LECTURE NOTES
For Nursing Students
TABLE OF CONTENTS
CHAPTER ONE: Introduction to Nursing Service
CHAPTER TWO: Philosophy of Nursing Service
CHAPTER THREE: Organization and organizational
CHAPTER FOUR: Functions of Management
CHAPTER FIVE: Decision Making
CHAPTER SIX: Theories of Leadership and Management
CHAPTER SEVEN: Managing
CHAPTER EIGHT: Evaluating Health Activities
CHAPTER NINE: Communication
CHAPTER TEN: Group Dynamics
CHAPTER ELEVEN: Conflict Resolution
CHAPTER TWELVE: Management of Change
CHAPTER FORTEEN: Project Plan Management
CHAPTER FIFTEEN: Quality Assurance/Improvement
References
CHAPTER ONE
INTRODUCTION TO NURSING SERVICE MANAGEMENT
Management is as old as human kind and existed since man has been organized in to communities. Managers influence all phases of our modern organizations. Our society simply could not exist as we know it today or improve its present status without a steady stream of
managers to guide its organizations. Peter Drucker makes this same point in stating that effective management is quickly becoming the main resource of developed countries and the most needed resource of developing ones
(1) Essentially, the role of managers is to guide organizations toward goal accomplishment. All organizations exist for some purpose or objective, and mangers have the responsibility for combining and using organizational resources to ensure that the organizations achieve their purposes. Management moves organizations toward these purposes or goals by assigning activities that organization member perform. If these activities are designed effectively, the production of each individual worker represents a contribution to the attainment of organizational goals. Managers strive to encourage individual activity that will lead to reaching organizational goals and to discourage individual activity that hinders organizational goal accomplishment. Management has no meaning apart from its goals
(2) Management must keep organizational goals clearly in mind at all times
1.2. Definition of management and nursing service administration
1.2.1. Definition of management
Different authorities define management differently but have strong unifying similarities in all the definitions. The term management can be used in several ways. For instance, it can simply refer to the process that managers follow to accomplish organizational goals. The term can be used, however, to refer to a body of knowledge. In this context, management is a cumulative body of information that furnishes insight on how to manage. Management is the art of getting things done through people. It is the process of reaching organizational goals by working with and through people and other organizational resources. It is the process of planning, organizing, leading and controlling the work of organization members and of using all available organizational resources to reach stated organizational goals. It is the process of directing, coordinating and influencing the operation of an organization to obtain desired result and enhance total performance.
1.2.2. Nursing service administration
Nursing service administration is a coordinated activity, which provides all of the facilities necessary for the rendering of nursing service to clients. Nursing service administration is the system of activities directed toward the nursing care of clients, and includes the establishment of over-all goals and policies within the aims of the health agency and provision of organization, personnel, and facilities to accomplish this goals in the most effective and economical manner through cooperative efforts of all members of the staff, coordinating the service with other departments of the institution. Nursing service administration is the marshaling of resources to accomplish a purpose. It is both an art and a science. It is a science in the sense that one may systematically study and analyze the behavior of people as a collective endeavor and, even their individual behavior in relationship to their individual purposes and to draw generalizations from them that are valid guides to foresight and action. It is an art because it requires qualities of dynamic character to make them effective in application. Nursing service administration is the process of planning, organizing, leading and controlling that encompasses human, material, financial and informational resources in an organizational environment to achieve the predetermined objectives. Nursing service is the process composed of the set of interrelated social and technical functional activities occurring within a formal organizational setting to accomplish predetermined objectives through utilization of human and other resources. The primary objective of the role of nursing service administration is the provision for continuous individual, group and community service, including whatever is necessary. In addressing the factors, which determine health, and to bring them back to self-directive activity towards their own health. The subsidiary objectives of this role are the professional activities of administration, including human relations, communications, teaching, research, and personal development, designed to further the primary objective-the optimum nursing care of patients. In this lecture note management and administration are used interchangeably.
1.2.3. Types of managers, managerial skill and roles
Nursing service managers are people who appointed to positions of authority, which enable others to perform their work effectively, who have responsibility for resource utilization and who are accountable for work. Nursing Leadership and Management results and can be proud of their organizations and what they do.
Types of managers
Traditionally classifications of managers are by level in the organizational hierarchy; common nomenclature is:
􀃖 Top level–such as board of directors, Presidents and vice presidents
􀃖 Middle level–such as directors of nursing, supervisory staffs and department heads
􀃖 First line/front line/ or supervisory management– such as head nurses and staffs.
Regardless of level, managers have several common attributes; they are:
􀃖 Formally appointed to positions of authority
􀃖 Charged with directing and enabling others to do their work effectively
􀃖 Responsible for utilizing resources
􀃖 Accountable to superiors for results
The primary differences between levels of managers are the degree of authority and the scope of responsibility and organizational activity at each level. For example, top-level managers such as nursing administrators have authority over and responsibility for the entire organization. Middle level managers such as department heads and heads of services have authority over and responsibility for a specific segment, in contrast to the organization as a whole and act as a liaison between top-level managers and first level managers. First line managers, who generally report to middle level managers have authority over and are responsible for overseeing specific work for a particular group of works.
Managerial Skills
Managers can also be differentiated by the extent to which they use certain skills: conceptual, human relations and technical skills. All managers use human relation skills because they accomplish work through people. Human relations skills include motivation, leadership and communication skills. The degree to which each is used varies with the nature of the position, scope of responsibility, work activity, and number, types and skills of subordinates. Senior managers use disproportionately more conceptual skills in their jobs than do middle level or first line managers. These include recognizing and evaluating multiple complex issues and understanding their relationships, engaging in planning and problem solving that profoundly affect the health service organization, and thinking globally about the organization and its environment. In contrast first line managers tend to use job related technical skills, or skills that involve specialized knowledge.
Managerial roles
All health service managers engage in planning, organizing, staffing, directing, controlling, and decision making to some degree. In addition, they perform other activities related to accomplishing work and organizational objectives that do not readily fall within the functional classification. These roles are defined as the behavior or activities associated with a management position because of its authority and status. Mintzberg's classification identifies:
􀃖 Interpersonal
􀃖 Informational and
􀃖 Decisional roles
Interpersonal role
The three interpersonal roles are
􀂙 Figurehead: all managers, but especially senior managers, are figureheads because they engage in ceremonial and symbolic activities such as greeting visitors and making speeches at organizational events.
􀂙 Liaison: involves formal and informal internal and external contacts.
􀂙 Influencer: includes activities inherent in the directing function, the purpose of which is to motivate and lead.
Informational role
The three informational roles of a manager are
􀂙 Monitor
􀂙 Disseminator and
􀂙 Spokesperson
Decisional Roles
The four decisional roles of a manager are
􀂙 Entrepreneur
􀂙 Disturbance handler
􀂙 Resource allocator and
􀂙 Negotiator
1.3 Health care, health services and health service organizational models Health care: is the total societal effort, organized or not, whether private or public, that attempts to guarantee, provide, and finance the promotion of health, prevention of diseases, and restoration of health and rehabilitation.
Health service: is the delivery of health care
Health service organizations: Deliveries of health services to clients occur in a variety of organizational settings. Health service organizations can be classified by ownership, profit motive, whether the client is admitted. Historically, hospitals and nursing facilities have been the most common and dominant health service organizations engaged in delivery of health services.
Health Service Organizational Model
Model
􀂙 Organizations are open systems
􀂙 Composed of inputs, throughput and output
1.4 The Benefit of good Management in Health Service organizations
􀂙 High lights priority areas
􀂙 Adopts the service to the needs of a changing situation
􀂙 Makes use of the most limited resources
􀂙 Improves the standard and quality of services
􀂙 Maintain high staff morale
CHAPTER TWO
PHILOSOPHY OF NURSING SERVICE MANAGEMENT
Mission
A mission statement is a broad general goal of an organization that describes its purpose in the community. The mission statement of a small community hospital may indicate that its purpose is to serve the health care needs of the immediate community and provide care for commonly occurring illnesses. A large university hospital may have a mission statement that encompasses research, teaching and care for complex problems. These two organizations will establish different priorities for spending, choose different technologies as essential to their missions, and
structure their staff in different ways. These mission statements provide the overall umbrella under which all functions of the organization take place. In addition to or even in place of a mission statement a general statement of philosophy may be used. When both are present, they should agree. The philosophy is typically longer and more detailed.
