk to your supervisor when angry, and do not respond with anger. Use I statements, and explain what you think. 6. If you want to present a new idea, give your supervisor a written proposal, then meet to discuss it after the supervisor has read it. 7. Accept feedback, and learn from it. 8. Never go above or around your supervisor. Always communicate directly with your supervisor first before going further up the chain of command. How Can I Communicate Effectively With Other Nursing Personnel? When you speak with other professional nurses, you are communicating in a lateral, or horizontal, flow of information. This flow is based on a concept of equality, in which no person holds more power than the other. This type of communication is best done in a work climate that promotes a sense of trust and respect among colleagues. When nurses work well together, their cohesiveness makes success more likely. This takes work and the deliberate use of facilitative messages ( Northouse, 2001). Ideally, professional nurses should view themselves as equals in their interactions with members of other health care disciplines, and their

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approach to communication should be lateral one, even with physicians. At the basis of this communication is the ability of the nurse to see himself or herself as competent and worthy of being an equal to physicians, social workers, dietitians, and others. To gain this self-confidence is a major goal of every recent graduate. How Can I Communicate Effectively With Patient Care Assistant? Even a recent graduate will soon be providing direction to licensed and unlicensed nursing personnel. It is important to remember that these people have needs for satisfaction and self-esteem, too. Directions do not need to be given in the form of authoritative commands unless an emergency demands immediate action in a prescribed way. Marquis and Huston ( 2000) suggest that when you provide direction, you need to think through exactly what you want to be done, by whom, and when. You need to get the full attention of the other person so that you know he or she is hearing you accurately. You should then give clear, simple instructions in step-by-step order, using a supportive tone of voice. Before the other person goes to do the task, ask for feedback to verify that he or she has accurately heard instructions. Finally, follow-up is necessary to be sure your directions were carried out and to find out what happened, in case something more needs to be done. Involving personnel who are at other levels of nursing care in the planning and evaluation of the care will increase their sense of responsibility for the outcomes and will help you to seem less authoritarian. How Can I Communicate Effectively By Using Technology? Many of us are learning to use the technology that is changing our workplace and making communication easier. Although cellular telephones, fax machines, portable personal computers, modems, and voice mail may be conveniences, they must be used thoughtfully to make a positive contribution to your overall image as an effective communicator. Deep and Sussman ( 1995) give the following tips for the successful use of communications technology: Do not misuse or overuse fax machines. Remember that the person on the other end must read every page faxed to him or her, so be brief. If you need to send a long document, use the mail. Send faxes only when you do not mind if the quality of the copy is not first-rate, because many people have fax machines that print less clearly than computers or even copying machines. When you leave someone a voice-mail message, speak slowly and distinctly. This is especially important when you are leaving your telephone number so that the other person can return your call. It is frustrating to receive a message but not be able to understand the name or have to replay the message to get all of the digits in the phone number. Make your voice-mail brief but complete, saying when you called, what you want the other person to do, and when you can be reached. Do not leave callers on hold if you are using call waiting. Explain to the first caller that you must briefly answer another call, then take the number of the second caller, with the assurance that you will call back as soon as you finish your first call. This interruption should take no more than 10 seconds. Be sure to write down the telephone number of the second caller so that you do not forget it by the time you finish the first call. When you call people, ask if they have time to talk and offer to call back at a more convenient time if necessary. People appreciate the courtesy and will be more likely to have a positive conversation with you if it is conveniently timed and is respectful of their busy schedule. If you are conducting a conversation or a meeting with a speaker telephone or by means of a teleconference, make sure that each party to the call is introduced to the other people. Do not

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use the speaker telephone unless you are including a group in the conversation. Even with a conference call, there should be some structure to the discussion, including an agenda or a specified purpose and time for the call. When you have business cards printer, include your e-mail address and fax number. If you are sending messages by e-mail, be sure to read your words carefully before sending them. Because you are sending words without the benefit of clarifying nonverbal communication, the likelihood of being misinterpreted is greater. Make sure your messages are as clear as they can be. Include your name and subject in the e-mail note. Do not send an emotional outbursts in an e-mail. These messages can seem more hostile then you intended, and you can alienate or anger many people. If you cannot state your message in person, then do not send it by email. Learn to use basic computer software. Most people can effectively use fewer than half of the programs to which they have access. Know how to use word- processing software. This is especially helpful in making your communication easier and more credible. When you need to send a personal message, especially a reminder or a thank you, the most powerful way is to send a handwritten note. This conveys the importance you connect with the message and continues the interpersonal aspect of the communication. If you need to communicate something that you expect will have a real emotional impact, do it face-to-face. This communication style has more force, too, but it also allows you an opportunity to read the other persons nonverbal communication and offers a chance to negotiate a comfortable understanding following your message delivery. ASSERTIVE STYLES OF COMMUNICATION All of us have a style or way of communicating with others that is often based on our own personality and self-concept. In other words, the kind of person we are and the way in which we see ourselves influence the process of communication. This style can be divided into three common types: passive or avoidant, aggressive, and assertive ( Marqyiz & Huston, 2000). The following are some characteristics of each style. Passive or Avoidant Behavior means that a person lets others push him around; does not stand up for himself; does what he is told, regardless of how he feels about it; is not able to share his feelings or needs with others; has difficulty asking for help; and feels hurt, anxious, or angry at others for taking advantage of him. Aggressive behavior means that a person puts his or her own needs, rights and feelings first and communicates that in an angry, dominating way attempts to humiliate or put down other people; conveys a righteous, superior attitude works at controlling or manipulating othe rs; is seen by others as punishing, threatening, demanding, or hostile; and shows no concern for anyone elses feelings. Assertive behavior means that a person stands up for himself or herself in a way that does not violate the basic rights of another person; expresses true feelings in an honest, direct manner; does not let others take advantage of him or her; shows respect for others rights, needs, and feelings; sets goals and acts on those goals in a clear and consistent manner and takes responsibility for the consequences of those actions; is able to accept compliments and criticisms; and acts in a way that enhances self-respect. See if you can match the person with his or her style by using the descriptions you have just read.

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JANE Jane is a very shy, quiet senior nursing student who cant think straight when her instructor asks her questions in the clinical area. She wishes she could be more like her classmates, who seem to find it easy to talk about their experiences during clinical conference. During her evaluation. Her instructor says she does not know enough theory and cant handle the pressures of the clinical unit. Jane says nothing and signs her evaluation. When she gets back to her room alone, she cries uncontrollably. SUSAN Susan is a senior nursing students who is highly verbal with her classmates. She is known to be opinionated and in every conference with her clinical group finds a chance to criticize someone. She blames the nursing staff on the clinical unit for making her look bad by giving her too much work to do and not enough time or help. When her instructor tells her she has not used enough theory in her written assignments, she says, Its not my fault; you should have told me sooner. MARK Mark is a senior nursing student who is described by his clinical group as goal-oriented and confident. He wrote learning objectives for himself at the beginning of the last clinical experience and brought them with him, along with a self-evaluation, for his final evaluation conference. He listened to his instructors suggestions, thanked her, and said, I appreciate your concern for the quality of my nursing skills. Im aware now of what I need to pay attention to in my first few months in my new job. If you decided that Jane used a passive or avoidant style, Susan used an aggressive style and Mark used an assertive style, you were right. Congratulations! WHY NURSES ARE NOT MORE ASSERTIVE? It seems as though many nurses do not consistently act or communicate in an assertive way. Some have a hard time believing in their own rights, feelings, or needs. This difficulty may have gotten its start in childhood through exposure to many negative statements or experiences. It is important to recognize that communication style is learned and reinforced over time. While in nursing school and working in the nursing profession, additional experiences or comments may reinforce those negative messages about self-worth. It can be very difficult to change behavior, especially when risk-taking is necessary. The first step is to recognize what the barriers are. What is it that prevents you from being more assertive? Is it previously learned behavior, or are you afraid of the repercussions of assertive communication? Check the list in the Box below. If this list includes statements you feel are true, then you have identified some roadblocks to your ability to develop more assertive communication. Look over this list of barriers to assertive communication and think about yourself. Do any of these explain your feelings? Assertiveness takes self-awareness and practice. It will help you to identify and

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accept your position right now with regard to assertiveness so that you can make a plan to develop this skill. Barriers to Assertiveness Assertive communication should not threaten others. If you do not have anything nice to say, do not say anything at all. If you feel uncomfortable when presenting your position or stating your feelings, then you are nonassertive. Assertiveness should come easily and spontaneously. Health care facilities do not promote or support assertive behavior. You cannot be assertive and consider another persons feelings and behavior. Assertive behavior is just another way of complaining. If I am assertive, I will lose my job. There is no difference between assertiveness and aggressiveness.

What Are The Benefits Of Assertiveness? Assertive communication is the most effective way to let people know what you feel, what you need, and what you are thinking. It helps you to feel good about yourself and allows you to treat others with respect. Being assertive helps you to avoid feeling guilty, angry, resentful, confused, or lonely. You have a greater chance to get your rights acknowledged and your needs met, which leads to a more satisfying life. What Are My Basic Rights As A Person And As A Nurse?
As an adult human being, you have some legitimate rights. You may have to do some work to allow yourself to believe in your rights. You may have learned other values that make it difficult to accept the validity of these rights. But belief in your own value as a separate individual and confidence in the positive concepts associated with assertiveness as a communication style will help you to believe in your rights. Consider the rights and responsibilities of the nurse. The issue of rights can become one-sided. When nurses consider rights, responsibilities must also be included. These rights are yours as a registered nurse; acquiring them and holding them are your responsibility ( Chenevert, 1988).

Changing ones behavior requires a conscious decision.

How Can I Begin To Practice Assertive Communication? There are a variety of ways to learn to be more assertive in your communication style, but they all involve self-awareness and practice. It may not feel totally comfortable at first, but as you work at it, assertive communication will come more naturally. You should practice being assertive in a situation where there is minimal risk to you, so that you can experience success. If sharing your feelings with your instructor or head nurse makes you extremely uncomfortable, set the situation aside. You can work on it after you are more confident. Share

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your feelings and practice being assertive with someone with whom you are comfortable. Personal risk should be at a minimum. It is helpful to practice being assertive by yourself at first. Rehearse what you might say by talking to yourself while looking in a mirror. Once you feel more comfortable, ask a friend to help you practice. The two of you can role-play some assertive conversations. You may even want to videotape or audiotape your practice so you can get an idea of how you look and how you sound. When you are ready, try out your new assertive communication skills in a mildly uncomfortable situation you would like to change. Pay attention to how you feel. Ask for feedback from the other person. You will then be able to evaluate your progress and decide what other information you want to practice. What Are The Components Of Assertive Communication? When you communicate assertively, you are able to describe your own feelings and needs, listen to and acknowledge the other persons feelings and needs, define the problem clearly and nonjudgmentally, use body language confidently, and negotiate a workable compromise ( Mindell, 2001). Following are two ways to think about expressing your feelings and needs: STRATEGY 1: I think I feel I want. STRATEGY 2: I feel about.. because Let us look at an example for each of these. I think weve been working every evening for 2 weeks on that report for the nursing office. I feel tired and cranky because Im not paying enough attention to my familys needs I want to ask someone else to write a section of the report. I feel hurt and angry about Dr. Jones yelling at me in front of you because I need to feel competent and respected at work. These statements can be successful when you maintain direct eye contact, stand up straight, and speak in a clear, audible, form tone of voice. After expressing your own feelings and needs, it is helpful to seek clarification of the other persons feelings or needs. This can be done with the following questions: How do you feel about that? What were you thinking and feeling at that time? How would that affect you? With skillful listening and clear communication, the problem can be defined without placing blame or putting down the other person. Notice the use of I messages. That indicates willingness to accept responsibility for the process of defining the problem and negotiating a workable solution. To find a compromise, you have to be willing to meet the other person halfway. You may agree to try it your way one time and the other persons the next. Or you may both agree to change or give up something. You may do something for him or her if she does something else for you. Remember that in the work setting you cannot always have things exactly as you want them. You must be willing to change and compromise ( Elgin, 2000).

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When To Use Assertive Communication Let us look at some examples of situations in which assertive communication would be helpful. Communicating Expectations Supervisor: Youre being pulled to the unit and the equipment unit today because theyre short-staffed. Nurse: I expect to be oriented into the unit and the equipment before I give nursing care because I havent worked on that unit in more than a year. Saying No Physician: Come with me right now. I need some help doing a procedure on Mr. Smith. Nurse: No, I cant come with you right now. I m doing a nursing assessment on Mrs. Anderson. Ill be finished in 20 minutes and will help you then.

Accepting Criticism
Head Nurse: It seems to me that you arent very good at doing care plans, and they never done on time. Nurse: I have been falling behind on my care plans. I would like to look at some examples of good care plans. Do you think you could help me with that? Id be willing to spend some time at home reviewing them. Accepting Compliments Home care patients spouse: You give really thorough care. Its obvious you know what youre doing. Nurse: Thank you. Your feedback is important to me. Giving Criticism Nurse: I want to talk with you about your care of Mrs. Samuelson. I found her sitting in a wheelchai r alone in the hallway. It is your responsibility to make sure that she is not left alone, so that nothing happens to her. Aide: I do not think thats my job. Nurse: We talked about your responsibilities this morning when you got your assignment. I expect you to
complete your assignment as directed or ask for help.

Providing Feedback Head Nurse: I wanted to tell you that I have noticed an improvement in your relationship with Dr. Turner. He has not complained about his patients care fro 2 weeks, and yesterday he told me that he had a satisfying discussion with you about home health care options for Mrs. Atkins. Nurse: Thank you. I have been working very hard at not responding angrily to his sarcastic comment s and criticisms.

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Asking for Help Nurse: It is hard for me to do this because I expect myself to care for all patients without difficulty. But I am having a hard time with Mr. Jones. He seems to have a way of pushing my buttons so I get angry. Community health Nurse Supervisor: Are you asking me for something? Nurse Yes, I need help in understanding why I get so angry at him, and I want to know how to handle him in a more positive way. Remember that you need to evaluate how your assertive communication feels to you and you need to seek feedback from other people about how you are being interpreted. You need to know whether people perceive you as aggressive rather than assertive. It may mean modifying your communication to make sure you are standing up for yourself without violating the rights of others. It should also be noted that some situations will not get resolved just because you communicated assertively. Finding a workable solution is a process involving other people who must take responsibility for their own feelings and needs. When others are unable to acknowledge their feelings, to listen, or to negotiate a compromise, your assertive communication may make you feel better about yourself but may not produce an immediate solution. But keep trying. Persistence pays off. Remember, too, that there are some situations in which you must simply follow orders. You cannot always meet your own needs; you must do what a physician or your head nurse tells you to do. Sometimes you must put side your own needs to meet the needs of the patients you are caring for. However, your judgment will increase as you gain experience, and you will recognize ways to communicate your needs and feelings, with the goal of improving the processes and procedures used in your work setting. _____________________________________________________________________________________

Critical Thinking Questions

1. A patients daughter comes to the nurses station and asks to speak to the nurse in charge. She is upset and angry because her mother is very upset about her new diagnosis of cancer, yet the family of the patient sharing the room is boisterous and laughing. How should a nurse leader handle this situation?

2. When patients and families are faced with a sudden hospitalization, tempers often flare and people are
much more sensitive to the length of time they must wait. Families may also be troubled by standard rules in a hospital, such as visiting hours and policies. How can the nurse leader mitigate these situations and use communication skills to keep these situations under control?

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 8: Please write the letter of your choice in the space before the number ___1.Asserive behavior is characterized by: a. apologizing frequently b. Sarcasm c. Standing up for ones rights d. blaming others ___2. A line of communication that emanates from subordinates to superior, and does not flow as easily. a. Horizontal b. Upward c. Outward d. Downward ___3. A type of messages that create a positive outcome in which the people communicating with each other feel good about the interaction. a. Positive feedback b. Facilitative c. Obstructive d. Assertive ___4. Within the workplace, the dominant communication style is: a. Non-direct, confident and assertive b. Non-verbal, confident and assertive c. Direct, confident and assertive d. Assertive, Understandable and Sensitive to the needs ___5. Sharing information with the members of the health care team requires _________approaches. a. Different b. Delegation c. Standardized d. Assertive ___6. A style of communication wherein the person lets others push him around. a. Passive or avoidant c. Assertive behavior b. Aggressive behavior d. passive aggressive ___7. A style of communication where in the person stands up for himself in a way that does not violate the basic rights of another person. a. Passive or avoidant c. Assertive behavior b. Aggressive behavior d. passive aggressive ___8. Changing ones behavior requires a ___________. a. Decision making c. Others opinion b. Conscious decision d. Willingness and acceptance ___9. This the most effective way to let people know what you feel, what you need, and what you are thinking. a. Assertive communication c. Aggressive communication b. Passive communication d. Openness and Honesty in communication ___10. When you communicate _________ you are able to describe your own feelings and needs, listen to and acknowledge the other persons feelings and needs, define the problem clearly and nonjudgmentally. a. Aggressively c. Assertively b. Directly and clearly d. Actively

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5. COORDINATION - synchronization of activities with the various services and departments enhances collaborative efforts resulting in efficient, smooth and harmonious work flow. - coordination also prevents overlapping of functions, enhances good working relationships and work schedules are finished on time. e.g. Coordination with the Medical Service, Administrative Service, Laboratory Service (Nothing by Mouth After Midnight For Fasting Blood Sugar in AM ), Radiology Service ( For Chole-GI Series in AM! Pls. withhold Breakfast Until After Exam), Pharmacy Service, Dietary Service, Medical Records, Community Agencies, Other Institutions and Civic Organization 6. STAFF DEVELOPMENT 7. DECISION MAKING -A decision is a course of action that is consciously chosen from available alternatives for the purpose of achieving a desired result.
Real World Interview

To retain our staff and to improve the quality of our client care, we must provide support to our novice nurses by implementing a mentorship program in our hospital to provide an ongoing support to develop their skills in problem solving, decision making, and prioritization. Terry Kuula
Director

Most people rise to the top of their chosen careers share a common characteristics: They are decisive. They make decisions and are not afraid to take risks. Factors Influencing Decision Making As nurses, we need to have working knowledge of what drives individuals ( i.e. our peers and our clients) to make choices that set up the cascade of courage, greatness, and autonomy vs. caution, maintenance, and dependency. a. Personal Perception and Preference Understanding how we perceive problems in clinical practice or in our professional lives helps us to see how we can influence our personal preference in decision making. b. Knowledge and Experience Increased knowledge and experience yielded more systematic data acquisition and greater diagnostic accuracy. Difference in diagnostic accuracy was attributed to the ability of the expert nurse to intuitively determine the correct region for the assessment, select relevant data, and recognize the changing relevance of cues as the situation evolves. c. Competence Campbell and Mackay ( 2001) identify three concepts as they define competence: a) The ability to practice in a specific role b) The influence of the practice setting on competence c) The integration of knowledge, skills, judgments, and abilities. Despite these definitions, no single universal definition exists of nursing competence. Nurses practice individually and in groups, in a wide array of clinical, nonclinical, and nontraditional settings. What is common to all nurses is the need to make clinical and professional decisions in their practice. To be effective decision-makers, nurses must have a solid anchoring in the core competencies related to entry to practice and must

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possess knowledge and abilities related to problem solving and decision making, which have been integrated into professional practice. e. Self-confidence Is a term used to describe how secure people are in their own decisions and actions. Perceptions of being less intelligent, less educated, and less competent result in relinquished authority to those perceived as being better. This observation plays itself out of many units within health care facilities on a day-to-day basis. In nursing, one has to earn ones stripes by gaining the confidence and the respect of ones peers. New graduates and new nurses joining an established team often feel that there is a need to prove themselves in order to be accepted by the more senior staff. Nurses who possess a high degree of confidence believe they have the competence ( i.e. the knowledge, judgment, and skill) to perform an action correctly or achieve some specific goal. Confident and competent nurses usually have little difficulty making clinical decisions, such as starting an intravenous in urgent/emergent situations, referring a client to social work, or ordering a pressure-reduction overlay mattress. Self-confidence is learned through repeated successful application of the decision-making process. Decisions that require courage, autonomy, and greatness, and result in positive client outcomes become strong motivators to support decision making. Decisions that illustrate caution, dependency, and maintenance have less intrinsic reward for the nurse, and therefore such decisions have little ability to motivate continued decision making. The outcome can be a lack of self-confidence, which is reinforced with every missed opportunity for decision making. f. Stress Stress arises when individuals perceive the environment to be demanding, because it exceeds their resources and threatens their personal well-being. Situations can be an anxiety-provoking for some and stimulating for others, depending on how people perceive the environment. Generally speaking, nurses with a internal locus of control in a clinical setting perceive opportunities to influence outcomes for their clients, other nurses, and the organization. This approach leads to a greater sense of personal job satisfaction and reduction of stress. Staff with an internal locus of control believe that external events and people are in control, and that they have very little choice over deciding their future. Moderate amounts of stress are required for optimal thinking. However, long-term effects of functioning within highly stressful environments, such as todays health care settings, include stereotypical, unimaginative thinking, overgeneralization, and loss of interest. Nurses identified the following factors as producing the greatest stress: interpersonal conflict, inadequate staffing, lack of support when dealing with death, and physical environment. In 2007, the nursing profession found that stress is a constant and results in higher rates of job strain, lack of job satisfaction, and higher illness rates among nurses. These results do not bode well for the future of nursing. Consequently, nurses and employers need to collaborate to create and maintain practice environments that support effective decision making at the point of care and thereby contribute to a high sense of job fulfillment and autonomy for nurses. g. Extrinsic Factors g.1 Organizational climate and culture g.2 Client choice and rights g.3 Legislation and Regulation Consideration of regulatory legislation, professional standards, best practice guidelines, and organizational policies and procedures is foundational to effective

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clinical decision making. Thus nurses must have knowledge and understanding of the regulatory framework that governs their practice, and they must understand other regulatory practice requirements defined in other types of legislations ( e.g. Laws that Affect the Nursing Practice). Decision Making as a behavior exhibited in making a selection and implementing a course action from alternatives. It may or may not be the result of an immediate problem. Both decision making and problem solving use critical thinking. Critical Thinking - is analyzing the way one thinks. It should be incorporated into all steps of problem solving and decision making.

Critical Thinking

Decision making

Problem solving

In everyday practice, nurses make decisions about client care. As nurses gain experience in clinical practice, decision making becomes more automatic, but the complexity of many decisions remains. 5 Steps in the DECISION- MAKING PROCESS Step 1. Identify the need for a decision Step 2. Determine the goal or outcome Step 3. Identify the alternatives or actions along with the benefits and consequences of each action. Step 4. Decide which action to implement. Step 5. Evaluate the action. CLINICAL APPLICATION Your client is on droplet precautions because he has been diagnosed with tuberculosis. As per hospital policy, only two visitors are allowed at a time to see the client. No children under 12 years of age

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are allowed. The client doe not speak English, and his family speaks very little English. You have noticed on two occasions that his visitors were not wearing masks. You inform the family about the importance of infection control practices and remind them of the hospitals policy regarding visitors. The family indicates to you that their grandfather really wants to see his 4-year-old grandson, who came to visit him from another province. Use your decision-making and problem solving skills to help you decide what to do. Step 1: Identify the need for a decision. Should you allow the grandson to visit? Consider all the information ( e.g. the hospital policy, professional practice standards, the clients wishes, and the clients anxiety level). Step 2: Determine the outcome. What is the goal? Consider the following questions: Can an exception to hospital policy be made? Is the goal to allow the client to see his grandson? Will the client and his family be satisfied? Step 3: Identify all alternative actions and the benefits and consequences of each. If you enforce hospital policy, the benefits are that all clients are treated equally and the written policy supports the decision. The consequences are that the client and his family may not be satisfied, and the grandson and grandfather may be upset. In addition, the grandsons health may be at risk. The alternative is to allow the grandson to visit. The benefits are that the clients level of anxiety will decrease, and the client and his family will be satisfied. The consequence is that the precedent is set that may make it difficult to enforce the existing hospital policy. Step 4: Arrive at the decision. Consider the two alternatives and the benefits and consequences of each. Make the decision and implement it. Step 5. Evaluate the decision. Was the goal achieved? From the beginning of their careers, new graduate nurses are faced with the responsibility of making decisions regarding client care. Beginning nurses commonly have more questions than answers. When nurses are faced with a difficult clinical decision, Marquis and Huston ( 2006) recommend consulting with others, such as other RNs on the unit or supervisors, as early as possible. Depending on the situation, recognize that you have knowledge and intuition that are valuable. With more experience comes greater trust in your decision making. MANAGEMENT APPLICATION Nurse managers sometimes face complex decisions. Decisions related to budget are common in our current health care environment with its emphasis on cost containment and quality maintenance. Disciplining an employee also creates a complex situation in which nurse managers must make decisions regarding the employees future. A decision-making grid may help to separate the multiple factors that surround a situation. A decision making grid by managers who were told they had to reduce their workforce by two full-time equivalents (FTEs). This grid is useful to visually separate the factors of cost savings, effect on job satisfaction. The manager needs to determine the priorities when developing a grid. Sample Decision-Making Grid.
Methods of Reduction Lay off the two most senior fulltime employees Lay off the two most recently hired full-time employees Reduce by staff attrition Cost Savings $ 93,500 $ 63,200 $ 78,000 Effect on Job Satisfaction Significant reduction Significant reduction Minor reduction Effect on Client Satisfaction Significant reduction Moderate reduction Minor reduction

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A decision-making grid is also useful when a nurse is trying to decide between two choices. Below is an example of a decision grid used by a nurse deciding between working at hospital A or hospital B. Sample Decision-Making Grid for Weighing Options
Elements Importance Score (out of 10) Likelihood Score (out of 10) Risk (multiply scores)

If I work at hospital A Learning Experience Good mentor support Financial reward Growth potential Good location Total If I work at hospital B Learning Experience Good mentor support Financial reward Growth potential Good location Total

10 8 6 8 10

10 8 6 8 10

100 64 36 64 100 364

8 7 8 9 6

8 7 8 9 6

64 49 64 81 36 294

The Program Evaluation and Review Technique (PERT) is useful in determining the timing of decisions. An advantage of the PERT diagram is that participants can visualize a complete picture of the project, including the timing of decisions from beginning to end. The flowchart provides a visual picture depicting the sequence of tasks that must take place to complete a project.

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DECISION TREE A decision tree can be useful in making the alternatives visible. A decision tree to reduce motor-vehicle crash fatalities.

Key numbers represent the figure that event will occur.

Whether to have a Sweetheart Decision

Advantages 1. 2. 3. 4. 5.
GANTT CHART

Disadvantages 1. 2. 3. 4. 5.

A Gantt chart can be useful for decision-makers to illustrate a project from beginning to end. Gantt chart used to show the progression of a nursing units pilot project.

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SWOT ANALYSIS: S Strength, W Weakness, O Opportunities, T Threat

GROUP DECISION MAKING Todays leadership and management styles include people in the decision-making process who will be most affected by the decision. Decisions affecting client care should be made by those groups implementing the decisions. The effectiveness of groups depends on the groups members. The size of the group and the personalities of group members are important considerations when choosing participants. More ideas can be generated with groups, thus allowing for more choices, which increases the likelihood of higher-quality outcomes. Another advantage of groups is that when followers participate in the decision-making process, acceptance of the decision is more likely to occur. Additionally, groups may be used as a medium for communicating the decision and its rationale. A major disadvantage of group decision making is the time involved. Without effective leadership, groups can waste time and be nonproductive. Group decision making can be more costly and can also lead to conflict. Groups can be dominated by one person or become the battleground for a power struggle among assertive members.