Organizational Philosophy and philosophy of Nursing Service Administration
Organizational Philosophy is its explicit and implied view of itself and what it is. Generally it is expressed in mission statements. The philosophy is directly linked to and rooted in the organizations cultural beliefs and values. Philosophy depicts the desired nature of the relationships between health service organizations and its customers, employees and external constituents. It is a set of beliefs that determines how organizational purposes are achieved and that serves as the foundation for agency objectives, policies and procedures. Nurses have the right to know the beliefs about nursing care, nursing practice and nursing management held by the collective group, which they are a part of the nursing department. A statement of philosophy is a valuable management tool. Nurses should be given a copy before they join the staff so that they can judge whether their personal philosophy is sufficiently in agreement with the organizational philosophy to enable them to become a contributing member of the department. Philosophy statements are relatively enduring documents because stated beliefs are usually expressions of firm commitment to the best that can be achieved and are derived from the broad goals of the agency. A useful philosophy has a timeless quality because basic premises change only under unusual conditions. Nevertheless, philosophy statements need to be reviewed periodically. If a review by all members of the department reveals that the statement still reflects the guiding beliefs of the collective group, there is no need to revise the document. If scrutiny indicates that the statement is not consistent with current agency goals or philosophy or is not effective in directing the actions of the department, then the statement should be rewritten to assure that it meets the criteria of compatibility, attainability, intelligibility, acceptability, measurability and accountability. When developing or reevaluating a philosophy, the manager should consider theory, education, practice, research, and nursing's role in the total organization.
Goals
Goals are the broad statements of overall intent of an organization or individual. They are usually stated in general terms. The purpose of writing goals is to identify where you are going and to enable you to evaluate when you have arrived there. A meaningful stated goal is one that succeeds in communicating the intent of those generating the goal. It should be stated in such a
way that it will be understood clearly by others. As a nurse in a health care institution, you need to be aware of the existence of several levels of goals: the institutional level, the nursing department level and the nursing unit level. The goal levels all need to relate to the health needs of the community, because these are the focus of health care.
Institutional Goals
Based on the community’s health needs, the institution forms goals and objectives. An institution that focuses thinking on goals for the future and activities that will move the organization toward these goals is referred to as a proactive institution. The managers of such institutions spend a great deal of time, money and energy on identifying possible future events and on preparing the institution to deal with them. Institutions that do not have specific or future oriented goals are reactive institutions. They spend their time reacting to events, that is, “putting out fires” rather than “preventing them.” A reactive facility would wait until such emergencies occurred and then would handle them as a crisis rather than as an anticipated event.
Nursing Department Goals
The goals of the institution definitely affect those of nursing service, which must support and complement institutional goals. In an institution with an overall goal of developing a mental health program, a nursing department goal may include developing nurses in psychiatry. The astute manager of a nursing department must also be proactive about the national issues facing nursing, community needs for nursing, and the needs within the institution itself. This manager would formulate goals to help the nursing department meet the challenges of care in the future, because the ultimate nursing department goal is quality client care.
Nursing Unit Goals
It is important that each employee understand the institutional and nursing department goals, because the group or unit goals develop from them. Each nurse should be able to contribute to the formation of unit goals in terms of philosophy of care, quality of care, and development of nursing expertise. Helping to formulate the goals for your unit is important, because these goals can also represent your individual goals. Unit goals develop from the group as a whole and often include individual goals in the process. Development and implementation of goals must be
meaningful to the group if they are to be successful. The member of the group must feel that they are the originators of the unit goals and objectives.
Organizational Climate
The climate of an organization refers to the prevailing feelings and values experienced by individuals. The feeling of thrust, belonging, esteem and loyalty are part of the climate. Values for competence and accomplishment are also part of the climate. The climate is bases on the official policies and procedures of the organization, and the feedback provided within the organization
CHAPTER THREE
ORGANIZATION AND ORGANIZATIONAL STRUCTURE
Objectives:
Systems Theory
Ludwig Von Bertalanffy introduced general system theory several decades age in an attempt to present concepts that would be applicable across disciplines and would be applicable to all systems. The theory was one of wholeness, proposing that the whole is more than the sum of parts; the system itself can be explained only as a totality. Holism is the opposite of elementarism, which views the total as the sum of its individual parts. A system may be defined as "sets of elements standing in interrelation". All systems have elements in common. Societies, automobiles, human bodies and hospitals are system The theory of open system is part of a general system theory; An open system is defined as a "system in exchange of matter with its environment, presenting import and export, building up and breaking down of its material components. Open systems theory emphasizes the relationship between a system and its environment and the interrelationships of different levels of system (Katz & Kahn, 1996, p.3). Systems are either closed or open. Closed systems are self-contained and usually can only be found in the physical sciences. This perspective has little relevance for the study of organizations. The open system perspective recognizes the interaction of the system with its environment. Katz and Kahn outline 10 characteristics that are common to all open systems. Understanding these characteristics helps one to conceptually understand how organizations function.
- The first characteristic is input, or importation of energy. Open systems import forms of energy from the external environment. As, the human cell receives oxygen and nourishment from the blood stream, and organization receives capital, human resources, material, or energy (e.g. electricity) from its environment.
- The second characteristic is through put, in which open systems transform the energy and materials. Just as the human cell transforms nourishment into structure, an origination can create a new product, process materials, train people, or provide a service.
- The third characteristic is output. Open systems export some product a manufactured substance, an inquiring mind, or a well body into the environment.
- Fourth, an organizations throughput works as a system of cyclic events. Organizational activities occur over and over again in a self-closing cycle, as the material that is input is transformed by throughput and results in output. System-boundaries-it follows that systems have boundaries, which separate them from their environments. The concept of boundaries helps us understand the distinction between open and closed systems. The relatively closed system has rigid, impenetrable boundaries; where as the open system has permeable boundaries between itself and a broader supra system. Boundaries are relatively easily defined in physical and biological systems, but are very difficult to delineate in social systems such as organizations.
- The fifth open system characteristic is negative entropy. To survive, open systems must reverse the entropic process, they must acquire entropy. The entropic process is the universal law of nature in which all forms of organization move toward disorganization or death" (Katz & Kahn, 1966). In order to arrest entropy and be transformed into negative entropy, a process of transformation with continuous up dates or changes in the organization is necessary. The outside forces and governmental agencies (importing resources from its environment) supply major financial support to fuel the system's ongoing functions and continue operational processes.
- The six characteristic of an open system is information input: the feedback and coding process. Every organization must take in information and feedback from the environment, code that information, and then store it so it can be used to predict the environment. Negative feedback is the type of input that allows the system to identify deviations in its functioning processes. Feedback enables the organization to maintain a steady state,
- the seventh characteristic of an open system. Sometimes called homeostasis, a steady state refers to the ability and desire of an organization to maintain some constancy in energy exchange. Just as the human body stays in a steady state, with no significant variation in its size and mass over time, so an organization attempts to stay in a steady state. This is acquired through avoidance of entropy.
- The eighth characteristic is differentiation, which occurs with growth of the organization. This requires multiplication and changes in established roles with new knowledge and expansion of expertise. This activity must create a constant flow of energy exchange as each member also continuously adapts to new functional changes. As a result, integration and coordination are achieved. This process leads to the establishment of a new organizational structure.
- The last characteristic of an open system is equi-finality: The principle that any final goal or end can be reached by a variety of means. As open systems move and develop within their environment, they may set different goals at different times and choose different methods to attain them, but the ultimate goal of any open system is survival. The adaptability of humans for survival represents equi-finality. The total nursing management process and each management functions can be preserved as a system consisting of several inputs, one or more throughput processes, numerous outputs, and multiple feedback processes between outputs and throughput, output and inputs, and throughput and inputs. When management malfunctions, in the major system or a subsystem, analysis of the interrelationships among system elements will usually reveal imbalances, obstruction of some point in the system. Usually, when the cause for system malfunction is accurately diagnosed, the problem can be eliminated or relieved by appropriate managerial interventions.
Organizational Structure
An organization is a group of people working together, under formal and informal rules of behavior, to achieve a common purpose. Organization also refers to the procedures, policies, and methods involved in achieving this common purpose. Thus, organization is both a structure and a process. Organizational structure refers to the lines of authority, communication, and delegation; can be formal or informal. Organizational process refers to the methods used to achieve organizational goals. An organization's formal structure is depicted in its organizational chart that provides a "blueprint," depicting formal relations, functions and activities. The principal purpose for defining the organization diagram is to clarify chain of command, span of control, official communication channels, and linkage for all department personnel. It is customary to show formal organization structure in a diagrammatic form with a three dimensional model having depth, height and width. Boxes containing various position titles are positioned vertically to highlight differences in status and responsibility. Position boxes are connected with lines to demonstrate the flow of communication and authority throughout the entire network. Different types of interconnecting lines signify different types of relation ships.
For example, a solid line between two positions, indicate direct authority or command giving relationship. A dashed line or broken or dotted line indicates a consulting relationship with no prescribed frequency of the structure to collaborate for planning or control purpose. Commands do not flow. The primary significance of formal organization structure is the frequency of communication between particular staff members. Particular worker is expected to relate directly with certain individuals and not others. For instance, the Nursing director must give direction to and receive reports from vice-director or supervisors and not others. In this sense, the formal organization structure restrains worker behavior.
The organization chart does not show the degree of authority that a manager has over subordinates. A manager with authority of head nurse may lack authority to hire or fire the worker.
Every organization also has an informal structure, characterized by unspoken, often covert, lines of communication and authority relationships not depicted in the organizational chart. The informal structure develops to meet individuals' needs for friendship, a sense of belonging, and power. The lines of communication in the informal structure (commonly termed "the grapevine") are concerned mainly with social issues. Persons with access to vital information can become powerful in the informal structure. Some administrators try to hinder the effects of informal organization because they facilitate the passing of information. The information may be rumor, but the best way to combat rumor is by free flow of truthful information. The informal organization can help to serve the goals of the formal organization if it is not made the servant of administration. It should not be controlled. A major shortcoming in its use is that not all employees are part of the informal organization.