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Advantages and Disadvantages of Groups Advantages Easy and inexpensive way to share information Opportunities for face-to-face communication Opportunity to become connected with a social unit Promotion of cohesiveness and loyalty Access to a larger resource base Forum for constructive problem solving Support group Facilitation of esprit de corps Promotion of ownership of problems and solutions Disadvantages Individual opinions influenced by others Individual identify obscured Formal and informal role and status positions evolve- hierarchies Dependency fostered Time-consuming Inequity of time given to share individual information Existence of nonfunctional roles Personality conflicts

TECHNIQUES OF GROUP DECISION MAKING NOMINAL GROUP TECHNIQUE Step 1: No discussion occurs: group members write out their ideas or responses to the identified issue or question posed by the group leader. Step 2: Presentation of the ideas of the group members along with the advantages and disadvantages of each. (Presented on a flipchart or a whiteboard). Step 3: Offers an opportunity for discussion to clarify and evaluate the ideas. Step 4: Private voting on the ideas. Ideas receiving the highest rating are the solutions implemented. DELPHI GROUP TECHNIQUE This differs from nominal technique because the group do not meet face to face. Questionnaires are distributed to group members for their opinions, and the responses are then summarized and disseminated to the group members. This process continues for as many times as necessary for the group members to reach consensus. An advantage of this technique is that it can involve a large number of ideas. CONSENSUS BUILDING Consensus is defined by the The American support the Heritage Dictionary (2000) as an opinion or position reached by a group as a whole; general agreement or accord. A common misconception is that consensus means everyone agrees with the decision 100%. Consensus means that all group members can live with and fully support the decision regardless of whether they totally agree. This strategy is useful with groups because all group members participate and can realize the contributions each member makes to the decision. A disadvantage decision making requires more time. This strategy should be reserved for important decisions that require strong support from the participants who will implement them. Consensus decision making works well when the decisions are made under the following conditions: All members of the team are affected by the decision Implementation of the solution requires coordination among team members The decision is critical, requiring full commitment by team members Although consensus can be the most time-consuming strategy, it can also be the most gratifying. GROUPTHINK Groupthink and consensus building are different. In consensus, the group members work to support the final decision, and individual ideas and opinions are valued. In groupthink, the goal is for everyone to be in 100% agreement. Groupthink discourages questioning and divergent thinking. It hinders creativity and usually leads to inferior decisions. The potential for groupthink increases as the

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cohesiveness of the group increases. An important responsibility of the group leader is to recognize symptoms of groupthink. Examples of these symptoms are: o Group members develop an illusion of invulnerability, believing they can do no wrong. This problem has the greatest potential to develop when the group is powerful and group members view themselves as invincible. o Stereotyping outsiders, which occurs when the group members rely on shared stereotypes such as, all Democrats are liberal or all Republicans are conservative to justify their position. People who challenge or disagree with the decisions are also stereotyped. o Group members reassure one another that their interpretation of data and their perspective on matters are correct regardless of the evidence showing otherwise. Old assumptions are never challenged, and members ignore what they do not know or what they do not want to know. Strategies to avoid groupthink include appointing group members to roles that evaluate how group decision making occurs. Group leaders should encourage all group members to think independently and verbalize their individual ideas. The leader should allow the group sometime to gather further data and reflect on data already collected. A primary responsibility of the managers or the group leader is to prevent groupthink from developing. LIMITATIONS TO EFFECTIVE DECISION MAKING Past experiences, values, personal biases, and preconceived ideas affect the way people view problems and situations. Incorporating critical thinking into the decision-making process helps to prevent these factors from distorting the process. Pitfalls to effective decision making: Making the decision based upon the first available information Being comfortable with the status quo or not wanting to rock the boat Making decisions to justify previous decisions even if those decisions are no longer satisfactory Pursuing supporting evidence that verifies the decision while ignoring evidence to the contrary Presenting the issue in a biased manner or with a leading question Assigning inaccurate probabilities to alternatives USE OF TECHNOLOGY IN DECISION MAKING The best source of clinical decision making and judgment is still the professional practitioner; however, computer technology can be used to support information systems, including decision making, for managers. Patient classification systems inventory control, scheduling staff, documentation of client care, order entry for tests, appointments and changes in policies and procedures are but a few examples of how computers can assist managers with tracking the information needed in a management role. Computer software for the clinical practitioner is available for clinical decision making and should be carefully critiqued prior to use. NURSES ROLE IN CLIENT DECISION MAKING In todays world, clients are taking a more active role in treatment decisions. Consumers of health care are more knowledgeable and have more options than in previous years. Nurses must be aware of clients rights in making decisions about their treatments, and they must assist clients in their decision making. When clients are active participants, compliance with prescribed treatments is more likely to follow. Empowering the client in this manner ultimately promotes a more positive outcome. STRATEGIES TO IMPROVE DECISION MAKING Comfort with decision making improves with experience. Early in the nurses career, the nurse is commonly indecisive or uncomfortable with decisions. Several strategies that help to improve critical thinking, eventually will also help improve decision making:

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At times, delaying a decision until more information is obtained may be the best approach. Asking why, what else, and what if questions will help you arrive at the best decision. When more information becomes available, decision can be revised. o Anticipate questions and outcomes. For example, when calling a physician to report a clients change in condition, the nurse will want to have pertinent information about the clients vital signs, lab values, and current medications readily available. Nurses who practice strategies to promote their own critical thinking will, in turn, be good decisionmakers. A foundation for good decision making comes with experience and learning from those experiences. By turning decisions with poor outcomes into learning experiences, nurses will enhance their decision-making ability in the future. DOS AND DONTS OF DECISION MAKING Do Make only those decisions that are yours to make. Write notes and keep ideas visible about decisions to utilize all relevant information. Write down pros and cons of an issue to help clarify your thinking. Make decisions as you go along rather than letting them accumulate Consider those affected by your decision. Trust yourself. Dont Make snap decisions. Waste your time making decisions that do not have to be made. Consider decisions a choice between right and wrong but a choice among alternatives. Prolong deliberation about decisions. Regret a decision; it was the right thing to do at that time. Always base decisions on the way things have always been done. o

Source: Adapted from the Small Business Knowledge base, 1999. Retrieved February 19, 2002, from http://www.bizmove.com

Key Concepts The ever-changing health care system calls for nurse to be effective decision-makers. The ability of nurses to make appropriate decisions will affect their employers ability to survive. A good critical thinker is able to examine decisions from all sides and take into account varying points of view. Use of the universal intellectual standards will improve a nurses critical thinking. Practising reflective thinking helps individuals become better critical thinker. Decision-making grids may be helpful to separate multiple factors during the decision-making process. The PERT model is useful for determining the timing of decisions. In some situations the nurse manager makes an individual decision. Other decisions call for group decision making.

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To be an effective decision-maker, individuals must identify and avoid certain traps during the decision-making process. The nurse must recognize the importance of empowering clients in making their own treatment decisions. The nurse needs to provide the client with information and assist the client to explore all possible options. Many strategies can be used to improve your decision making. Obtaining all the information, asking yourself why and what if questions, and developing good habits of iniquity are a few of the strategies that will help improve your decision-making skills. Real World Interview

One of my clients at night on the medicine unit was complaining of a vague chest pain. I assessed him and was not
sure what caused his discomfort. I phoned the physician-on-call and was advised that he was busy in emergency and would come to see the client as soon as possible. Then I called the Rapid Response Team (RRT) to assess the client. The RRT arrived and completed an ECG; it showed minor ischemic changes. The RRT informed the physician-oncall of the changes in the ECG. The client was prescribed nitro for his angina. I was glad that I listened to my gut instinct and decided to call the RRT, instead of waiting for the physician to see the client. The problem was diagnosed early enough to prevent further damage to the clients heart. I felt I made the ri ght decision by calling the Rapid Response Team. Mara Lopez, RN New Graduate

Real World Interview

I often find decisions about disciplinary action the most difficult ones to make. But, when I use a decision-making
model, it helps me make the best decision. My goal in the decision-making process is often twofold to help the nurse to learn from the experience and to provide the nurse with appropriate tools to prevent similar mistakes happening in the future. Erica Nurse manger Intensive Care Unit

Critical Thinking Question

1. You are a new nurse manager and have been in your position for two months. You are working on the holiday schedule, and the unit secretary with the most seniority comes to you and says that she needs both the week of Christmas and the week of New Years Day off because she will be out of town. You remind her that hospital policy does not allow employees to have both holidays off. The secretary tells you that the previous manager always approved the request and that she has already bought plane tickets. Apply the steps of decision making to this situation. 2. You are a manager of a 12-bed surgical unit. Your supervisor informs you that 12 more beds will be opened for neurosurgical clients, and you are to be the manager. Draw a PERT diagram to depict the sequence of tasks necessary for the completion of the project.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 9: Please write the letter of your choice in the space before the number ___ 1. Decision making is best described as the process one uses to a. Solve a problem c. reflect on a certain situation b. Choose between alternatives d. generate ideas ___2. Occasionally, making a decision is difficult because of the multiple factors that surround certain situations. To separate these factors, the nurse manager may utilize a a. Decision grid c. Delphi group technique b. Nominal group technique d. Consensus strategy ___3. Which of the following is the best description of consensus? a. Everyone in the group agrees with the decision 100 percent. b. All members of the group vote on the selected action. c. Every group member compromises d. Every group member fully supports the decision, once it is made ___4. It has been found that nurses identified the following factors as producing great stress: a. Interpersonal conflict, inadequate staffing, lack of support, overgeneralization b. Loss of interest, Interpersonal conflict, inadequate staffing, lack of support c. Interpersonal conflict, inadequate staffing, lack of support, physical environment d. Unimaginative thinking, loss of interest, inadequate staffing, physical environment ___5. A term used to describe how secure people are in their own decisions and actions. a. Self-reliance b. Self-efficacy c. Self-confidence d. Self-dependence ___6. An analyzation of what one thinks that should be incorporated in all steps of problem solving and decision making. a. Decision making b. Critical thinking c. Problem solving d. Analysis ___7. Which of the following is a symptom of groupthink? a. The group members continually disagree with one another. b. The group members cannot come to a decision. c. The group members stereotype outsiders. d. The group members share a common bond. ___8. Nurses who practise strategies to promote their own critical thinking will, in turn, be good decision makers. a. True b. False c. Not sure ___9. This can be useful for decision makers to illustrate a project from beginning to end: a. Gantt Chart b. Decision Tree c. Nominal Group d. Delphi Technique ___10. They still remains to be the best source of clinical decision making and judgment: a. Patients condition c. Professional practitioner b. Patient classification system d. Policies and procedures

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8. MOTIVATING MOTIVATION Is a skill in aligning employee and organizational interest so that behavior results in achievement of employee wants simultaneously with attainment of organizational objectives. Many managers claim that motivating employees is their most difficult daily task. Managers must stimulate workers to release their energies constructively toward the accomplishment of assigned tasks. Common practical problems encountered by managers include the following: 1. Employees often differ in their needs. 2. Managers often dont, or may not accurately perceive, what employees want 3. Managers have limited flexibility in offering economic rewards. 4. The reward that may prove to be most motivating for some people are often difficult to use. Motivation is a function of understanding needs, tensions, wants, incentives, and a perception of the environment. 2 Types of Needs: 1) Primary (physiological) 2) Secondary (social and psychological )

EMPLOYEE WANTS The various types of human needs are converted by employees into specific wants in the organization. 1. Pay. This want helps in satisfying physiological, security, and egoistic needs 2. Security of Job. Because of threats from technological change. 3. Congenial associates. This issues from the social need of gregariousness and acceptance. Management can aid the process by carefully planned and executed induction programs, provision of means to socialize through rest periods and recreational programs, and promoting the formation of work teams through work-station layout and human-related work procedures. 4. Credit for work done. This issues from the egoistic classification of needs and can be supplied by management through verbal praise of excellent work, monetary rewards for suggestions, and public recognition through awards, releases in employee newspapers, and the like 5. A meaningful job. This issues from both the need for recognition and the drive toward self-realization and achievement. 6. Opportunity to advance. Not all employees want to advance but most like to know that the opportunity is there, should they desire to use it. This feeling is influenced by a cultural tradition of freedom and opportunity. 7. Comfortable, safe, and attractive working conditions. 8. Competent and fair leadership 9. Reasonable orders and directions 10. A socially relevant organization These wants provide an array of motivational tools that managers may utilize to motivate behavior toward desired directions. Motivational force is greatest if the wants is highly valued, if the person feels capable of performing as specified, and if he or she perceives that the reward will actually be allocated.

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IV CONTROLLING/EVALUATING
the process by which managers attempt to see that actual activities conform to planned activities performance is measured & corrective action is taken to ensure the accomplishment of organizational goals

Basic Components 1. Establishing standards, objectives and methods for measuring performance 2. Measuring actual performance Honest CORRECTION 3. Comparing results of performance with standards & objectives & is appreciated more than identifying strengths & areas for correction flattery. 4. Acting to reinforce strengths or successes & taking corrective action Proverbs 28:23 as necessary Nature & Purpose 1. Establishes trust and commitment to the system by all personnel through the use of an effective communication system 2. Clarifies organization & individual objectives 3. Presents uniform & fair standards with precise definitions of each standard, goal & objective 4. Compares expectancy with performance EVALUATION OF MANAGEMENT PERFORMANCE A managers performance can be measured by two criteria: EFFECTIVENESS Is defined by Peter Drucker, one of the most respected writers in management, as doing the right thing This means that a manager has the responsibility for selecting the right goal and the appropriate means for achieving that goal. Thus, a manager needs to be able to select the right decision from among all alternatives and then to select the right method from many methods for implementing that decision. EFFICIENCY Is measuring the cost of attaining a given goal. It is concerned with how resources (money, time, equipment, personnel) are used to get the desired results. If the minimum cost is spent to obtain the desired goal, the manager is being efficient. The managers responsibilities require that she or he be both effective and efficient. From an evaluation viewpoint, efficiency is important but effectiveness is vital. A manager who does the wrong things (ineffectiveness) with minimum use of resources (efficiency) is not helping the organization. On the other hand, the manager who makes the right choices but may not have a completely smooth operation as the change is implemented is, despite partial inefficiency, assisting the organization.

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Control Mechanics 1. Standards of Care Yardsticks for gauging the quality and quantity of services. Established criteria of performance, planning goals, strategic plans, physical or quantitative measurements of products, units of service, labor hours, speed, cost, capital, revenue, program and intangible standards. An acknowledged measure of comparison for quantitative or qualitative value, criterion or norm, a standard rule or test on which a judgment or decision can be based. 2. Total Quality Management (TQM) - A way of ensuring customer satisfaction through the involvement of all employees in learning how to reliably produce and deliver quality goods and services. Primary Goal: To improve internal and external customer satisfaction through quality control. Components of TQM: 1. Quality Planning 2. Quality Teams Principles of TQM 3. Quality in Daily Work

1. Customer Satisfaction 2. Management by Facts (speaking with facts) 3. Respect for People 4. P-D-C-A (Plan-Do-Check-Act)

The real meaning of Quality is TOTAL QUALITY which means: * integrity of function and composition * doing right things right

The Quality Grid

Right Things Wrong Ordered the right equipment but installed incorrectly Right Things Right Ordered the right equipment and installed correctly

Wrong Things Wrong Ordered the wrong equipment and installed incorrectly

Wrong Things Right Ordered the wrong equipment but installed correctly

3. Nursing Audit an examination, a verification or an accounting of predetermined indicators. The three basic forms are: 3.1 Structure audit focuses on the setting in which care takes place: physical facilities, equipment, caregivers, organization, policies, procedures and medical records are measured by means of checklist. 3.2 Process audit implements indicators for measuring nursing care to determine whether nursing standards are met. Generally task-oriented 3.3 Outcome audit evaluates nursing performance in terms of establishing client outcome criteria: may either be concurrent or retrospective

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Control Techniques 1. Nursing rounds cover issues like patient care, nursing practice and unit management 2. Nursing operating instructions policies which become standards for evaluation as well as controlling techniques 3. Gantt charts depict a series of events essential to the completion of a project or program 4. Critical control points and milestones specific points in a master evaluation plan at which the nurse judges whether the objectives are being met, qualitatively and quantitatively. 5. Program Evaluation and Review Technique (PERT) uses a network of activities, each of which is represented as a step on a chart. Includes time measurement, an estimated budget and calculation of the critical path (the sequence of events that would take the longest time to finish) 6. Benchmarking technique whereby an organization seeks out the best practice in its industry so as to improve its performance. It is a standard or point of reference, in measuring or judging quality, values and cost.

What is

5 S?

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What is 5S? Is a systematized approach to organize work areas, keep rules and standards, and maintain the discipline needed to do a good job. It utilizes workplace organization and work simplification techniques to make work easier, faster, cheaper, safer and more effective. The practice of 5 S develop positive attitude among workers and cultivates an environment of efficiency, effectiveness and economy. Other Benefits of 5 S

5 S improves
CREATIVITY of people COMMUNICATION among people HUMAN RELATIONS among people TEAMWORK among people enhances COMRADESHIP among people gives VITALITY to people

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WHY 5 S 1. Workplace becomes clean and organized. 2. Work becomes easier and safer. 3. Results are visible to everyone. 4. Visible results trigger generation of more and new ideas. 5. People are automatically disciplined. 6. People become proud of well-organized workplace. 7. Resultant good image of the organization generates more business and positive impression to the public. SEIRI (Sort) Remove unnecessary items and dispose them properly Make work easy by eliminating obstacles Provide no chance of being disturbed with unnecessary items Eliminate the need to take care of unnecessary items Prevent accumulation of unnecessary items Some SEIRI Practices 1. Sorting and evaluation criteria 2. Disposal tags 3. Designated storage area 4. Disposal procedure 5. Material list SEITON (Systematize) Arrange necessary items in good order so that they can be easily picked up for use Prevent loss and waste of time Easy to find and pick-up necessary items Ensure first-come-first-served basis Some SEITON Practices 1. Place goods in wider frontage along passages 2. Store goods for first-in-first-out retrieval 3. Have a fixed location for everything 4. Label items and their locations systematically, mark everything 5. Separate special tools from common ones 6. Put frequently-used items nearer to the user 7. Make things visible to reduce searching time, organize by color 8. Do not pile up items without separator 9. Put everything at right angles to the passage line 10. Fix unstable articles for safety 11. Provide signs for abnormal condition or when help is needed 12. Keep space for safety equipment and evacuation passages clear SEISO (Sweep) Clean your workplace completely

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Easy to check abnormality Prevent machinery and equipment from deterioration Keep workplace safety and easy to work

Some SEISO Practices 1. Big Seiso (Clean-Up) Day 2. Put aside 3 5 minutes cleaning daily 3. Assign owner to each machine 4. Combine cleaning with inspection 5. Make daily maintenance points clear by providing visible instructions 6. Provide necessary tools for critical points of cleaning 7. Prevent causes of dust and dirt (Do not wait until things get dirty) SEIKETSU (Standardize) Maintain high standards of housekeeping and workplace organization at all times. Maintain cleanliness and orderliness Prevent misoperation Make it easy to find out abnormality Standardize good practices Some SEIKETSU Practices 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Visual control signs Color coding Foolproofing (Poka-yoke) Responsibility labels Wire Management Inspection marks Maintenance labels (Create a maintenance system for Housekeeping) Prevention of dust, dirt, noise and vibration I-can-do-it blindfolded One-point lessons VISUAL CONTROL

Visual Control is a technique to enable people to make the rules easy to follow, differentiate normal and abnormal situations and act accordingly, with the use of visual aids. TYPES OF VISUAL CONTROL 1. 2. 3. 4. 5. 6. 7. Display to help people avoid making operating errors Danger alerts Indicators of where things should be put Equipment designation Cautions and operating reminders Preventive maintenance displays Instructions

QUALITY
The TOTALITY of features and characteristics of products or services that bears on its ability to satisfy stated and implied needs.

ISO 8402

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SHITSUKE (Self-discipline) Enhance autonomous management activities (Do things spontaneously without being told or ordered) Maintain the discipline needed to do a good job Upgrade productivity and quality consciousness

Some SHITSUKE Practices 1. Wash hands after going to the toilet 2. Wash hands before and after meals 3. Eat and smoke at designated areas 4. Keep workplace always clean and tidy 5. Wear clean uniform and shoes 6. Observe proper office decorum 7. Follow safety rules 8. Put things back in their proper place after use 9. Work according to standards 10. Treat workplace as your second home 11. Always remember that much of your waking time is spent in the workplace 12. Practices the above-mentioned 4Ss until it becomes a habit What can an individual gain from 5 S? Makes our workplace pleasant Makes our work more efficient Improves our safety Improves quality of our work and our products What can a company gain from 5 S? A clean and well-organized workplace Is high in PRODUCTIVITY Produces QUALITY products and services Reduces COST to a minimum Ensures DELIVERY on time Is SAFE for people to work in Makes employee MORALE high Why 5S brings such benefits? 5S gives vitality to people 5S rationalizes operation of the company

PRODUCTIVITY .above all, an attitude of the mind. It seeks to improve what already exist. It is based on the belief that one can do things better than yesterday and better tomorrow than today. Atsuko Ishiwara, JICA Expert

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CONCEPTS IMPORTANT TO LEADERSHIP & MANAGEMENT

A. TIME

MANAGEMENT
Gain control of your time, and you will gain control of your life. Anonymous.

Time and Planning

When you get your personal life organized, you will become effective n getting priorities accomplished at home. When you get your school activities organized, you will study more effectively, be less stressed, and be able to prioritize more effectively. With these two areas organized, there will be more time for you to spend on yourself! You will find that once you get organized with your clinical schedule, you will become a more effective nurse and begin to have the time to perform the type of nursing care that you were taught. Often you will hear nurses complain about not having enough time in clinical to provide the type of bath or teaching they would like to do because of the lack of time. Check them out; most often they are the most guilty of wasting time (e.g. taking time to gossip after report, wasting time complaining that they do not have enough time, not delegating effectively, allowing unnecessary interruptions, not organizing their patient care, or not delegating when appropriate). Work hard, and you will have a lot of food; WASTE TIME, and you will have a lot of trouble. Proverbs 28:19 Time Management - is a technique for allocation of ones time through the setting of goals, assigning priorities, identifying and eliminating time wastes and use of managerial techniques to reach goals efficiently. THE URGENT VS. THE IMPORTANT URGENT BUT UNIMPORTANT URGENT & IMPORTANT

B
THE 80/20 LEADER NON-URGENT & UNIMPORTANT

C
THE CRISIS LEADER NON-URGENT BUT IMPORTANT

A
THE SHUFFLER

D
THE PLANNER

Beginning in the lower left corner with quadrant A, we find people who are caught with the shuffles. They dont really know where to turn to escape the trifling minutia that demand attention. E.g. the demands of the trivial, the unimportant, the inconsequential, the irrelevant -- puny problems, sometimes the junk mails. Quadrant

B:

Someone did a survey on a leaders urgent telephone interruptions while in personal conference with someone else. The result: 70% of the telephone calls were less important than the issues involved in the personal conversation. The 80/20 rule said the that we tend to spend

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80% of our time on what produces just 20% of the results. Apparently we devote most of our time to that which may be urgent but often turns out to be unimportant. As managers we must work toward turning the ratio around. Lets spend our time on things that bring the greatest results Quadrant

C.

Nothing is wrong with the important. But if the important item is always in the urgent position, youve got a crisis. There are times that crisis leadership is th e way to go. If there is a fire in the house, thats urgent and important. But who wants to be putting out fires everyday? There is a better way to manage the work we do within the time frames we have. This brings us to

Quadrant D: If you can truly deal with the important before the important becomes urgent, you are a winner. You will not only save time but save the need to manufacture energy bursts that frustrate you and everybody around you. How do you get into the 4th quadrant? You organize and prioritize your life. Good planning wont rid you of all your hassles or lightweights but it will help you evaluate where you may be operating from the many situations you face everyday. If you spend most of your time on the important rather than the urgent, you will accomplish much more than most other people --- and thus save a whale or a lot of time.

MANAGING TIME in THE CLINICAL SETTING

One of the main sources of job dissatisfaction reported by nurses is too little time. This limited time to provide patient care has been accelerated by the nursing shortage and the increase in numbers of patients and the acuity of these patients. In response to these issue, nurses must develop competent skills in time management and priority-setting. Nurses can use several techniques to maximize the time spent providing patient care. Remember the 80/20 rule. Another example 20% of your patients will require 80% of you time! Those 20% should be the sickest patients; when their care and needs Time management and work organization can be challenging are met first, then the rest of the assignment is much easier. It will be important to determine which patients require the most time (the 80%): do they require time that can be delegated to someone else, or do they require the time because they are the most unstable and ill patients.

GET ORGANIZED BEFORE THE SHIFT REPORT Develop your personal flow sheet, or use one provided by the agency to write down information you need to begin coordinating care for the group of patients. Modify this form as you discover areas needing improvement. Make several copies so you will always have one handy. Avoid gossiping and other distractions as you receive a report and begin to fill out your time-management ( or work

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organization) form. Get the information needed to plan the care for your patients, and begin to organize your shift activities. ~ Critical Thinking: Can you prioritize and delegate this RNs assignment appropriately?

WORK ORGANIZATION WORKSHEET

Time 7-8 Activities MAR Room 416 Room 417 Room 418

Shift report Vitals

8-9

Blood sugar 7:30 insulin

IV @ 125 /hr Turn pulses Meds x2 9 lf leg dsg Assists with meal Complete bath Pulses Turn Turn Pulses Assist with meals

Assessments Meal

Meds x 3-9 up for meals Shower Chg bed Pain meds Up for meals Bld sugar Insulin ? Meds x 2 - 12

7:45 pre-op NPO Consent form To OR

9-10

10-11 11-12

Chart Meal trays lunch

Chg bed

12-1

Chart assessment
1-2

IVPB - 12 Turn Pulses Lf leg dressing change

Return frm OR? NG suction I.V.

Diabetic teaching

2-3

I & Os IVs Report info

Prioritize patients by using the ABCD system or Maslows Hierarchy of Needs. Of highest priority are the patients with problems or potential problems related to the airway, next are those having any difficulty with breathing, and then circulation. When using Maslows Hierarchy of Needs to assist with prioritization, you need to meet physiological needs first: that is, resolve any difficulty with oxygenation first. Again, remember to be flexible and reprioritize as emergencies occur.

For example, a characteristic assignment for the day could be: A patient who is 1 day postoperative and wants something for pain. A geriatric patient who is vomiting. A patient with diabetes who is angry about the care from the last shift. A geriatric who has soiled the bed with urine.

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Which of these patients needs your immediate attention? Most likely the one who is vomiting because he is at increased risk for aspiration, then probably the patient who is in pain, then the angry patient, and so on. With each patient, you may spend less than 5 minutes in the room before you move on the next patient. But you will have a good idea of what each patients immediate needs are. Identify the busiest times on the unit; do not schedule a dressing change when medications need to be given. Plan on preparing medications at least 30 to 45 minutes before the hour they are due. This will provide time to research any medications with which you are unfamiliar. Do not procrastinate; start early. If you have dressing changes for several patients, start with the cleanest and progress to the more contaminated wounds. If you have diabetic teaching for three patients, maybe you can get them together and do it at one time. Critical Thinking # How do the efficient nurses on your clinical unit prioritize their time and their patients? PRIORITIZE YOUR CARE Setting priorities has become difficult in relation to the dichotomy between the expected outcomes of efficiency and effectiveness and the perceived limitation of resources, including time. Priority setting is not only based on patient needs, but it is influenced by the needs of the organization and the accountability of the nurse. Priorities are established and reprioritized throughout the day according to patients assessed needs and unscheduled interruptions, both minor and emergent. Plan your day aro und the patient that you perceive to be the sickest. This is the patient who is at the greatest risk of harm if you do not address his needs first. Prioritize your patients after you receive report and immediately proceed to the patient whom you have placed highest on your priority list. Remember, this prioritization may change as you complete your initial assessments. Additional modification will be made according to the placement of patients rooms to avoid wasted time and movement. When you first enter the patients rooms, introduce yourself as you wash your hands and complete a quick environmental assessment. Think about any supplies you will need when returning to the room. Complete the focused assessment, validate the safety of your patient, and proceed to your next patient. Once you have completed your initial rounds, reassess your initial prioritization, modify according to your assessments and plan your day. PLAN TIME FOR CHARTING

Do not put charting off until the end of the shift. On a busy unit, you will forget half of what you have done for all your patients by the end of the day. How many times have you seen staff nurses staying late so they can complete their charting? Make notes for charting on your work organization form, and cross through it when it is charted. Plan on stopping about three to four times a shift to make charting entries. Do not obliterate anything on your form because you will need the information for an accurate shift report Watch for those nurses who always seem to get everything done, done well, and still enjoy

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nursing. Ask them about their secrets of time management, and try out some of their tips. REQUEST CONSISTENT PATIENT ASSIGNMENTS WHENEVER POSSIBLE This allows you to develop relationships with your patients and their families and promotes time management as you become familiar with the special needs of these patients. ORGANIZE YOUR WORK BY PATIENT By using this technique, the nurse maximizes the number of tasks that can be accomplished with each visit to the patient. The nurse thinks strategically about How can I multitask or accomplish several objectives in one visit to the patient? By using this technique, the nurse would combine the assessment, administration of medications, and teaching during one patient visit.(refer to work organization sheet) DEVELOP AND USE ASSERTIVE COMMUNICATION Assertive communication is a technique used to get ones needs met without purposely hurting others. It incorporates the principles of therapeutic communication, active listening skills, and willingness to compromise. When you use these skills, you will be able to express yourself more effectively during challenging situations and handle confrontation in a professional manner. When you are confronted by a situation that provokes anger, take a deep breath, pull yourself away, get your emotions under control, and then approach the individual privately in a nonthreatening manner. Following are some hints for using assertive communication: Use I statements: I am really upset..