Organizational characteristics
1. Span of control - refers to the number of employees a manager can effectively oversee. Mostly top executive cannot manage as many employees’ managers at lower levels. Theoretically, A 1:3 supervisory ratio is common at the top of an organization; a 1:6 ratio is common at the middle; and a 1:20 or larger ratio is common at the base.
The effective span of control for each manager depends on work pace and pattern of workers skill and knowledge, the amount of work in interdependence. The top executive must supervise managers of different specialties; although mid level and first level managers supervise workers in the same specialty that performs similar tasks often in a common work area.
When span of control is too broad, the manager has insufficient time to observe and cannot evaluate performance or give feed back. On the other hand, too narrow span of control has time to supervise each one closely, and too close supervision discourages subordinates problem solving independent judgment and creative thinking. Research shows that worker
productivity is higher when close supervision is impossible.
Organizational Principles
• The principle of unity of Command: An employee may interact with many individuals in the course of the work but should be responsible to only one supervisor.
• The principle of Requisite Authority: when responsibility for a particular task is delegated to a subordinate, subordinate must also be given authority over resources needed for task
accomplishment.
• The Principle of Continuing Responsibility: When a manager delegates a function to a subordinate, the manager's responsibility for that function is in no way diminished.
• The Principle of Organizational Centrality: Workers who interact with the greatest number of other workers receive greatest amount of work related information and become most powerful in organizational structure.
Organizational Concepts
1. Responsibility- is the obligation to do, to the best of one’s ability, the task that has been assigned, or delegated. In any organization, responsibility begins with the overall objective of the organization. For example, for nurses in a hospital, service or patient care is the responsibility.
2. Authority- the right of decision and commands. An individual with authority has the right to make decisions about his or her own responsibilities. Responsibility and authority are delegated down the scalar chain.
3. Delegation- is the process of assigning duties or responsibilities along with corresponding authority to another person. Authority must be delegated with the responsibility.
4. Accountability- is answering to someone for what has been done. It is related with responsibility.
Centralization versus Decentralization
In a highly centralized organization, the chief executive makes most decisions. Decentralization is the allocation of responsibility and authority for management decisions downward through the chain of command. In centralized, decisions made at the apex of the organization takes longer period of time than decisions made at the lower levels. Therefore, highly centralized organizations are slow in adapting to major changes. Lower level workers become passive, unenthusiastic and mechanical.
The executive who will not permit supervisors to select staff, determine staff schedule, institute working improvements, evaluate goal achievement, and recommend policy change deprive middle managers of opportunities for professional growth.
Decentralization of responsibility leads to improved employee morale. When middle managers are given responsibility for decision-making, they in-turn make still further, empowering staffs to formulate unit level work plans, policies and procedures.
As job responsibility and autonomy increase, so does job satisfaction. It improves staff nurse moral and retention. The head nurse's tasks in a decentralized organization are similar to a nursing director task in a highly centralized organization. Therefore, expert staff specialist should support the head nurses.
Types of Formal Organization Structures
Line Pattern/Relationship: This is the oldest and simplest type of formal organization chart. It is a straightforward, direct chain of command with superior subordinate relationships. The line pattern is more efficient than other structures, because it provides clear authority-responsibility relationships between workers and requires less information transmission between
managers and workers.
The typical line pattern is divided laterally into segments representing different nursing specialties. The perspective of workers differs from the bottom to the top of the structure. Workers at the base of pyramids-
Nursing assistants, Orderlies, staff nurses perform the basic work of nursing mission, i.e. direct patient care.
Employees in the middle of the structure- head nurses, patient care coordinators, supervisors are responsible for professional decision-making and direction of day to day operations. Personnel at the top of the structure- Vice president or director and assistant directors are responsible for non-programmed decision making, such as goal setting, program planning, and performance evaluation.
Advantages of Line Pattern
􀂙 It is easy to orient new employees, because of clearly defined interpersonal relations as well as responsibility and accountability;
􀂙 Easy to manage, because orders can be transmitted quickly;
􀂙 Well established division of labor;
􀂙 There is a clear-cut work specialization and role separation.
Disadvantage
􀂙 As a result of specialization, it makes employee's task narrow, repetitive performance and causes communication difficulties among specialists;
􀂙 Since it is rigid, workers tend to resist innovative changes and resist recommendations from outsiders;
􀂙 Line pattern causes passivity and dependence in staff members and autocratic behavior in managers. The strong chain of command and concentration of authority at the top of hierarchy cause lower level employees to refer difficult problems to their immediate superior. Managers talk more than to listen;
􀂙 It is characterized by weak integration of different divisions or departments. Interaction is only on the same division and there is no lateral communication. Head nurses will never seek advice from a more experienced head nurse in a different clinical division to resolve a patient care.
Line and Staff Pattern/Relationship/in an Organization
Line functions are those that direct responsibility for accomplishing the objectives of a nursing department. For the most, part they are filled with registered nurses licensed assistant nurses or other types of nurses. Staff functions are those that assist the line in accomplishing the primary objectives of nursing. They include clerical, personnel, budgeting, and finance, staff development, and research. The relationship between line and staff are a matter of authority. Line has authority for direct supervision of employees, while staff provides advice and counsel.
To make staff effective, top management ensures that line and staff authority relationships are clearly defined. Personnel of both should work to make their relationships effective; they attempt to minimize friction by increasing mutual trust and respect.
The advantage of a line and staff pattern is that key management functions that the chief executive has neither skill nor time to execute well are delegated to functional experts who can devote full time to the assigned function without being distracted by responsibilities of day today management of personnel and material.
The disadvantage of line and staff pattern is that staff officers have less power than line officers, because the latter direct the basic operations. Furthermore, staff officers must stand quietly in the background, while line managers receive recognition for improvements. Staff positions are also located at the periphery of formal structure, which casts incumbents in the role of social isolates.
Matrix Organizational Structure
This Pattern is a complex construct in which and employee may be responsible to two or more bosses for different aspects of work. In this pattern, a staff nurse stationed on a given patient unit is responsible to the head nurse of that unit but also to a case manager who oversees the clinical progress of her patients. It could also be through vertical and horizontal coordination.
Potential problems with a matrix type organization can easily be discerned. If, for example, the head nurse and the case manager give conflicting orders to the staff nurse, the job may be indefensible, or a manipulative staff nurse may play his/her two bosses off against each other. When a matrix organization is used, there must be clear decision rules and, it is hoped, good
interpersonal relationships. The employee must know which boss has the final word when they receive conflicting orders or conflicting demands concerning work priorities.
Functional Line and Staff Pattern
A third type of formal organization structure is the functionalized line and staff organization. In this structure, staff officers are no longer purely advisory but have some command authority over line employees.
The director of in-service may have the authority to decide how much indoctrination training and what type of orientation each new nurse must receive and when orientation classes will be held. The director of quality improvement may have the authority to assign selected staff nurses to gather data on critical indicators of care quality, regularly submit quality monitoring reports, and remedy identified problems.
As a nursing organization increases in size, it may evolve from a pure line, to a line and staff, and finally, to a functional line and staff structure. The advantage of functionalized line and staff organization is that the expert responsible for a specified management function, such as staffing, policies, quality improvement, or staff development, has authority to command line managers to implement needed actions that relate to the expert’s specified function.
Standards for evaluating the effectiveness of line and staff relationships in a hierarchical organization Standards
1. Line authority relationships are clearly delineated and defined by the organizational and/or functional charts and policies;
2. Staff authority relationships are clearly delineated and defined by the organizational and /or functional charts and policies;
3. Functional authority relations are clearly delineated and defined by the organizational and /or functional charts and policies;
4. Staff personnel consult with, advise and provide counsel to line personnel;
5. Service personnel functions are clearly understood by line and staff personnel;
6. Line personnel seek and effectively use staff services;
7. Appropriate staff services are being provided by line nursing personnel and other organizational departments or services;
8. Services are not being duplicated because line and staff authority relationships.
Systems of Nursing Service Delivery
Effective management makes the organization function, and the nursing manager has a responsibility of nursing care delivery systems that demonstrate ways of organizing nursing’s work. Within these systems there are advantages and disadvantages for quality of care, use of resources, and staff growth.
Case Method
The new method, traced back to Florence Nightingale, began in the early days of the nursing profession and was the convenient and appropriate way to manage care. Individuals are assigned to give total care to each patient, including the necessary medicine and treatments. The nurses report to their immediate superior, who is the head nurse. The disadvantages of this system are that all personnel might not have been qualified to deliver all aspects of care, and depending on the structure, too many people were reporting to the head nurse (overextended span of control).
Functional Method
The functional method is the next step to deal with different levels of caregivers. Assignments of patient care are made by the level of task; in other words, each person performs one task or functions in keeping with the employees’ educational experience. For example Nurse Aides /Health Assistants/ give baths, feed patients, and take vital signs to all patients. Professional nurses are responsible for medications, treatments, and procedures for all patients. The head nurse is responsible for overall direction, supervision, and education of the nursing staff.