Describe the behavior that has upset you and focus on the present: :You have been having excessive personal telephone calls over the past 2 days.. Discuss the consequences of the behavior: this behavior is contrary to the agency policy and could result in. State how the behavior needs to be modified and the time for this change: You must immediately stop this interruption to your work and request that only emergency phone calls be.

Hints that can help you make use of time: (by Don Reynolds, Adventist Education, Dec-Jan. 1993) 1. Be industrious but not over- anxiously busy. A relaxed attitude lengthens a mans life (Prov. 14:30). Solomons analogy about ants has much to teach us on this point. They busily but calmly do whatever needs to get done. 2. Avoid spinning your wheels. Be like Mary. Among all the things clamoring for attention, keep focused on whats important. 3. Do it now if possible. Postponing something that can be done immediately wastes time. E.g. if a memo in your hands should be processed immediately but you set it aside for later actions thats inefficient as well as stress-producing 4. Share our workload. Many of you have readers or teacher aides. Some do not utilize them to their full potential. Then there are volunteers. This kind of help is available as never before are living longer and retiring earlier. WE need to tap into this growing pool of talent.

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5. Use your time twice. During your travel time you can listen to audiotapes. Or fill them with your own dictation your creative thinking, planning ideas or whatever. 6. Chart your energy cycle. Some people are morning people. They are ready to go when their feet hit the floor at 6:00 a.m. Otherswell dont talk to them for the first 30 minutes in the morning. They dont reach their peak of productivity until later in the day. Chart your own energy cycle and work accordingly. 7. Settle rifles quickly. Its surprising how much time this can save. If it doesnt make any particular difference which way it goes, settle it quickly! Which route should we take? Little or no difference settle it now. 8. Eliminate the things you shouldnt be doing. Ask yourself these questions: (1) What am I doing that should not be done by me or by anyone else? (What can I stop doing and no one will be affected or know the difference?) (2) What am I doing that should or could be done by someone else? Delegate is the one-word answer here. When you assign a task to someone else, also give that person enough authority to get the job done. 9. Develop foresight. Insight is one thing; foresight is quite another. Foresight deals with the future, and the demands planning. Little planning time means more work time. Adequate planning time means less work time. And the total time (work time and planning time) will be less when planning time is right. The value of planning ahead is as valid as this text: If your axe is dull and you dont sharpen it, you will have to work harder to use it. It is smarter to plan ahead (Ecclesiastes 10:10) If you dont do regular and effective long-range planning, you are not taking your job seriously. When you will end up with these four key questions in almost any area of your administration. Where are we now? Where do we want to go? How will we get there? How ill we know we have arrived? 10. Schedule regular meetings. This can save everybodys time. You dont have to meet just because you are scheduled to. If there isnt an agenda, cancel the meeting. No one will be too upset! 12. Plan for the unexpected. In your daily schedule, program some time for the unavoidable unexpected things that always happen. You will have fewer stress symptoms, and maybe even fewer ulcers. 13. Make a to do list. List what needs to be done for the day and for the week, and then prioritize attack the major duties. Time is irreversible, irreplaceable, inelastic, and keeps on happening. All of us have the same 0 minutes in an hour. The same 168 hours each week, the same 65 days each year. What makes effective is getting organized and managing ourselves well.

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Other Time-saving Technique, Devices, and Methods to Better Use of Time 1. Conduct an inventory of your activities. Identify your time problems. Examine your old habits that get in the way of using your time well. Examine how and when you procrastinate and understand why you are doing so. 2. Set goals and objectives and write them down. Set priorities. Plan on making things happen than on reacting to crises. 3. With the use of calendars, executive planners, logs or journals, write what you expect to accomplish yearly, monthly, weekly or daily. Use an easy method to keep these information concise and organized. 4. Break down large projects into smaller parts. Do first things first and concentrate on one thing at a time. Get all the data you need to avoid breaks in your work. Complete each task the first time. 5. Devote a few minutes at the beginning of each day for planning. At the end of each day, account for the tasks you have accomplished. Prepare a list of what is to be done the following day. 6. Organize your work space so it is functional. Sort paper work on your table according to priority. 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 more time in training and motivating people than to doing the technical work. To accomplish this, activities and tasks should be delegated to the lowest practicable level. 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. Maintain a telephone log so you can return calls at one time if possible. Prior to call, outline your basic points. Move immediately into the business of the call. 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.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 11: Please write the letter of your choice in the space before the number ___1. This refers to a technique for allocation of ones time through the setting of goals, assigning priorities to reach goals efficiently. a. Time and Planning b. Time management c. Time organization d. |Scheduling ___2.A type of a leader that in most times deals more with the urgent and important: a. The Planner b. 80/20 leader c. Shuffler d. Crisis leader ___3. In this, you will not only save time but save the need to manufacture energy bursts that frustrate you and everybody around you. a. The Planner b. 80/20 leader c. Shuffler d. Crisis leader ___4.In using the Maslows Hierarchy of Needs, of highest priority are patients with problems or potential problems related to: a. difficulty of breathing b. circulation c. airway d. fluid ___5. ____ is not only based on patient needs, but it is influenced by the needs of the organization and the accountability of the nurse. a. Time management b. Priority setting c. Priorities d. Staffing ___6.Once you have completed your initial rounds, ______ your initial prioritization, modify according to your assessments and plan your day. b. Identify d. Assess c. Reassess d. Write down ___7.This allows you to develop relationships with your patients and their families and promotes time management as you become familiar with the special needs of these patients: a. Organize your work by patient c. Plan time for Charting b. Develop and use assertive communication d. Consistent Patient Assignments ___8.A technique used to get ones needs met without purposely hurting others: a. Assertive communication c. Facilitative messages b. Facilitative communication d. Therapeutic communication ___9. This technique will help the nurse maximize the number of tasks that can be accomplished with each visit to the patient. a. Prioritization of Care c. Consistent Patient Assignment b. Planning of Time for charting d. Organizing work by patient ___10.Work hard, and you will have a lot of food; __________, and you will have a lot of trouble. a. Waste time b. Waste resources c. Waste money d. Procrastinate

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B. CHANGE Change is the process of making something different from what it was ( Sullivan & Decker, 2001, p.249) i. Different actions are performed to achieve outcomes ii. Goals or outcomes may or may not change iii. Most changes are implemented for positive reasons ( to improve patient care, efficiency, accuracy) iv. Most organizational changes are planned and purposeful

The CHALLENGE OF CHANGE Change is frightening only when you are not a part of it or you have no input into it. The staff nurse has a responsibility to provide input, even if it is not invited, and to become involved in the planning and implementation of change. Equally important is the evaluation of change. Evaluating honestly and making necessary modifications are as important to the success of a change project as the planning and orderly implementation. If nothing else is learned, learn to embrace change as an opportunity to improve client care and to advance the profession of nursing. Look at conflict resolution as an opportunity to learn something new or as the opportunity to persuade others. Most change is implemented for a good or reasonable purpose. Most organizational change is planned. The change is intentional and goal-oriented, with activities that are proactive and purposeful. If employees do not understand the reason behind change, they should ask. TYPES OF CHANGE 1. Personal change a. made voluntarily for ones own reasons, usually for self-improvement. May include altering your diet for health reasons, taking classes for self-improvement, removing yourself from a destructive or unhealthful environment or situation. b. For example, a nurse moves to a smaller hospital setting to decrease stress and work day instead of night hours or a nurse changes work setting to become a telephone triage nurse after sustaining a back injury while lifting patients in a long-term care facility. 2. Professional change a. Voluntarily and planned change in a job position or obtaining credentials ( training or education), to further an individuals career goals b. For example, a nurse seeking professional change may take a nursing certification examination or choose to work in a different specialty area for professional development. c. It is often planned and can involve extensive change in both your personal and professional lives. Although either personal or professional change may be stressful, if it is voluntary and carries intrinsic or extrinsic rewards, it is often considered important and worth the stress. 3. Organizational change a. Planned and change undertaken to improve outcomes, efficiency, financial standing, or to meet some other organizational goal b. Changes in organizations may take employees by surprise if plans are not clearly communicated

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c. For example, an organization decides to move all nurses from eight-hour to twelve-hour shifts. This is a major operational change and those affected need to be informed about and include in the change process. d. Organizational change that is not handled well causes an increase in staff stress and resistance and often mistrust of management ( Sebastian, 1999; Anderson, 2003). Organizational change can affect 5 different aspects of an organization: its culture, structure, technology, physical setting, and human resources. Changing an organizations culture may be one of the most difficult changes because the underlying values and goals of the organization need to change. a. Changing structure involves altering authority relations, job redesign, or similar structure variables. b. Changing technology includes modification in the way work is processed, or in the methods and equipment used. c. Changing the physical setting involves altering the space and layout arrangements. d. Changing human resources refers to changes in employee skills, expectations, or behavior. Note: The first thing that a manager need to know about the change process is that resisting change is a natural response for most people. All of us are most comfortable in our state of equilibrium, where we feel in control of what we are doing. To deal effectively with change, it is important to understand that every change can be understood, evaluate in light of its impact on the individual, and one hopes, eventually be embraced.

Various reasons why people resist change, and understanding them will help the manager to implement the change process effectively. The following are the most common factors that cause resistance to change: A perceived threat to self in how the change will affect the individual personally A lack of understanding regarding the nature of change A limited ability to emotionally cope with change A disagreement about the potential benefits of the change A fear of the impact of the change on self-confidence and self-esteem Those who want to change have a tendency to push, but those who are being asked to change tend to push back to maintain things as they were. PLANNED OR UNPLANNED Change can be planned or unplanned. Planned change is more productive & it occurs when there is a directed and designed implementation of some element within the organization. Changes can affect all aspects of an organization, including policies, goals, organizational philosophy, work environment, and even structure. Planned change can be used for all sorts of projects, ranging from the minor to the most complex. Unplanned change, sometimes called reactive change, occurs when a problem forces a person or organization into a situation in which it must respond. These changes are often minor but sometimes can involve projects that are large in scope and complexity. Examples in nursing include changes in staffing because of nurse who call in sick, clients who experience cardiac arrest, or even equipment failures, such as when electricity fails or a water main breaks. Nurses often take on the role of the change agent, that is, the one who brings about the change.

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Nurses as change agents (one who is responsible for bringing about change) a. In institutions a. Nurses are most significant determiners of the length of patient stay in hospitals b. Nurse expertise and organizational skills determine cost and quality of care provided c. Nursing is the largest part of any organizations personnel budget d. Organizations known for outstanding nursing care have a competitive advantage in the health care marketplace. b. Outside institutions a. Nurse change agents help move the health care system from a medical to a nursing model b. Promote healthy living c. Develop and manage prevention programs d. Create quality, cost-effective care for a wide range of patient populations e. Provide case management services for most efficient use of technology and other resources f. Fill service gaps after people leave institutions g. Work as advocates for undeserved populations c. Entrepreneural role of nurse change agent a. Entrepreneurial nurses see change as healthy b. Characteristics of entrepreneur nurse include imagination, ingenuity, and persistence c. Changes in nursing roles resulting from entrepreneurial change include advanced practice nursing, case management, critical paths, and other professional practice models. Dos and Donts of Effective Change Agents Dont develop a sense of trust o have a hidden agenda establish common goals o be unpredictable facilitate effective communication o miss or reschedule meetings frequently establish a strong team identity o use threats or bluffs to manipulate contribute as much as possible members find reasons to celebrate and recognize o volunteer to be the record keeper accomplishments o follow the rest of the crowd.

Do

o o o o o o o

Change in nursing environments A. According to Marquis and Huston ( 2000), there are three basic reasons to introduce change: a. solve a problem; for example, inadequate staffing of RNs for a hospitals weekend or holiday shifts b. improve efficiency; for example, provide care for postoperative patients using the most costeffective mix of credentialed and noncredentialed care providers. c. Reduce unnecessary workload on a person or group, for example, to ensure that an RN on the 311 p.m. shift is supervising no more than a certain number of assistive staff. B. Other reasons why change occurs in the nursing environment a. Technology. Automation for patient recordkeeping, billing, and diagnostics is constantly changing and becoming more networked. Although few organizations are completely paperless the trend is toward more, not less, technology. b. Changes in corporate structures. Restructuring is an ongoing activity, as organizations try to survive changing demands and markets by adding, expanding, or reducing services. c. Reimbursement. Pressure from payors and others, such as governments to control spending by emphasizing preventive care and less expensive outpatient vs. more costly inpatient services.

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d. Advances in treatment and medications. Increasing emphasis on preventive treatments, community health initiatives, outpatient services, ambulatory surgery centers to meet patient care needs most effectively while controlling cost. e. Biomedical discoveries. Stem cell research, genetic therapies that can cure disease and improve quality of life. CHANGE AGENT CHARACTERISTICS AND STRATEGIES A. Effective change agents tend to have most of the following characteristics, which can be cultivated and practiced: Ability to combine ideas from a variety of unconnected sources Ability to energize and motivate others Well-developed interpersonal skills, including group management and problem-solving skills Ability to work with system details while keeping the big picture in mind A balance of flexibility and persistence effective change agents are open-minded enough to see when they need to change, but are persistent enough to stick with their ideas in the face of nonproductive resistance from others. Confident and not easily discouraged Ability to think realistically and strategically Ability to inspire others trust in them; often occurs due to a history of integrity and success with other change efforts Ability to articulate ideas and vision Ability to handle resistance from those who oppose change B. Change Agent Strategies that can be used to facilitate change, depending on the amount of resistance and the characteristics of the change agent: a. Power-coercive a.1 application of power by legitimate authority, such as law, policy, or financial appropriations a.2 people in control enforce changes; those not in power may not even be aware that changes; those not in power may not even be aware that changes are occurring and, even if aware, have little or no power to alter the course of change a.3 leadership response to resistance: accept it or leave it a.4 used when high levels of resistance are expected, change is critical, time is short, and there may be little or no chance of securing organizational consensus. a.5 an example is the governments change in payment for patient care based in a diagnosisrelated group (DRG) rather than costs b. Empirical-rational b.1 Knowledge is the most powerful element for change b.2 This model assumes that people are rational and will act in their own self-interest, when that self-interest is made clear to them b.3 Assumes that the change agent is able to persuade people that changes will benefit them b.4 Effective when there is little resistance to change and the change is perceived as reasonable or beneficial b.5 This model could effectively be used to implement a technology change; for example, having nurses use PDAs to track procedure scheduling in an outpatient surgical setting. The change agents job would be to explain the benefits to staff and patients of such a system as well as to provide appropriate training and backup, to further decrease any resistance.

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c. Normative-reeducative c.1 assumes that people act in accordance with social norms and values, and that they are less likely to change, based on information and rational arguments c.2 change agent focuses on peoples behavioral motivators such as roles, relationships, attitudes, and feelings rather than rational motivators. c.3 emphasis is not on persuasion but on interpersonal relationships between the change agent and the people he or she is influencing to change. c.4 seen as an effective way to implement change in a health care environment c.5 effective for starting new services, for example, a postsurgical follow-team, or to make systematic changes, for example, changing from inpatient to ambulatory surgical programs. All change requires the ability to overcome resistance to change (called restraining forces) by a driving force that pushes toward change. When the driving force and restraining forces are equal, then no change occurs and the status quo is maintained. Change occur only when the driving force is greater than the restraining force. Those who want to change have a tendency to push, but those who are being asked to change tend to push back to maintain things as they were. It is important when attempting to implement change to identify the restraining forces and ways to overcome them. Habit, comfort, and inertia are the three most common restraining forces. Planned change works best when it is well organized, proceeds at a steady pace, and has a definite date for achievement. There is a level of excitement that raises energy levels when a change is near completion, but postponing the date for the change can drain that energy and lead to disappointment. THEORIES OF CHANGE How change occurs fall in two categories: Linear change theories ( assumes that change occurs in a step-wise, logical way) and nonlinear change theories ( assumes that change is more chaotic than controlled). A. Traditional (linear) change theories include: a. Lewins Force-Field Model (1951) which is made up of 3 steps: 1. Unfreezing refers to the thawing of the current or old way of doing things. Individuals begin to be aware of the need for doing things differently, that change is needed for a specific reason. 2. Movement (moving to a new level) intervention or change is introduced and explained. Those affected by change learn its benefits and disadvantages therefore are discussed, and the change the move to a new level is implemented. 3. Refreezing the change or the new way of doing or operation becomes the norm as it is incorporated into the routines or habits of the people affected. b. Lippitts Phases of Change (1958) . Derived from Lewins model but defines seven total steps in the change process. 1. Diagnose the problem: for example, inadequate supervision of assistive staff 2. Assess motivation and capacity for change: does the staff want to be more closely supervised; is an RN available and willing to take on this challenge? 3. Assess change agents motivation and resources: does the RN have excellent organizational and communication skills? Is he or she motivated by the desire to improve how patient care is delivered ( as opposed to doing supervision to avoid other job responsibilities)?

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4. Select appropriate progressive change objectives: for example, in the next month, assign all staff to a mentor , institute weekly meetings of noncredentialed personnel, and arrange for the supervisory RN to complete a managing difficult people course. 5. Choose appropriate role for change agent: for example, mentor, facilitator ( rather than criticizer or enforcer) 6. Maintain the change once it has started: provide logistical support to meet the RNs needs to continue to act as a change agent; provide feedback forum for the assistive staff 7. Terminate the helping relationship: once the change is instituted and has become the norm, no need to supervise the supervisor or otherwise oversee his or her staff. c. Havelocks six-step model. Like Lippits model, this is based on Lewins model, but breaks the change process into additional steps. Havelock particularly emphasized the essential role of planning in any change endeavor Planning Stage: c.1 build a relationship: people affected by the change need to be involved in it, and this occurs through building relationships in the organization c.2 diagnose the problem c.3 acquire resources: gather the money, technology, staff, etc. needed to successfully implement change Moving Stage: c.4 choose the solution c.5 gain acceptance for the solution: Havelock believed that this step would occur only if the first step ( building relationships) had occurred. c.6 Stabilize and self-renewal: organization functions on the new level; change becomes part of the norm and the organization enjoys the benefits of the change. d. Rogers Diffusion of Innovations theory ( 1983) this emphasizes the changeability of change itself that efforts to implement change may be rejected at first, then later accepted. The initial word is not the final word. This method involves a five-step process of innovation and decision-making. 1. Knowledge: people who can make the decision are introduced to the change and begin to understand it. For example, a home care agency begins to learn about telemonitoring technology for patients with CHF. 2. Persuasion: people form a favorable ( or unfavorable) attitude about the change. For example, some nurses discuss how the technology saves travel time, while others express their frustration with computer compatibility problems in the field. After a time, a general perception forms ( such as:there are glitches but the system works overall or the technol ogy is flawed and increases our workload). 3. Decision: people engage in various activities that lead to a decision to either adopt or reject the change. For example, nurses with more computer experience mentor others in troubleshooting; supervisors call all nurses using the telemonitoring technology, and have them fill out a survey that rates their satisfaction or dissatisfaction about the telemonitoring program. Supervisors then solicit specific feedback that can guide modifications when necessary. 4. Implementation: the change is put into action; at this stage, the change maybe adapted to better fit the situation. For example, the home care staff may decide to add an autorecord feature to a blood pressure monitor, to compensate for inaccurate reporting by visually impaired patients. 5. Confirmation: decision makers seek reinforcement that their decision was correct; conflicting feedback might result in the nurses look for data that confirm that technology benefited both patients ( avoiding rehospitalization) and nurse ( less travel, quicker response time).

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B. Nonlinear change theories a. Chaos theory developed by Thietart and Forgues and they say that: a.1 most organizations have the potential to be chaotic a.2 organizations often undergo a series of rapid changes, and stabilize until the next round of rapid changes occurs a.3 leadership in these organizations must be flexible and able to respond quickly and appropriately to the rapid changes THEORIES ABOUT REACTIONS TO CHANGE. Bushy identified 6 behaviors that people exhibit in response to change: 1. Innovators: people who enjoy the challenge that change brings and often instigate or implement change 2. Early adopters: open to change; will work with change that is brought to them but are not as change-focused as their innovators 3. Early majority: people who enjoy the status quo but who will adopt change earlier than average, to avoid being left behind. 4. Later majority: slower to adopt change; often express reluctance about or skepticism of change efforts. 5. Laggards: last people to adopt to change; may be suspicious of change; prefer stability and tradition 6. Rejectors: people who openly oppose or reject change; they maybe direct or indirect in their resistance. The Change Truck how will you respond? React - move out of the way. Let the truck (change) pass you by. However, opportunities may be missed. Do not act just stand there and let the truck run over you. It will leave you behind and more than likely in worse shape than when you started. Act start running when you see it coming. Pace with it until you can decide when to jump on and steer it in the direction you want to move.

Example: Patti is working in a medical-surgical unit at a 200 bed acute-care hospital. She constantly hears her peers complaining about the lack of adequate nursing staff, and over the past 3 months, two full-time staff nurses have resigned. To cover the unit, part-time staff from temporary agencies and from the hospital staffing pool are being used to supplement the remaining regular staff. Because this staff has little orientation to the unit and is frequently assigned where they are needed the most, the continuity of care and a potential for increased errors in patient care became a major concern. Rather than continuing to complain about the situation or considering leaving it, Patti decided to act and try to steer the change truck. She approached a few of the nurses and initiated a discussion about the changes in staffing and how scheduling had become a nightmare for the charge nurse. She enlisted the

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support of several of the staff to begin problem solving possible outcomes. They agreed that increased staffing was probably not a possible immediate solution and determined to work within the constraints that they had. Several of the pool nurses were receptive to requesting that their assignment be limited to this one unit and agreed to schedule their hours to complement each other. This, in essence, would add a shared full-time position, at no additional cost, and would also provide consistency of patient care. When the proposal was presented to administration, they agreed to support the idea on the basis of its economic and patient-centered benefits. Strategies the change agents can use to manage change (Anderson 2003). 1. Articulate vision a. use the same key words for all discussions about the change b. constantly remind people of the goals and vision the positive things that will come as a result of the change 2. Map out a timeline for the change and the steps required 3. Plant seeds a. talk to key people in the organization about what will happen or what is expected; use and repeat key words or core message(s) b. information will quickly filter through the rest of the organization 4. Carefully select the change project team, making sure that a. stakeholders are strongly represented b. there are sufficient experts to evaluate the change c. people who are expected to resist change are also included 5. Create consistency a. set and keep meeting dates b. use timeline to stay on track with change process activities 6. Provide regular updates a. in writing b. to supervisors, peers, and subordinates 7. Deal with conflict directly a. check out rumors; it is essential for change agent leaders to tap into the grapevine the informal communication structure of any organization. Even if information being passed on the grapevine is incorrect, it establishes a reality for many of those who will be affected by change. b. Do not seek conflict, do not ignore it either 8. Maintain a positive attitude, and avoid getting discouraged in the face of resistance 9. Be aware of political forces at work a. get consensus on key actions as the change process progresses, especially for issues of policy, finance, or operating philosophy b. recognize barriers that arise and work to get consensus to overcome them 10. Know who the leaders are a. recognize both formal and informal leaders b. create a relationship with them and consult them regularly 11. Maintain self-confidence and foster trust with others CHANGE AGENT STRATEGIES ( Lancaster, 1999) Following are some strategies the change agent can use in managing process: 1. Begin by articulating the vision clearly and concisely. Use the same words over and over. Constantly remind people of the goals and vision.

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2. Map out a tentative timeline and sketch out the steps of the project. Have a good idea of how the project should go. 3. Plant seeds or mention some ideas or thoughts to key individuals from the first step through the evaluation step so that an idea of what is expected is under consideration. 4. Select the change project team carefully. Make sure it is heavily loaded with those who will be affected and other experts as needed. Select a variety of people. For example, an innovator, someone from the late majority group, a laggard, and a rejector are probably good to include. These people provide insight into what others are thinking. 5. Set up the consistent meeting dates and keep them. Have an agenda and constantly check the timeline for target activities. 6. For those not on the team but affected by the project, give constant and consistent updates on progress. If the change agent does not update staff, someone on the project team will, and the change agent wants to control the messages. 7. Give regular updates and progress reports both verbally and in writing to the executives of the organization and those affected by the change. 8. Check out rumours and confront any conflict head on. Do not look for conflict, but do not back away from it or ignore it. 9. Maintain a positive attitude and do not get discouraged. 10. Stay alert to political forces both for and against the project. Reach consensus on important issues as the project goes along, especially if policy, money or philosophy issues are involved. Obtain consensus quickly on major issues or potential barriers to the project from both executives and staff. 11. Know the internal formal and informal leaders. 12. Having self-confidence and trust in oneself and ones team will overcome a lot of obstacles. Additional Ways To Facilitate Change 1. Recognize and respond to the impact of change on people a. Avoid arguing with people about their feelings regarding change, and avoid telling them that it isnt so bad; support the need for change with facts that are important to people unsettled by the change taking place. b. Acknowledge with empathy that people are often unsettled by changes 2. Use communication skills to help people process the impacts of change. a. Give people a chance to talk through their feelings b. Use conversations to provide information about the change who, what, when, where, why, how c. Repeat the message. Use the 7x7 rule of saying a message seven different times in seven different ways 3. Anticipate grief a. People undergoing change often experience grief stages (shock, denial, anger, bargaining, anxiety, and sadness) b. Openly recognize that even positive change can mean the loss of a valued way of doing things, and that grief may occur. 4. Acknowledge period of confusion, when people maybe confused or unhappy about the changes that are occurring 5. Expect resistance, a natural reaction to change WHO INITIATES CHANGE AND WHY? Another aspect to consider when evaluating change is who wants the change and why. Is it the system? Is it the management? Is it you, the nurse? Or is it the patient? Change should be carefully

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planned and implemented for specific reasons. By identifying who is initiating change, the implementation can be better understood. System. The most common reason for change is that what you did before is no longer effective. For example, the handwritten medical record system is largely being replaced by the electronic medical record because the old system does not allow for the integration of the information in the record, generates volumes of paper, and is not adequate to keep pace with the number of patients and the need to access key information qusickly from various individuals both inside and outside of the traditional hospital (home health nurse or hospice nurse at the patients home). Management: Change frequently occurs when new management enters the scene. This provides a new perspective and view regarding how the system operates. For example, a new vice president of nursing decides to implement critical pathways. The overall organization may benefit from the change; however, the employee may be wondering How will the implementation of critical pathways change my job? Do I know how to implement a critical pathway?
CRITICAL THINKING What changes have you made in your life? How long did one situation last before it changed again? You have just learned to deal successfully with the changes associated with being a student. Now you are facing the challenge of change again as you prepare for your role as a practicing registered nurse.

Patient. When costumers are not happy, something within the system needs to change. What are the specific problems, and how can they be resolved? For example, patients are complaining about lengthy admission procedures. Faxing physician orders or allowing direct admission to units may streamline the admission process. Yourself. Sometimes we impose change on ourselves we may or may not like it, but we see a need for it. Who ever wanted to go on a diet and enjoyed doing it? Stop to consider how you are going to implement the change. How will your work environment be affected? Can you delegate any part of it? If change involves other employees, make them a part of that change. They will own the results that is, you will use the WIIFM principle: Whats In It For Me? Note: Change depends on your own perspective. You will be either actively involved in changes or choose to take a passive role. The choice is yours.

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Five Steps toward conquering change.

People do not change until the pain of staying the same is greater than the pain

of change
Unkown

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The table below summarizes the characteristics and helpful interventions associated with the change process. Emotional Phases of the Change Process
Phase Equilibrium Denial Characteristics High energy; feelings of balance, peace, and harmony Denies reality that change will occur; experiences negative changes in physical health, emotional and cognitive behavior. Blames others; may demonstrate envy, rage, or resentment. Efforts made to try and eliminate the change; frequently talks in such terms as If only. Interventions Explain how changes will impact the status quo. Actively listen, be empathetic and use reflective communication. Offer stressmanagement programs. Be assertive and assist with problem solving. Encourage employee to determine the source of his/her anger. Search for real needs and problems and explore ways to achieve outcomes through conflict management and winwin negotiation skills. Encourage quiet time for reflection as inner search for identity and meaning occur. Encourage expression of sorrow and pain. Have lots of patience as employees learn to go. Allow employees to move at own pace. Patiently explain again, in detail, the desired change. Assume a directive management style, assign tasks, provide direction.