Advantages
􀂃 Reduce personnel costs
􀂃 Supports cost control
Disadvantages
􀂃 Fragments nursing care
􀂃 May decrease staff job satisfaction
􀂃 Decreases personal contacts with client
􀂃 Limits continuity of care
Team Nursing
A dramatic change occurred after World War II in the years between 1943 and 1945. The level and number of auxiliary personnel began increasing, and the professional nurse was assuming more and more of the management functions. Because of the changing configuration of the work group and the dramatic social upheaval, a study was commissioned to device a better way to provide nursing care. Dr. Eleanor Lambertson of Columbia University in New York and Francis Perkins of Massachusetts General Hospital were the authors of the system known as team nursing. Team nursing was developed to deal with the influx of post war workers and the head nurse’s overextended span of control. This was accomplished by arranging the workers in teams. The team consists of the senior professional nurse becoming the team leader; the members of the team are
other registered nurses (RNs), licensed practical nurses (LPNs) or vocational nurses, and nurses’ aides. Each is being given a patient assignment in keeping with the employee’s education and experience. The team leader make the assignments, delegated the work through the morning report, make rounds throughout the shift to make sure patients are being cared for properly, and conducts a team conference at the end of the shift to evaluate the patient care and plan an update nursing care plans. Since 1950, team nursing is becoming a popular way to structure nursing care. Team nursing is a pattern of patient care that involves changing the structural and organizational framework of the nursing unit. This method introduces the team concept for the stated aim of using all levels of personnel to their fullest capacity in giving the best possible nursing care to patients. The structural and organizational changes necessary for this method includes the introduction of the nursing team with the team leader assuming responsible for the management of the patient care. The head nurse decentralizes authority to the team leader to direct the activities of the team members. The head nurse is no longer the center of all communication on the division because the members communicate directly with the team leader. The team leader had the responsibility for synchronizing the abilities of her/his team members so that they are able to function effectively in a team relationship. Emphasis is placed on the ability of all participants of patient care to plan, administer, and evaluate patient care.
The team approach to patient care represents more than reorganization or restructuring of nursing service. Instead, it is a philosophy of nursing and a method of organizing patient care. The difficulty with this method concerns the nurse’s absence at the bedside; the nurse is directing the care of others and thus not using nursing’s specialized knowledge as the best provider of
patient care. Problems with this system have become the stimulus for a new system.
Advantages
􀂃 Supports comprehensive care
􀂃 May increases job satisfaction
􀂃 Increases cost effectiveness
Disadvantages
􀂃 Decreases personal contact with client
􀂃 Limits continuity of care
Primary Nursing
Primary nursing as a system of care provided for a way to provide quality comprehensive patient care and a framework for the development of professional practice among the nursing staff. Primary nursing was a logical next step in nursing’s historic evolution. By definition, primary nursing is a philosophy and structure that places responsibility and accountability for the planning, giving, communicating and evaluating of care for a group of patients in the hands of the primary nurse. Primary nursing was intended to return the nurse to the bedside, thus improving the quality of care and increasing the job satisfaction of the nursing staff. The primary nurse is expected to give total care, to establish therapeutic relationship, to plan for 24 hours
continuity in nursing are through a written nursing care plan, to communicate directly with other members of the health team, land to plan for discharge. The patient’s participation is expected in the planning, implementing, land evaluating of his or her own care. Perhaps the best aspect of primary nursing is the improved communication provided by the one-to-one relationship
between nurse and patient. Associate nurses are involved with this method by caring for the patients in the absence of primary nurse. Their responsibilities include continuing the care initiated by the primary nurse and making necessary modifications in the absence of primary nurse. Primary nursing was adapted in organizations to fit the staffing patterns and general nursing philosophy. Because of the need for high percentage of professional nurses, other modifications of the system developed,
such as modular nursing.
Advantages
􀂃 May increase job satisfaction
􀂃 Improves continuity of care
􀂃 Allows independent decision making
􀂃 Supports direct nurse-client communication
􀂃 Encourages discharge planning
􀂃 Improves quality of care
Disadvantages
􀂃 Increases personnel costs initially
􀂃 Requires properly trained nurses to carry out
systems principles
􀂃 Restricts opportunity for evening and night shift
nurses to participate
Case Management
More recently, a new method of nursing care delivery has evolved known as case management. The American Nurses Association (ANA) has defined case management to be a system of health assessment, planning, service procurement and delivery, coordination, and monitoring to meet the multiple service needs of clients. This is an all-inclusive and comprehensive model and is not restricted to the hospital setting. When a patient deviated from the usual expected course of recovery or health, consultation ensures to quickly correct the problem. This requires a great deal of systematic knowledge about a patient's problems and putting that knowledge into a type of nursing care plan (case management plans) with time lines to demonstrate progress or deviations from the critical paths. In addition to the nursing and medical services that are required for patients, other services are included, such as physical therapy and respiratory therapy.
Advantage
􀂃 Improves nurse responsiveness to clientsn changing needs
􀂃 Improves continuity of care
􀂃 May increase nurse’s job satisfaction
Disadvantage
􀂃 Increases personnel costs
Learning Activities
1. Describe the form of organizational structure of the nursing division on which you work as an employee. Discuss the changes that could be made to make it more functional.
2. Obtain the organizational chart of nursing from any department. Is it centralized or decentralized? Where does the nursing fit?
3. Discuss the functioning of the nursing delivery system (s) in your health care organization and does it make the nursing delivery system more efficient or effective? How do you improve it?
4. Using "standards for evaluating the effectiveness of line and staff relationships in an hierarchical organization," evaluate the
nursing division or service in which you work as a student or as an employee.
CHAPTER FOUR
FUNCTIONS OF MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:
• Define the common terms used in the management process
• List down the expected functions of a nurse manager
• Discuss the concepts of each function using some examples
• Describe the effect of delegation on the manager’s responsibility for the delegated functions.
Definitions
• Planning – determining the long-and short-term objectives (ends) of the institution or unit and the actions (means) that must be taken to achieve these objectives.
• Staffing- Selecting the personnel to carry out these actions and placing them in positions appropriate to their knowledge and skills
• Organizing- Mobilizing human and material resources so institutional objectives can be achieved.
• Directing- Motivating and leading personnel to carry out the actions needed to achieve the institution’s objectives.
• Controlling- Comparing results with predetermined standards of performance and taking corrective action when performance deviates from these standards.
• Decision Making- Identifying a problem, searching for solutions, and selecting the alternative that best achieves the decision
maker’s objectives.
Management Functions of a Nurse Manager
Success of management depends on learning and using the management functions. These functions include planning, organizing, staffing, directing, coordinating and controlling. These functions represent these activities expected of managers in all fields. Managers develop skill in the implementation of these functions as they gain experience in th role of managers. Nurse Managers also use the same functions as they fulfill their responsibilities in the organization.
Planning
Planning is a technical managerial function that enable organizations to deal with the present and anticipate the future. It is the first and fundamental function of management because all other management functions are dependent on it. Planning is deciding what is to be done, when it is to be done, how it is to be done and who is to do it. It is an orderly process that gives organizational direction. Planning is the process of determining how the organization can get where it wants to go. Planning is the process of determining exactly what the organization will do to accomplish its objectives. In more formal terms, planning has been defined as ‘the systematic development of action programmes aimed at reaching agreed objectives by the process of analyzing, evaluating and selecting among the opportunities which are foreseen.
Purpose of planning
􀂙 It gives direction to the organization.
􀂙 It improves efficiency.
􀂙 It eliminates duplication of efforts.
􀂙 It concentrates resources on important services.
􀂙 It reduces guess work. It improves communication and coordination of activities
The planning hierarchy
Planning responsibilities are different for managers at each organizational level.
Strategic planning
Top-level managers, formulate long-term strategic planning to reinforce the firm’s mission (the mission clarifies organizational purpose) Strategic plans are specified for five years period or more; but circumstances dictate the planning horizon.
Tactical planning
Middle management is responsible for translating strategies into shorter-term tactics. Tactical plans are often specified in one-year increments. Eg. annual budget. Translating strategic plans into measurable tactical objectives is important because most strategic objective is rather vague.
Operational planning
Operational planning is accomplished by fist-line managers. Operational planning is most concerned with budgets, quotas and schedules. These are refinements of tactical objectives in which work is defined and results are measured in small increments. Time horizon for operational planning is very short. Most plans at this level reflect operational cycles.
Operational objective are:
􀂙 Narrow in scope
􀂙 Short-lived
􀂙 Subject to sadden change.
In order to fulfill her/his own job responsibilities and to guide subordinates towards agency goals, the nurse manager must spend scarce materials and human resources wisely. Since the nursing service operation in even a small agency is immensely complicated, careful planning is needed to avoid waste, confusion and error.
The formal planning process
Formal planning is a systematic process. It consists of five guidelines. These guidelines provide a general pattern of rational planning.