Anger

Bargaining

Chaos

Diffused energy; feelings of powerlessness and insecurity and a sense of disorientation. No energy left; nothing seems to work; sorrow, self-pity and feelings of emptiness. Lack of enthusiasm as change is accepted passively. Some renewal of energy and willingness to take on new roles or assignments resulting from change. Willingly expends energy to explore new events that are occurring, reunification of emotions and cognition. Feelings of empowerment as new projects ideas are initiated.

Depression

Resignation Openness

Readiness

Reemergence

Mutually explore questions and develop an understanding of role and identity. Employees take actions based on own decisions. Adapted from Perlman D, Takacs GJ: The ten stages of change. Nurs Manage 21 (4): 34, 1990

Leaders/managers must act as role model during the change process. It is important that change is presented in a positive light, particularly because change frightens most people. Remember the phrase fear of the unknown. Does it apply to change? One can never overcommunicate when it comes to change, particularly to those affected by the change. The only thing really constant about change is change itself! Malloch (2003) suggest that change is. A never -ending journey (p.12). Every point of arrival is also a point of departure. As a result, leaders must carefully balance periods of effort and action with periods of rest and celebration so that the stakeholders will be regularly refreshed and reenergized to meet future challenges. Real world Interview
One of the things I have learned about change it to include everyone affected by the change in the plan from the beginning. Everyone is encouraged to voice an opinion regarding the change and the change process. It is understood that if their ideas are not realistic, the rationale would be explained and not ignored. This encourages everyone to be committed to the process. Sheila Joseph, BScN Unit Manager

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Note the relation between change process and nursing process Nursing Process vs. Problem Solving vs. Change Process Nursing Process Problem Solving Change Process Assessment Data gathering Recognition that a change is needed; collect data Identification of possible Definition of problem Identification of problem to nursing diagnoses be solved Selection of nursing Selection of one of possible Selection of one of possible diagnosis alternatives alternatives Development of plan Development of plan Implementation of plan Implementation of plan Implementation of plan Implementation of plan Evaluation Evaluation of solution Evaluation of effects of change Reassessment Evaluation of solution Stabilization of change in place

ROLES and CHARACTERISTICS OF THE CHANGE AGENT Lead the change process by Maintain vision of change example Communicate change, progress, and Manage process and group feelings dynamics and show others how to Knowledgeable about the adapt to change organization Demonstrate that the change is Honest and direct critical and inspire response from Respected others Intuitive Understand feelings of the group experiencing the change; engage them in the process Maintain momentum and enthusiasm

Real world Interview

I have always enjoyed trying new things and development to my potential. However, I have no patience for a manager who is not truthful. Once she pretends to have the answers, and makes up her plan as she goes, I lose all respect, and trust is destroyed. It s okay to say, I dont know, but you need to find the answer, and report back to me. Dont lie to me. Margaret Mary, RN Staff Nurse CONCLUSION As a new graduate, you will be facing many transitions, including the transition from staff nurse to a leadership position of nursing manager. Having a good understanding of management styles and your own early adoption of a leadership and management style that fits both your personality and needs of your particular place of employments nursing staff will be important to your success. Decision making skills and understanding change theory will provide you with the tools to build effective nursing management practices.

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Name: _______________________________________ Section: ______ Date: ___________ Review Questions # 12: Please write the letter of your choice in the space before the number ___1. A voluntarily and planned change in a job position or obtaining credentials such as training or education is an example of: a. Personal change c. organizational change b. Professional change d. resistance to change ___2. When people in control enforce changes in an organization and others in the organization have no input into these changes, this is an example of which of the following change strategies? a. Normative-reeducative c. change-stabilization b. Power-coercive d. rational-empirical ___3. The change strategy that assumes that people act more in accordance with social values and are less likely to change based on information or rational arguments is called the: a. Stabilization-evaluation strategy c. Normative-reeducative strategy b. Rational-empirical strategy d. Power-coercive strategy ___4. Unfreezing, moving to a new level, and refreezing are steps that make up which of the following theories / models of change? a. Lewins Force-Field Model c. Havelocks Six-Step Change Model b. Lippits Phases of Change d. Rogers Diffusion of Innovations ___5. According to this change theory, effort to implement change may be rejected at first and accepted later; thus an initial rejection is not that final word. Which theory is this? a. Lewins Force-Field Model c. Havelocks Six-Step Change Model b. Lippits Phases of Change d. Rogers Diffusion of Innovations ___6. This theory says that organizations often undergo a series of rapid changes, and then stabilize until the next round of rapid changes occurs. a. Lippits Phases of Change c. Chaos theory b. Havelocks Six-Step Change Model d. Learning organization theory ___7. In Bushys theory about peoples reaction to change, the people who enjoy the status quo but who will adopt change earlier than average to avoid being left behind are called: a. Innovators b. Laggards c. Early majority d. Early adopters ___8. Identify the problem or opportunity and collecting or analyzing data about a possible change are activities of which step of the change process? a. Assessment b. Planning c. Implementation d. Stabilization ___9. The final step needed to complete the change process is called: a. Assessment b. Planning c. Implementation ___10. The 7 x 7 rule of communicating a message about change means: a. Send the message seven different times in seven different ways b. All methods should be 7x7 inches c. There should be no more than 49 messages in any change process d. Send seven messages a day for seven days

d. Stabilization

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C. CONFLICT RESOLUTION
Everything that irritates us about others can lead us to an understanding of ourselves. (Carl Jung)
Can you imagine a world without conflict? Why, it would be a world without change! Conflict is inevitable wherever there are people with differing backgrounds, needs, values, and priorities. The presence of conflict in a situation is not necessarily negative but may, in fact, have some positive results. As a process, conflict is neutral. Following are some possible outcomes of conflict:

There is a better approach to conflict resolution than fighting it out.

o o o

o Disturbing issues are brought into the open, which may avert a more serious conflict. Group cohesiveness may increase as individuals resolve issues. New leadership my develop as a consequence of resolution. The results of conflict can be constructive, which occur when productive outcomes are achieved; or destructive, leading to poor communication and creating dissatisfaction.

Conflict - A disagreement or clash between ideas, principles, or people ( Encarta ) - Competitive or opposing action of incompatibilities (Merriam-Webster) - conflict exists when an inner or outer struggle occurs regarding ideas, feelings or actions CAUSES CONFLICT? Let us look at some common factors of conflict as they relate to nursing: Role Conflict. When two people have the same or related responsibilities with ambiguous boundaries, the potential for conflict exists. For example, a nurse in the 11 pm to 7 am shift may be uncertain whether he or the nurse on the 7 Am to 3 PM shift is responsible for administering enemas until clear on a patient scheduled for a barium enema. Communication conflict. Failing to discuss differences with one another can lead to problems with communication. Communication is a two-way process; when one person is unclear in a communication, the process falls apart. A recent graduate may find that with a busy schedule, numerous patient demands, and a shortage of time, it is easy to forget to notify a patients family of a change in visiting hours a great annoyance to the family members who can visit when they arrive. Goal Conflict. We all have unique goals and objectives for what we hope to achieve in our places of employment. When one nurse places his or her personal achievement and advancement above everyone elses conflict can occur.

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Personality Conflict. Wouldnt it be great if we got along with everyone? Of course we all know that there are just some people with whom we have a difficult time. The situation is all too familiar, and many times we may find ourselves with such thoughts as Ill try and overlook her negative, lousy behavior; after all she doesnt have much of a family life. Trying to change another persons personality is like guaranteeing an unhappy ending to a story. Ethical or Values Conflict. During a cardiac arrest, a young graduate nurse has difficulty with the physicians order of No Code, on a young adolescent patient. She has difficulty taking care of the adolescents because he reminds her of her younger brother who died tragically in an automobile accident. Conflicts in nursing may fit into one or more of the aforementioned categories. Consider some common areas of conflict among nursing staff, including scheduling days off, determining vacation leave, assigning committees, patient care assignments, and performance appraisal, to name just a few. COMMON AREAS OF CONFLICT BETWEEN NURSES AND PATIENTS AND BETWEEN NURSES AND PATIENTS FAMILIES 1. Quality of Care. This is by far the most common area of conflict and the easiest to remedy. Families typically are concerned with how well their loved one is being attended to, how friendly the nurses are, how well the hospital or home health services are provided and coordinated, and how flexible the hospital is with visiting hours and meeting their special needs. 2. Treatments decisions. This area of conflict often arises between the family of an elderly adult and the nurse. A physician may order a treatment with which the family does not agree. In this situation it is very important that the nurse not defend the physicians orders or atte mpt to persuade or establish with the family that the physician or nurse knows whats best for the patient. In these situations the issue is rarely the treatment itself but rather the familys desire to decide what is right for their loved one. Be sure to clarify the orders and explain to the family that you are supposed to carry them out unless the family negotiates directly with the physician to change them. 3.Family involvement. The situation of a young adult diagnosed with cancer illustrates numerous issues that may arise concerning the presence of family members during procedures and the extent of their involvement in the overall care. Such issues are based on the familys real need to feel significant and adequate in meeting the young adults needs. 4.Quality of parental care. This can become an issue when nurses are unhappy with how parents are participating in their childs care. It is helpful to offer parenting classes, to encourage parents to meet other parents, and to model positive parenting techniques. 5.Staff inconsistency. This is another easily preventable issue. Make sure that each shift is consistent in enforcing hospital policies and that they notify other shifts of any attempts at manipulation by family members or patients. CONFLICT RESOLUTION WAYS TO RESOLVE CONFLICT Unresolved conflicts waste time and energy and reduced productivity and cooperation among people with whom you work. In contrast, when conflicts are resolved, they strengthen relationships and improve the

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performance of everyone involved. The key to successfully managing conflict is tailoring your response to fit each conflict situation instead of just relying on one particular technique. Each technique represents a different way to achieve the outcome you want and to help the other person achieve at least part of the outcome that he or she wants. How do you know which technique to use? That depends on the following: o How much power do you have in this situation compared with the other person? o How much do you value your relationship with the person with whom you are in conflict? o How much time is available to resolve the conflict? Model for Conflict Resolution

This model above incorporates several views on conflict resolution. Filley (1975) described three basic strategies for dealing with conflict according to outcome: win-win, lose-lose, and winlose. Various others have identified five responses to resolve conflict. They are as follows: competition, accommodation, avoidance, compromise, and cooperation. Let us look at an example and apply the model. Suppose the head nurse on your unit has posted the vacations for the month of December. You, as a recent graduate, have requested to be off during the week of Christmas so that you can be with your family. You notice on the schedule that none of the recent graduates has received the Christmas holidays off. You feel that this is unfair because you will not have an opportunity to be with your family during the Christmas holidays. How can you resolve this conflict? APPROACHES TO CONFLICT RESOLUTION: Competition. Is a conflict resolution technique that produces a winner and a loser ( win-lose situation). The concept is that there is an all-out effort to win at all costs. This technique may be used when time is too short to allow other techniques to work or when a critical, though unpopular, decision has to be made quickly. This technique is often called forcing because the winner forces (use of power) the loser to accept the winners stance on the

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conflict. It sets up a competition between you and your head nurse. Typically, competition is used to resolve conflict when person has more power in a situation than the other. In the given situation, the head nurse refuses your request for Christmas vacation, explaining that the staff members with more seniority have priority for vacation at Christmas time. Avoidance. Is a very common technique. The parties involved in the conflict ignore it, either consciously or subconsciously. Avoidance is unassertive and uncooperative, and leads to lose-lose situation. In some situations, avoidance is not considered a true form of conflict resolution because the conflict is not resolved and neither party is satisfied. In the given situation, you would not have approached the head nurse with the Christmas schedule issue. Usually both persons involved feel frustrated and angry. There are some situations in which avoiding the issue might be appropriate, such as when tempers are flaring or when strong anger is present. However, this is only a short-term strategy; it is important to get back to the problem after emotions have cooled. Accommodation. Is often called cooperating. In this technique, one side of the disagreement decides or is encouraged to adjust or adapt to the other side by ignoring or sidestepping their own feelings about the issue. People often accommodate when the stakes are not that high and the need to move on is pressing. In the given situation, the head nurse would basically put her own concern aside and let you have your way, possibly even working in the scheduled slot for you. Accommodation is the lose-win situation, in which you accommodate the other person at your own expense but often end up feeling resentful and angry. The head nurse loses and the graduate nurse wins in this situation, which may set up conflict among staff and other recent graduates. Frequent use of this method, however, can lead to feelings of frustration or being used one person is used to get the cooperation of another. When is accommodation the best response? Is it when conflict would create serious disruption, such as arguing, or when the person you are in conflict with has the power to resolve the conflict unilaterally? Basically, in this response to conflict, differences are suppressed or played down while agreement is emphasized. Compromise. Is a method used to achieve conflict resolution in situations in which neither side can win and neither side should lose (bargaining). Compromise is rampant in our society and is useful for goal achievement when the stakes are important but not necessarily critical. Compromise is often seen as appeasement each side gives up something and each side gains something. Compromise is a good technique for minor conflicts or conflicts that cannot be resolved satisfactorily for both sides. Both parties win and lose. It is a moderately assertive and cooperative step in the right direction in which one creates a modified win- lose outcome. In the given situation, the head nurse compromises with you by allowing you to have Christmas Eve off with your family, but not the entire week. The problem lies in the reduced staffing that will occur for a short period of time. The compromise may not be totally satisfactory for either party, but it may be offered as a temporary solution until more options become available. Collaboration. Occurs in conflict resolution when both sides work together to develop a mutually acceptable outcome. It is an assertive and cooperative means of achievement important goals, which results in a win-win solution. This technique requires both sides to seek an acceptable solution to the conflict so all patients feel their goals or objectives have been achieved. This involves a high level of concern for the problem, the outcome, and the

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relationship. It deals with confrontation and problem solving. The needs, feelings, and desires of both parties are taken into consideration and reexamined while searching for proper ways to agree on goals. In the given situation, you and the head nurse discuss the week of Christmas vacation and the staffing needs and agree that you will work first three days of that week and the head nurse will work the second half of that week. You also agree to be there the first part of the week to complete the audit on the charts from the previous week for the head nurse. In this situation both persons are satisfied, and there is no compromising what is most important to each person. That is, the head nurse gets her audit completed and the recent graduate gets to spend half of the Christmas week with her family. What is your particular style for resolving conflict? When there is no immediate, pressing sense of time to solve an issue, then any of the five techniques can be used. However, when you are facing an emergency situation or a rapidly approaching deadline, your best bet is to use competition or accommodation. Just remember the following key behaviors in managing conflict: Deal with issues, not personalities Take responsibility for yourself and your participation. Communicate openly. Listen actively. Sort out the issues. Identify key themes in the discussion. Weigh the consequences. * There is no standardized conflict resolution but it depends upon the situation. It takes creative nursing management and understanding to recognize that conflict will exist whenever human relationships are involved. This needs to be tempered with open, accurate communication and active listening by maintaining an objective, not emotional stance, as conflict resolution strategies are utilized. CAREFRONTING Carefronting means directly approaching the other person in a caring way is that achieving a win-win solution is most likely With this approach neither party loses anything important and the relationship does not suffer Some believe this is the only biblical way of resolving conflict (Matt. 18:15-17) Conditions of Carefronting. Both parties must be committed to: face to face negotiations maintaining good relationships crating a solution in which both parties are winners calm reasoning without resorting to emotional responses separating the person from the issue
LOVE AND FORGIVENESS? As Christians we have not applied the Scriptures to our own institutional or individual lives. Jesus commandment to love one another has been nullified by division, litigation, and hostility. At times a veritable civil war has been fought out in the Christian community. One is reminded of the story of Stonewall Jacksons observation of fighting among his own men. He reportedly told them, Remember, gentlemen, the enemy is over there.
Lynn and Juanita Buzzard, Resolving Our Difference s. 3.