Situation audit or environmental assessment
It analyzes the Past, current and future forces that affect the organization. Expectation of outside interests such as government officials, insurance companies and consumers are sought. Expectations of inside interests such as nurse, doctors, administrators and other staffs are collected. Environment, demographic, resources, legal, technological factors should also be considered.
Establish Objectives
Every plan has the primary purpose of helping the organization succeed through effective management. Success is defined as achieving organizational objectives. These are performance targets, he end results that managers seek to achieve.
Characteristics of objectives
Well-defined objectives have several Characteristics.
They are:
• Specific
• Measurable
• Realistic and challenging
• Defined time period
Involve management and staff
Involving a greater number of managers will result in better plans and more wide spread acceptance of objectives.
Develop alternatives
A successful planning process will generate several options for manages to consider. These options are alternative courses of action that can achieve the same result. The task of management is to decide among them. Managers usually consider many alternatives for a given situation, but a viable alternative suggests a proposed course of action that is:
• Feasible
• Realistic
• Sufficient
Communicate plans
Planning requires clear and effective communication at all levels before performance begins to mirror expectations. Objectives are written and plans are documented to give employees direction. Managers communicate plans into two categories:
A. Standing use plans- are those that are used on a continuous basis to achieve consistently repeated objectives. Standing plans take the form of:
• Policies
• Procedures
• Rules
Policies: A standing plan that furnishes broad
guidelines for channeling management thinking
toward taking action consistent with reaching
organizational objectives. It provides guidelines for
behavior. Policies are also instruments of delegation
that alert subordinates to their obligations. Effective
policy statements are clear, understandable, stable
overtime, and communicated to everyone involved.
Procedures: a standing plan that outlines a series of
related actions that must be taken to accomplish a
particular task. It is an explicit set of actions, often
sequential in nature, required to achieve a well
defined result. Formal procedures provide specific
and detailed instructions for the execution of plans.
Good procedures provide a sequence of actions that
once completed fulfill specific objectives, reinforce
policies and help employees achieve results
efficiently and safely.
Rule: is a standing plan that designates specific
requires action. It indicates what an organization
member should or should not do and allows as no
room for interpretation. It is a statement that tends to
restrict actions or prescribe specific activities with no
discretion. Rules usually have a single purpose and
are written to guarantee a particular way of behaving
in a particular way.
B. Single use plans-are those that are used once
to achieve unique objectives or objectives that
are seldom repeated. They are communicated
through:
• Programs
• Budget
• Schedule
Programs: is a single use plan designed to carry out
a special project within an organization. It comprises
multiple activities orchestrated to achieve one
important objective.
Budget: is a single use financial plan that covers a
specified length of time. It describes in numerical
terms resources allocated to organizational
activities. By budgeting, managers identify resources
such as money, material and human resource. It
also communicates performance expectations.
Schedule: is a commitment of resources and labor
to tasks with specific time frames.
Approaches to planning
There are three distinct approaches that describe
who has the responsibility for formulating plans:
• Centralized top down planning- is the
traditional approach to planning in which a
centralized group of executives or staff
assumes the primary planning responsibility.
• Bottom-up planning- is an approach that
delegates planning authority to division and
department managers, who are expected to
formulate plans under the general strategic
umbrella of organizational objectives.
• Team planning- is a participative approach to
planning where by planning teams
comprising managers and staff specialties
initiate plans and formulate organizational
objectives.
Organizing
Organizing may be defined as the arranging of
component parts into functioning wholes. The purpose
of organizing is to coordinate activities so that a goal
can be achieved. The terms “planning” and “organizing”
are often used synonymously. For example, organizing
is considered step in the nursing process; however,
planning is the second. In the managerial process (i.e.,
managerial theory of leadership, planning is considered
the first step and organizing, the second.
In the managerial, planning is the determination of what
is to be accomplished, and organizing is the
determination of how it will be accomplished. However,
most authors still describe the two processes with
considerable overlap.
In the nursing process, planning includes writing
objectives, setting priorities, and determining activities to
meet the objectives. Thus, organizing may be
considered part of the planning, even though it is not
specifically identified. Planning, and thus organizing,
may be viewed as being part of all processes, including
the leadership process. Thus, planning and organizing
may be said to answer the what, why, how, when, and
where questions about specific activities.
There are six steps in the organizing process:
1. Establish overall objectives
2. Formulate supporting objectives, policies and
plans
3. Identify and classify activities necessary to
accomplish the objectives
4. Group the activities in light of the human and
material resources available and the best way of
using them under the circumstances
5. Delegate to the head of each group and the
authorities necessary to perform the activities
6. Tie the groups together horizontally and
vertically, through authority relationships, and
information systems.
Establishing Objectives
The first step in the process of organizing is to establish
overall objectives. Objectives are explicit, concise
statements of what is to be accomplished. They provide
directions for selecting materials and methods to
achieve the desired goal. Behavioral objectives can be
measured through observable performance. Overall
objectives are usually broad and give a general idea of
what is to be accomplished.
Five criteria for sound objectives in a management area
have been established. First, the objective must be
acceptable to both the leader and the group who will be
involved in achieving it. They must agree that it is worthy
of their efforts. All members of the group should see the
objectives as related to the purpose of the group.
Second, the objective must be attainable within a
reasonable period of time, that is, it must be realistic.
Third, the objective must be motivational, that is, it
should be stated in such a way that it causes the group
to want to strive toward reaching it. When the nurseleader
collaborates with group members in establishing
objectives, members’ ideas should be included, so that
they will feel a part of the objective. When members
have input into the objective, it becomes their own, and
they are motivated to achieve it.
Fourth, the objective must be simple. It should be
clearly describe only one behavior. A good objective is
as brief as possible, yet it’s meaning is clear.
Finally, the objective must be communicated to all
persons who are concerned with its achievement. The
leader, the group, and their superiors should all know,
initially and throughout the process, the goals toward
which they are working.
Formulate Supporting Objectives
Another part of the second step in the organizing
process is the recognition of existing policies,
procedures, and rules that affect the task and
objectives. A policy is a guide to action that provides a
standard decision for recurring problems and is made by
top-level administrators. Policies aid in keeping activities
in line with the overall objectives of the organization. For
example, all critical patients on being discharge must go
to the door in a wheelchair” is a policy to aid in meeting
the overall goal, “patients will not fall in the hospital.” If a
policy states that a registered nurse must discharge all
patients, an objective cannot provide for health
assistants or volunteers to discharge patients.
Identify and Classify Activities
If the written objectives are very specific, the required
activities will be obvious. The activities that a nurse will
have to perform to provide care include giving
medications, bathing patients, making beds…. The
nurse leader must know when, what, how and why
activities are done. Then prioritize activities based on
biological and behavioral sciences.
Group Activities
The fourth step in the process of organizing is to group
activities according to the human and material resources
available. Once all the activities have been identified
and given a priority, the nurse leader must analyze her
resources, so that they can be used to best advantage
in terms of time, talents, and economy. The nurse leader
must assess both her group members and the material
resources that she has at hand.
Delegation
Delegation is the process of assigning part or all of one
person’s responsibility to another person or persons.
Delegating is an effective management competency by
which nurse managers get the work done through the
employees.
The purpose of delegation is efficiency; no one person
can do all the work that must be done; therefore, some
work must be passed on, or delegated to others.
However, it must be remembered that, even when an
activity is delegated to someone else, the ultimate
responsibility for that activity still belongs to the nurseleader
(i.e. the person who delegated the activity.
Nurse managers need to be able to delegate some of
their own duties, tasks, and responsibilities as a solution
to overwork, which lead to stress, anger, and
aggression. As nurse managers learn to accept the
principle of delegation, they become more productive
and come to enjoy relationships with the staff. The
following list suggests ways for nurse managers to
successfully delegate.
• Train and develop subordinates. It is an
investment. Give them reasons for the task,
authority, details, opportunity for growth, and
written instructions if needed.
• Control and coordinate the work of subordinates,
but do not go over their shoulders. To prevent
errors, develop ways of measuring the
accomplishment of objectives with
communication, standards, measurements,
feedback and credit.
• Follow up by visiting subordinates frequently.
Expect employees to make suggestions to
improve work and use the feasible ones.
• Encourage employees to solve their own
problems, and then give them the autonomy and
freedom to do.
• Assess results. The nurse manager should
accept the fact that employees will perform
delegated tasks in their own style.
• Give appropriate rewards
• Do not take back delegated tasks.
Barriers to Delegating
Barriers in the Delegator
􀂃 Preference for operating by oneself
􀂃 Demand that everyone “know all the details”
􀂃 “I can do it better myself” fallacy
􀂃 Lack of experience in the job or in delegating
􀂃 Insecurity
􀂃 Fear of being disliked
􀂃 Refusal to allow mistakes
􀂃 Lack of confidence in subordinates
􀂃 Perfectionism, leading to excessive control
􀂃 Lack of organizational skill in balancing workloads
􀂃 Failure to delegate authority commensurate with
responsibility
􀂃 Uncertainty over tasks and inability to explain
􀂃 Disinclination to develop subordinates
􀂃 Failure to establish effective controls and to
follow up
Barriers in the Delegatee
􀂃 Lack of experience
􀂃 Lack of competence
􀂃 Avoidance of responsibility
􀂃 Over dependence on the boss
􀂃 Overload of work
􀂃 Immersion in trivia
Tie together
The final step in the process of organizing is that of
coordination. Group of group members must be placed
horizontally and vertically into a framework of authority
relationships and information systems in the
organizational structure. The goal of organizing is the
coordination of activities, and it is with this last step that
the framework is fully established. It brings the whole
process together. Even though all the five previous
steps are satisfactorily completed, if the members’
activities are not tied in, the process can still fail.
Members need to know to whom they can go for help
and relief.
• Open communication lines are and essential part
of coordination
• Group members must also know to whom they
can turn for assistance
• Group members, as well as the nurse leader,
must be aware of who is fulfilling which tasks, so
that they will be able to find one another when
necessary.
Staffing
Staffing is the management activity that provides for
appropriate and adequate personnel to fulfill the
organization’s objectives. The nurse manager decides
how many and what type of personnel are required to
provide care for patients. Usually the overall plan for
staffing is determined by nursing administration and the
nurse manager is in a position to monitor how
successful the staffing pattern is as to provide input into
needed change.
Staffing is a complex activity that involves ensuring that
the ratio of nurse to patient provides quality care. The
situation of a nursing shortage and the high activity
levels of admitted patients to acute care areas
complicate this process. Staffing depends directly on the
workload or patient care needs. An ideal staffing plan
would provide the appropriate ratio of caregivers for
patients’ individual needs based on data that predict the
census.
Directing
Directing is a function of the manager that gets work
done through others. Directing includes five specific
concepts; giving directions, supervising, leading,
motivating, and communicating, as described below:
• Giving directions is the first activity and suggests
that directions should be clear, concise and
consistent and should confirm to the
requirements of the situation. The manager
should be aware of the tone of the directives.
Different types of situations require different
emphasis. For example, and emergency
situation calls for different variation of voice than
does a routine request.
• Supervising is concerned with the training and
discipline of the work force. It also includes follow
up to ensure the prompt execution of orders.
• Leading is the ability to inspire and to influence
others t the attainment of objectives
• Motivating is the set of skills the manager uses to
help the employee to identify his/her needs and
finds ways within the organization to help satisfy
them.
• Communicating: involves the what, how, by
whom, and why of directives or effectively using
the communication process.
Coordinating
Coordinating is by definition the act of assembling and
synchronizing people and activities so that they function
harmoniously in the attainment of organizational
objectives. Think about the situations in your own life
when you have had to coordinate the multiple activities
for an important event. An example in everyday life that
demands coordination is a wedding. The music, flowers,
ceremony and numerous other considerations must be
coordinated so that each can contribute to make the
wedding beautiful and joyful. The more assurance that
all parties are cooperating and fulfilling their
agreements, the more likely that the wedding will be a
success with minimal complications.
Controlling
Is the regulation of activities in accordance with the plan.
Controlling is a function of all managers at all levels. Its
basic objective is to ensure that the task to be
accomplished is appropriately executed. Control
involves establishing standards of performance,
determining the means to be used in measuring
performance, evaluating performance, and providing
feedback of performance data to the individual so
behavior can be changed. Controlling is not
manipulation, rigid, tight, and autocratic or oppression.
Management by objectives (MBO) can be considered as
a control mechanism. Based on MBO principledetermining
objectives (standards) against which
performance can be measured can be stated. Second,
specific measures have to be established to determine
whether these objectives are met. Third, the actual
accomplishment of the objectives would be measured in
relation to the standard and this information would be
fed back to the individual. Then corrective action could
be taken.
Learning Activities
1. Observe a manager using the functions of a
management. Think about what it is the manager
does while performing each of the following:
1.1 Directing
1.2 Coordinating
1.3 Controlling
2. Divide the class into three groups. Have each group
represent a different level of management. Give
each group time to devise a plan that would reflect
the type of planning expected at each level.
CHAPTER FIVE
DECISION MAKING
Objectives:
At the end of this chapter, the student should be able to:
1. Describe the types of decisions
2. Explain the mechanisms of decision-making
3. Discuss the steps of logical decision-making
4. Identify the factors responsible for decision-making
5. Discuss the importance of decision making for nurse
managers?
6. Recognize the decision-making tools
7. Explain the barriers for decision-making and
mechanisms of overcoming it
Decision Making
Decision making-is a choice made between two or
more alternatives. It is choosing the best alternative to
reach the predetermined objective. Thus decisionmaking
is a process of identifying and selecting a course
of action to solve specific problem.
Types of decisions
Decisions made in the nursing service can be
categorized depending upon the following criteria
• How much time the manager spends in making
decision
• What proportion of the organization must be
involved in making decision
• The organization function/ the nursing/midwifery
functions on which they focus
On the basis of these there are three classifications:
1. Ends -Means
2. Administrative-Operational
3. Programmed-Non-programmed
1. Ends-Means
Ends: deals with the determination of desired
individual or organizational results to be
achieved
Means: decisions deal with strategic or
operational programmes, activities that will
accomplish desired results. These usually occur
during managerial planning processes, strategy
and objective formulation processes
2. Administrative-Operational
Administrative: made by senior management,
which have significant impact throughout the
organization. Usually this type of decision is
concerned with policy, resource allocation and
utilization.
Operational: are generally made by mid level and
first line managers and address day to day
operational activities of a particular
organizational
3. Programmed-Non -programmed
Programmed-these are repetitive and routine in
nature. Since they can be programmed,
procedures, rules and often manuals are
formulated to cover those situations
None programmed: unique and non- routine
Conditions that initiate decision making
1. Opportunity/threat
2. Crisis
3. Deviation
4. Improvement
Ways of Decision Making
1. Relying on tradition: taking the same
decisions that had been undertaken when
similar problem arouse in the past
2. May appeal to authority and make decisions
based on suggestions from an expert/a
higher level management
3. Priori reasoning: based on assumption
4. Logical decision making: is a rational,
intelligent and systematic approach to
decision making
Steps of logical Decision Making
1. Investigating the situation
• Define the problem
• Identify the problem objective
• Diagnose the cause
2. Develop alternatives
3. Evaluate alternatives
4. Implement and follow up
Factors Influencing Decision Making
1. Decision makers attribute
• Knowledge, experience, and judgment
• Perception and personality
• Values and philosophy
2. The Situation
• Urgency of solution and time pressures
• Magnitude and importance
• Structure and uncertainty and risk
• Cost benefit
3. Environmental Constraints
• External
• Internal
Implications for Nurse Managers
The activities of the problem solver, the nature of the
situation and the environmental constraints influence
how decision is done; resource spent in performing it,
and the quality of the ultimate decision. However, these
influences are not mutually exclusive. Managers should
recognize these attributes and be sensitive to the factors
that affect decision-making, change their method as
appropriate, modify and mitigate detrimental influences
when possible, and cope with those that cannot be
changed. In this way, they will improve the quality of
decision-making.
Encouraging creativity
• Convergent thinking-the problem is
divided into smaller and smaller pieces to
find a more manageable perspective.
• Divergent thinking: One's view of the
problem is expanded. The problem is
considered in different ways
• Brain storming: under favorable
circumstances a group working together
can identify more ideas than an individual
or the group of individuals working
separately. It is a technique managers
can use to create a free flow of ideas
Decision Making Tools
There are many tools. The most common are:
1. Probability theory: is the likelihood that
an event or outcome will actually occur
and allow decision makers to calculate an
expected value for each alternative.
Expected Value (EV) = Income it would
produce (I) x its probability of making that
income (P).
2. Decision tree= are graphic decision
making tools used to evaluate decisions
containing a series of steps
Deciding to decide
1. Is the problem easy to deal with
Tip: avoid being bogged down in trivial
details. Effective managers reserve decisionmaking
techniques for problems that require
them.
2. Might the problem resolve itself
Tip: prioritize and rank problems in order of
importance
3. Is it my decision
Tip: the closer to the origin of the problem the
decision is the better. Before deciding ask
the following questions:
• Does the issue affect other
departments?
• Will it have a major impact on the
superior's area of responsibility?
• Does it need further information
from higher level?
• Does it involve serious breach of
my department’s budget?
• Is this problem outside my area of
responsibility or authority?
If the answer to any of these questions is 'YES' pass it
to your superior.
Barriers to Effect Decision-Making
1. Easy recall: the more easily can recall the
event, the more frequently they believe it
occur
2. Easy search: not to put effort to seek
information from the appropriate sources
3. Misconception of chance: Most people do
not understand the nature of random
events
4. Confirmation gap
5. Relaxed avoidance: the manager decides
not to decide or act after noting that the
consequences of inaction will not be
serious
6. Defensive avoidance: Faced with a
problem and unable to find a good
solution based on past experience, this
manager seeks a way out. He/she may
let someone else make decisions. This
resigned posture may prevent
consideration of more viable alternatives.