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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 12: Please write the letter of your choice in the space before the number

___1. Which of the following is a true statement about conflict? a. It seldom occurs as part of the change process in health care settings b. It highlights differences in values, beliefs, or actions c. It is automatically negative d. It discourages creativity and innovation ___2. Conflict that occurs between groups or teams is called: a. Interpersonal b. intrapersonal c. organizational

d. dysfunctional

___3. In this conflict resolution method, a person ignores his or her own feelings about an issue in order to agree with the other side. a. Collaborating b. confronting c. Accomodating d. Withdrawing

___4. With this method of conflict resolution, each side gives up something as well as gets something. a. Negotiating b. Competing c. Avoiding d. Compromising

___5. A conflict resolution approach that neither party loses anything and believed to be approaching the other person in a caring way to achieve win-win solution. a. Negotiating b. Forgiving c. Carefronting d. Confrontation

131 CHRISTIAN LEADERSHIP

THE TESTING TIMES OF A LEADER Pastor Fredrick Russell Four Major Testing for a leader: I. TIMES of DISCOURAGEMENT Let us not to be weary in well doing: for in due season we shall reap, if we faint not. (Galatians 6:9) FOUR Laws for Dealing With Discouragement Law # 1 The Law of Positive Thinking. 1. Negative thinking brings on discouragement. 2. A positive mental ATTITUDE speeds you trough discouragement. Law # 2: The Law of REST and RECUPERATION. Then as Elijah lay and slept under a broom tree, suddenly an angel touched him, Arise and eat.. (1King 19:5) 1. Rest is the single best ANTIDOTE for discouragement. 2. Rest permits a leader TIME to regain their energy. *You need to take a vacation & you need to pay for it. The higher you go. The more problems you will have or get into. When you are discouraged you lose perspective. *Joke time: Sometimes it was Moses who wanted to kill the people. Law # 3: The Law of Perspective 1. Staying Balanced is a must in keeping perspective. I am not able to bear all these people the burden is too heavy For me, (11:14) You cant do it all Law # 4: The Law of RECALL 1. Call to memory what God has DONE in the past. 2. Call to memory what God has SAID in the past. * Read your Bible for encouragement. Jeremiah 29:11 (NIRV) Comprehensiveness Goodness Optimism I know the plans I have for you I want you to enjoy success. I do not plan to harm you I will give you hope for the years to come

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II TEST of CHANGE The essence of real leadership is to allow your people to see your need and desire for learning. Your actions speak louder than your words. Todays leaders must be students of change first, before they become teachers of change to others. Jack Kahl, Manco,Inc. Constant change is here to stay. Unknown *People do not change until the pain of staying the same is greater than the pain of change. Joshua 1:1-18 The Biblical Pattern for Change: A. Learn from those who have CHANGED. (Joshua 1:1) B. Let go of the PAST so you can change. (vs.2) C. Initiate change. (vs. 3) D. KNOW what you are trying to change. (vs. 5) E. God HELPS you through the process of change. (vs. 5) F. To change requires COURAGE. (vs. 6) The most striking thing about highly effective leaders is how little they have in common. What one swears by, another warns against. But one trait stands out: the willingness to risk. Larry Osborn G. Dont get SIDE TRACKED as you change. (vs. 7) H. Embrace GODS principles for change. (vs. 8) I. Dont get DISCOURAGED as you go through change. (vs.9) J. Talk to your LEADERS/INFLUENCES before you begin to change. (vs.10) K. Prepare the people for change. (vs.11) L. Help Others so they can change. (vs. 13-18) When you soar like an eagle, you attract the hunters. Milton S. Gould III TIMES of CONFLICT The Basic Art of Confrontation: 1. Seek WISDOM. 2. EXAMINE your own heart first. 3. Timing is important, but dont PROCRASTINATE or give in to unnecessary delays. 4. Conduct the confrontation with a WORD and LOVING attitude. 5. Be direct, succinct stay FOCUS, and make sure they understand the issue at hand. 6. Communicate in a clear way that you understand their position or perspective. 7. Communicate clearly what ACTION you desire to take place. 8. Reaffirm your COMMITMENT to the individual as a person. 9. Put the issue in the PAST so far as you are concerned. Check list for an effective and redemptive confrontation: -Did I separate the person from the action? -Did I do my home work, get my facts straight, and pray first? -Did I confront only what person can change? -Were my heart and motives right? -Was a specific of action agreed upon, and the person affirmed?

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IV TIMES of STAGNATION (Personal) You are the way you are because thats the way you want to be. If you really wanted to be any different, you would be in the process of changing right now. Fred Smith Its amazing what happens when you recognize your good qualities, accept responsibility four your future, and take positive action to make that future brighter. Zig Ziglar, Over the Ttop GET up REACH out OWN up WORK out TUNE up HELP out Trying & failing, learning from failure, & trying again works a lot better than waiting for perfection. John Ortberg 10 GREATEST LEADERSHIP LESSONS IVE LEARNED THUS FAR.. Fredrick A. Russell The growth and development of people is the highest calling of leadership. John Maxwell Leaders get out in front and stay there by raising the standards by which they judge themselves, and by which they are willing to be judged. Fred Smith Leaders need to submit themselves to a stricter discipline that is expected of others. Those who are first in place must be first in merit. Unknown
Leadership Lesson # 1: The greatest show of power is the ability to exercise restraint.

The Problem of Power in the Wrong Hands: Saul, the first King of Israel, is an example of power in the wrong hands. 1. 2. 3. 4. 5. 6. POWER can be used RUSHLY. (1 Sam.14:24) POWER can be used UNREASONABLY.(14:44) POWER can be used SELFISHLY.(15:9) POWER can be used PIOUSLY. (15:30) POWER can be used JEALOUSLY. (18:8) POWER can be used REVENGEFULLY.(18:9-10)

There are several kinds of power. One is coercive power, used principally to destroy. Not much that endures can be built with it. Even presumably autocratic institutions like business are learning that the value of coercive power is inverse to its use. Leadership by persuasion and example is the way to build. Robert Greenleaf, Servant Leadership. The Potential of Power in the Right Hands: David, the second King of Israel, is an example of power in the right hands. 1. POWER can be used MERCIFULLY.(1 Sam. 24:6) 2. POWER can be used REASONABLY.(25:33)

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3. 4. 5. 6. POWER can be used UNSELFISHLY.(26:8-11) POWER can be used KINDLY.(11 Sam. 9:6-8) POWER can be used GRACEFULLY.(16:5-11) POWER can be used RESTRAINTS at all times.(18:5) theyre dealing from a position of weakness, hold your ground---be firm. Four ways to handle criticism: A. Consider the SOURCE from which the criticism was given. B. Consider the SPIRIT of the criticism that was given. C. Consider the CONTEXT which the criticism was given. D. Consider the FACTS of the criticism that was given. Abraham Lincoln was constantly assailed by the most vicious, personal, and hateful attacks. But he never gave into them. He always stood on principal and handled himself with character. He chose never to fight back using the tactics of his enemies. He always took the higher road. LINCOLN PRINCIPLES OF LEADERSHIP WHEN UNDER ATTACK * Refrain from reading attacks upon yourself s you wont be provoked. * Dont be terrified by an excited populace and hindered from speaking your honest sentiments. * Its not entirely safe to allow misrepresentation to go uncontradicted. * If you yield to even one false charge, you may open yourself up to other unjust attacks. * If both factions or neither shall harass you, youll probably be about right. Beware of being assailed by one and praised by the other. * The probability that you may fall in the struggle ought not to deter you from the support of a cause you believed to be just. Source: Donald T. Phillips, Lincoln on Leadership
Leadership Lesson # 3: No matter what happens, never loose control of yourself; for

Leadership Lesson # 2: When a person or group is attacking you personally, you will know

even if you win, youll regret it in the morning. No man is fit to command himself. another that cannot command. William Penn A wise man controls his temper, he knows that anger cause mistakes. Solomon Victor Frankl suggests that there are three central values in life: 1. The EXPERIENTIAL: That which happens to us. 2. The CREATIVE: That which we bring into existence 3. The ATTITUDINAL: Our response in difficult circumstance. Frankl makes the point that the highest of the three values is ATTITUDE. In other words, what matters most is how we respond to what we experience in life.

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WE HAVE THE POWER TO CHOOSE OUR RESPONSE Stephen Covey Leaders Who Do Not Control Themselves: 1. FAILS at modeling before the people. 2. FORFEITS the respect of the people. 3. FACILITATES duplication by the people.
Leadership Lesson # 4: Own

up to mistakes immediately! The quicker you do, the better it will be.

MAKE your apology sincere. INVITE the offended to talk. SEND A message of openness. TAKE the initiative. ASK for forgiveness. KNOW who to go. ENCOURAGE the growth of all. SPEND time in prayer.
No one lives in a mistake-free zone
Leadership Lesson # 5

Always be kind.

The most difficult time to be Kind is when People are Being Unkind. This is Part of the Hurts of Leadership. How to Handle the Hurts in Leadership 1. Understand that getting hurt is part of the LEADERSHIP package. 2. Travel the HIGH ROAD. 3. Find a way to RELIEVE STRESS. 4. Focus on the VISION of the organization. Remain Calm, Be Kind Colin Powells Rules for Leadership #10
Leadership Lesson # 6

Be prepared to own up anything you shared in confidence, for it will probably be shared with others.

Russells Rules for Speaking.. A. Speak only what you know to be TRUE. B. Speak only that which is KIND. C. Speak only to that which can be BACKED UP. D. Speak only that which you dont mind being QUOTED. E. Speak only to GOD about some things. Leadership Lesson # 7: When dealing with a people sensitive issue, never delegate it

to someone else.

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Three Leadership Matters You NEVER DELEGATE: 1. Matters of your followers HEART (discipline, correction, wrongs etc.) 2. Matters of your organizations HEALTH (conflict, vision, direction etc.) 3. Matters of your fellow leaders HEAD (team, unity, esprit de corps etc.) Delegation is needful for leaders, for they cannot do it all on their own. But there are some things that a leader can never delegate, for if you delegate it, you die. Fredrick Russell
Leadership Lesson # 8

: The leader is always responsible for setting the standard for integrity in
their organization.

In the Year 2002, Enron and MCI, two great American companies, were less known for their products and services, but more by the lack of integrity displayed by their leaders. When the leader lacks integrity, the entire organization will be affected. It may take some time, but invariably the cancer that comes from a lack of integrity will metastasize throughout the entire organization. Great Qualities That leader must display at all Times, Both in Public and in Private: Honesty Principle Discretion Character Truthfulness Loyalty Nobleness Christlikeness Leadership Lesson # 9: Despite what is happening around you, happiness is a choice. Happiness is really about Attitude EliminateThese Words Completely 1. I cant 2. If 3. Doubt 4. I dont think 5. I dont have time 6. Maybe 7. Im afraid of 8. I dont believe 9. (minimize) I 10. Its impossible Make These Words a Part of Your Vocabulary 1. I Can 2. I will 3. Expect the Best 4. I know 5. I will make time 6. Positively 7. I am confident 8. I do believe 9. (promote) You 10. God is able From John Maxwell book, The Winning Attitude

Leadership Lesson # 10

I cannot lead unless I pray.

In An Autobiography of Prayers. Albert E. Day asserts that prayer makes us more God conscious and less me conscious.

Prayer is: Affirming our design to realign our lives with principles and will of God
Confessing our inability to consistently do that on our own Counting our many blessings regardless of appearances or circumstances

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Validating the truth of Gods guidance and grace Enlisting and unleashing powerful angelic forces to come to our aid Giving thanks for the opportunity to serve, and the power to grow personally and spiritually Making the heart large enough until it can contain Gods gift of Himself.

HOW TO KEEP GROWING A LEADER IS A READER

1. Seek for: A. WISDOM/UNDEERSTANDING/INSIGHT. B. APPLICATION C. OPPORTUNITY D. MEMORY E. CONCENTRATION Read with a PURPOSE and read selectively. Read to RETRIEVE Read EVERYDAY Set a GOAL for the year. Dont feel as if you must FINISH the book. Remember the AUTHORS name with the title of the book. Encourage your SPOUSE and your CHILDREN to read. Budget MONEY for the book. Read with a DICTIONARY close at hand. Discuss and APPLY what you are learning. Make a life long COMMITMENT to be a reader.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

_____________________________________________________________
MANAGEMENT FUNCTIONS Planning Organizing
Staffing Delegating Directing Coordinating Controlling Monitoring Evaluating Budgeting Auditing

PLANNING ORGANIZING

COMMUNICATION
DIRECTING CONTROLLING
bottleneck

=GOAL

MANAGER vs. LEADER

Not All Leaders Are Good Managers A good manager makes decisions and who can communicate well

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****************************************************************************** Your attitude determines your altitude You are the way you are because thats the way you want to be. If you really wanted to be any different, you would be in the process of changing right now. Fred Smith

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God bless you. future Christian Nurse Leader and Manager of AUP!
Maam Jackie Polancos