7. Panic: the manager feels pressurized not
only by the problem but also time
Overcoming barriers to individual problem solving
1. Setting priority
2. Acquiring relevant information
3. Proceeding methodically and carefully
Learning activities
1. Define decision-making
2. Define some of the common concepts in decisionmaking
3. What is a decision environment?
4. Explain the impact of gathering too much
information
5. Explain the three types of decisions
6. How do nurse managers make decision?
7. What are the steps to be followed in logical
decision-making?
8. What are the factors necessitating decisionmaking?
9. Why do you think the importance of decision
making for nurse managers?
10. List the decision-making tools
11. What the barriers for decision-making? How can
we overcome these problems?
CHAPTER SIX
THEORIES OF LEADERSHIP AND
MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:
• Trace the evolution of early leadership and
management theories into the contemporary leader
manger theories
• Compare and contrast the democratic style to the
authoritarian and laissez faire styles; Theory X to
Theories Y and Z
• Discuss the three elements of situational leadership
theory (contingency model) and discuss it
associated it with Path-Goal theory
Leadership and Management Theories
What is the Difference between Management and
Leadership?
Mangers come from the “headship” (power from
position) category. They hold appointive or directive
posts in formal organizations. They can be appointed for
both technical and leadership competencies, usually
needing both to be accepted. Managers are delegated
authority, including the power to reward or punish. A
manager is expected to perform functions such as
planning, organizing, directing (leading) and controlling
(evaluating).
Informal leaders, by contrast, are not always managers
performing those functions required by the organization.
Leaders often are not even part of the organization.
Florence Nightingale, after leaving the Crimea, was not
connected with an organization but was still a leader.
Managers focus on results, analysis of failure, and
tasks, management characteristics that are desirable for
nurse managers. Effective managers also need to be
good leaders. Manager-leaders ask for information,
provide positive feedback, and understand the power of
groups. Mistakes are tolerated by manager-leaders who
challenge constituents to realize their potential.
Similarities between Leadership and management
Gardner asserts that first class managers are usually
first class leaders. Leaders and leader-managers
distinguish themselves beyond general run-of-the-mill
managers in six respects:
􀂃 They think longer term-beyond the day’s crises,
beyond the quarterly report, beyond the horizon.
􀂃 They look beyond the unit they are heading and
grasp its relationship to larger realities-the larger
organization, of which they are a part, conditions
external to the organization, global trends.
􀂃 They reach and influence constituents beyond
their jurisdiction, beyond boundaries. Thomas
Jefferson influenced people all over Europe.
Gandhi Influenced people all over the world.
􀂃 They put heavy emphasis on the intangibles of
vision, values, and motivation and understand
intuitively the non-rational and unconscious
elements in the leader constituent interaction.
􀂃 They have the political skill to cope with the
conflicting requirements of multiple
constituencies.
􀂃 They think in terms of renewal. The routine
manager tends to accept the structure and
processes, as they exist. The leader or
leader/manager seeks the revisions of process
and structure required by ever changing reality.
Good leaders, like good managers, provide visionary
inspiration, motivation, and direction. Good managers,
like good leaders, attract and inspire. They want to
pursue goals and values they consider worthwhile.
Therefore, they want leaders who respect the dignity,
autonomy, and self-esteem of constituents.
Early Leadership Theories
A. Trait Theories – If you have ever heard the
statement that “leaders are born, not made”, then
you have heard someone expressing the
fundamental belief underlying a trait theory of
leadership. Trait theories assume that a person
must have a certain innate abilities, personality
traits, or other characteristics in order to be a
leader. If true, it would mean that some people
are naturally better than others.
B. Great Man Theory – According to the “Great
man” theory of leadership tremendous influence
of some well known people has actually
determined or changed the course of history.
Some believe that these people possessed
characteristics that made them great leaders.
Such important historical figures, such as
Caesar, Alexander the great, Hitler, and Gandhi
have been studied to find the characteristics that
made these men leaders of their time.
C. Individual Characteristics- Many studies have
focused on ascertaining which individual physical
or personality traits are associated with
leadership. Despite the fact that no single trait
has been discovered in all leaders, some popular
beliefs remain and influence selection of
individuals' positions, because they seem
stronger and more dominating. A tall person can
be physically imposing and can literally “look
down” on other people.
There are also certain traits and behaviors commonly
associated with leadership abilities. For example, the
most outspoken person in a group is often assumed to
be a leader even when other evidence does not support
this assumption. The most intelligent or skilled person in
a group is often designated the leader because other
group members admire this person.
Charismatic Leaders- Charisma is the quality that sets
one person apart from others: supernatural,
superhuman, endowed with exceptional qualities or
powers. Charismatic leadership can be good or evil.
Charismatic leaders emerge in troubled times and in
relation to the state of mind of constituents. They
eventually run out of miracles even though the leaders
are magnetic; persuasive and fascinating.
Behavioral Theories
The behavioral theories, sometimes called the functional
theories of leadership, still focus on the leader. The
primary difference between the trait and behavioral
theories is that the behavioral theories are concerned
with what a leader does rather than who the leader is.
They are still limited primarily to the leader element in a
leadership situation, but they are far more action
oriented and do consider the co-actors.
Authoritarian-Democratic-and Laissez-Faire styles
The classic research done by Lewin, Lippitt, and White
(White, Lippitt, 1960) on the interaction between
leaders and group members indicated that the behavior
of the leader could substantially influence the climate
and outcomes of the group. The leaders’ behaviors were
divided into three distinct patterns called leadership
styles: authoritarian, democratic, and laissez-faire.
These styles can be thought of as a continuum from a
highly controlling and directive type of leadership to a
very passive, inactive style as illustrated in fig. .
The authoritarian leader maintains strong control over
people in the group. This control may be benevolent and
considerate (Paternalistic leadership) or it may be
dictatorial, with the complete disregard for the needs
and feelings of group members. Authoritarian leaders
give orders and expect group members to obey these
orders. Directions are given as commands, not
suggestions. Criticism is more common from the
authoritarian leader than from the other types, although
not necessarily a constant occurrence. Mostly
authoritarian leaders are also quite punitive.
The leader alone, not by the group, does decisionmaking.
Some will try to make decisions congruent with
the group's goals. The less benevolent leaders will make
decisions that are directly opposed to the group's needs
or goals. The authoritarian leader clearly dominates the
group, making the status of the leader separate from,
and higher than, the status of group members. This
reduces the degree of trust and openness between
leader and group members, particularly if the leader
tends to be punitive as well.
Authoritarian leadership is particularly suitable in an
emergency situation when clear directions are the
highest priority. It is also appropriate when the entire
focus is on getting the job done or in large group when it
is difficult to share decision making for some reason. It is
often referred to today as a directive or controlling style
of leadership.
In contrast, democratic leadership is based on the
following principles:
1. Every group member should participate in
decision-making.
2. Freedom of belief and action is allowed within
reasonable bounds that are set by society and by
the group.
3. Each individual is responsible for him self or her
self and for the welfare of he group.
4. There should be concern and consideration for
each group member as a unique individual.
Democratic leadership is much more participative and
far less controlling than authoritarian leadership. It is not
passive, however. The democratic leader actively
stimulates and guides the group toward fulfillment of the
principles listed and toward achievement of the group's
goals.
Rather than issuing commands, democratic leader offer
information, ask stimulating questions, and make
suggestions to guide the work of the group. They are
catalysts rather than controllers, more likely to say "we"
rather than" I" and "you" when talking about the group.
They set limits, enforce rules, and encourage
productivity. Criticism is constructive rather than
punitive.
Control is shared with group members who are expected
to participate to the best of their abilities and experience.
The democratic style demands a strong faith in the
ability of group members to solve problems and to
ultimately make wise choices when setting group goals
and deciding how to accomplish these goals.
Most studies indicate that democratic leadership is not
as efficient as authoritarian leadership. While the work
done by a democratic group is more creative and the
group is more self-motivated, the democratic style is
also more burdensome. First, it takes more time to
ensure that everyone in the group has participated in
making decision, and this can be very frustrating to
people who want to get a job done as fast as possible.
Second, disagreements are more likely to arise and
must be resolved, which can also require much effort.
Democratic leadership is particularly appropriate for
groups of people who will work together for an extended
time, when interpersonal relationships can substantially
affect the work of the group. It is often called supportive
or participative leadership today. There are variations in
the degree to which decision-making is shared with the
group, with styles midway between democratic and
autocratic. For example, a leader may encourage in put
from group members and consider their views but make
the final decision.
The laissez faire leader is generally inactive, passive,
and non-directive. The laissez- faire leader leave
virtually all of the control and decision making to the
group and provides little or no direction, guidance, or
encouragement. Laissez faire leaders offer very little to
the group: few commands, questions, suggestions, or
criticism. They are very permissive, set almost no limits,
and allow almost any behavior.
Some laissez faire leaders are quite supportive of
individual group members and will provide information or
suggestions when asked. The more extreme laissez
faire leader, however, will turn such a request back to
the group. When the laissez faire style becomes
extreme, no leadership exists at all.
In a laissez faire group, members act independently of
each other, disinterest will set up, activity becomes
chaotic and the frustration level rises. The goals are
unclear and procedures are confusing or absent
altogether. In most situations, however, laissez faire
leadership is unproductive, inefficient, and
unsatisfactory. Laissez-faire leadership is often called
permissive or non -directive leadership today.
Authoritarian Democratic Laissez faire
Degree of
freedom
Degree of
control
Decision
making
Leader
activity level
Assumption of
responsibility
Output of the
group
Efficiency
Little freedom
High control
By the leader
High
Primarily the
leader
High quantity,
good quality
Very efficient
Moderate
freedom
Moderate
control
Leader and
group
together
High
Shared
Creative,
high quality
Less efficient
than
authoritarian
Much freedom
No control
By the group or
by no one
Minimal
Relinquish
Variable may
be
poor quality
Inefficient
Fig- 6.1 comparison of authoritarian, democratic, and
Laissez-faire leadership styles
Management Theories
Likert’s Management System
Authoritative _Democratic_______________________
System 1
Exploitative
Authoritative
System 2
Benevolent
Authoritative
System 3
Consultative
Democratic
System 4
Participative
Democratic
Top management
Makes all decisions
Top management
makes most
decisions
Some delegated
decisions made at
lower levels
Decision making
dispersed
throughout
organization
Motivation by
coercion
Motivation by
economic and ego
motives
Motivation by
economic, ego, and
other motives such
Motivation by
economic rewards
established by
as desire for new
experiences
group participation
Communication
downward
Communication
mostly downward
Communication
down and up
Communication
down, up, and with
peers
Review and control
functions
Concentrated in top
management
Review and control
functions primarily
at top
Review and control
functions primarily
at the top but ideas
are solicited from
lower levels
Review and control
functions shared by
superiors and
subordinates
Situational Theories
1. Contingency Theory (Fred Fiedler) -
In the contingency model, three situational variables are
used to predict the favorability of a situation for the
leader: the leader's interpersonal relations with group
members, the leaders' legitimate power, and the task
structure.
Variables affecting Leadership Effectiveness
1. Leader-member relations- the personal
relationships between the leader and the
members of the group. (The better the
relationships, the more favorable the situation).
2. Degree of task structure- how specifically the job
can be defined so that everyone knows exactly
what to do. (The more structured the task, the
more favorable the situation).
3. Position Power- the leaders place within the
organization and the amount of authority and
power given to the leader. Position power may
be strong or weak; it does not reflect the strength
of the individual leader’s personality; rather it
measures the leader’s status in the organization.
(The greater the position power, the more
favorable the situation).
According to the contingency model, a nurse manager
should modify situations based on group relations,
personal power, and task structure to improve staff
productivity. A nurse manager who uses the
contingency model must have a thorough understanding
of her/his relationship with staff members, her/his power
and status within the organization, and the nature of the
group task.
2. Path -Goal Theory (Robert House)
Robert House's Path Theory, introduced in 1971, is
concerned with motivation and productivity. According to
this theory, the motivational function of management is
to help employees see the relationship between
personal and organizational goals, clarify the "paths" to
accomplishing these goals, remove obstacles to goal
achievement, and reward employees for the work
accomplished.
3. Contemporary Leader-Manager Theories
Theories X and Y (Douglas McGregor)
In his 1960 book, the Human side of Enterprise,
McGregor (1960) compared two different sets of beliefs
about human nature, describing how these led to two
very different approaches to leadership and
management. The first, more conventional approach, he
called Theory X, and the second, more humanistic,
approach was termed as Theory Y.
Theory X is based on a common view of human nature:
the ordinary Person is lazy, unmotivated, irresponsible,
and not too intelligent and prefers to be directed rather
than act independently. Most people do not really like to
work and do not care about such things as meeting the
organization's goals. They will work only as hard as they
must to keep their jobs, and they avoid taking on
additional responsibility. Without specific rules and the
threat of punishment, most workers would come in late
and produce careless work.
Based on this view of people, leaders must direct and
control people in order to ensure that the work is done
properly. Detailed rules and regulations need to be
developed and strictly enforced. People need to be told
exactly what to do, and how to do it. Close observations
is necessary to catch mistakes, to make sure people
keep working, and to be sure that rules, such as taking
only 30 minutes for lunch, are obeyed.
Motivation is supplied by a system of rewards and
punishments. Those who do not obey the rules are
reprimanded, fined or fired. Those who do obey the
rules are rewarded with continued employment, time off
and pay rises.
According to theory Y, the behavior described in theory
X is not inherent in human nature but a result of
management emphasis on control, direction, reward,
and punishment. The passivity, lack of motivation, and
avoidance of responsibility are symptoms of poor
leadership and indicate that people's needs for
belonging, recognition, and self-actualization have not
been met.
Theory Y proposes that the work itself can be
motivating and rewarding. People can become
enthusiastic about their work and will support the team
or organization's goals when these goals also meet their
need. They can be trusted to put forth adequate effort
and to complete their work without constant supervision
if they are committed to these goals. Under the right
conditions, the ordinary person can be imaginative,
creative, and productive. Theory Y leaders need to
remove obstacles, provide guidance and encourage
growth. The extensive external controls of theory X are
not necessary because people can exert self-control
and self-direction under theory Y leadership.
4. Theory Z (Ouchi) /participative approach to
management/
Ouchi (1981) expanded and enlarged on theory Y and
the democratic approach to leadership to create what he
calls theory Z. Like theory Y, Theory Z has a humanistic
viewpoint and focuses on developing better ways to
motivate people, assuming that this will lead to
increased satisfaction and productivity.
Theory Z was developed in part from a study of
successful Japanese organizations. It was adapted to
the American culture, which is different in some ways
but similar in its productivity goals and advanced
technology. Elements of theory Z include collective
decision-making, long-term employment, slower but
more predictable promotions, indirect supervision, and a
holistic concern for employees.
Collect Decision-making - This is democratic,
participative mode of decision making which is extensive
and involving everyone who is affected by the decision.
Everyday problems are also dealt with in a participative
manner through problem solving groups called quality
circles; in which all members of a team or deportment
are encouraged to identify and resolve problems faced
by group or organizations.
Long-Term Employment- Employees move around
with in the organization, taking on different functions and
working in different departments. People who do this
become less specialized but more valuable to the Z
organizations, which is consequently more willing to
invest in training its employees and encouraging their
growth. In turn, they are better able to understand how a
department works and its problems and capabilities.
Slower promotions - Rapid promotions can be
misleading; if everyone is promoted rapidly, your relative
position in the organization does not really change. It
also means that close working relationships with in
groups do not have times to develop, nor is there any
incentive to develop them. Slower but more predictable
promotions allow sufficient time to make a thorough
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evaluation of the individual's long-term contribution to
the organization.
Indirect supervision- Workers become a part of the
culture of the organization and are intimately familiar
with its working philosophy, values, and goals.
Decisions are made not only on the basis of what will
work but also on the basis of what fits the culture of the
organization. A person who is well acquainted with
these characteristics of the organization does not need
to be told what to do or what decision to make as often
as a new, unassimilated employee is.
Holistic Concern- Trust, fair treatment, commitment,
and loyalty are all characteristics of the Theory Z
organization. These characteristics are part of the over
all consideration for each employee as a whole,
including concern for the employee's health and well
being, as well as his/her performance as a worker.
Motivating Staff
Why do you motivate people?
Motivation is unquestionable important in health care
institutions because, like in any other organization,
people are required to function effectively if they are to
provide adequate patient care. This implies that a health
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care institution must motivate qualified personal to seek
employment in the institution and then motivate them to
remain on the job. Continual turnover means continual
recruiting and training costs, inconvenience, and
disruption of staff functions.
A leadership function is to arouse, excite, or
influence another person to behave in some role or
perform some action the person would not ordinarily
do.
Motivation Theories
Need hierarchy Theory (Maslow)
Maslow (1943; 1954) stated that a lower level need is
prerequisite, or controls behavior until it is satisfied, and
then the next higher need energizes and directs
behavior. The hierarchy, from the lowest to the highest
level, is as follows: (a) physiological needs (e.g. hunger,
thirst), (b) safety needs (i.e., bodily safety), (c) need for
love and sense of belongings (e.g. friendship) affection,
(love), and (d) need for self-esteem (e.g. recognition,
appreciation, self respect) and (e) self actualization (e.g.
developing one's whole potential).
Maslow's need theory is frequently used in nursing to
provide an explanation of human behavior. A patient's
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needs are viewed in this hierarchical order, with nursing
care directed toward meeting the lower level needs
before addressing higher needs.
Two Factor theories- Hertzberg (Theory of Job
satisfaction)
Hertzberg enlarged on the theory Y approach by
dividing the needs that affect a person's motivation to
work into two sets of factors: those that affect
dissatisfaction and those that affect satisfaction. The
first set, called hygiene factors are those factors that
meet a person's need to avoid pain, insecurity, and
discomfort. If not met, the employee is dissatisfied. The
second set, called motivation factors are those that meet
needs to grow psychologically, when met, the employee
feels satisfied. These are distinct and independent
factors according to Hertzberg. Meeting hygiene needs
will not increase satisfaction, and meeting motivation
needs will not reduce dissatisfaction.
Engineers and accountants were asked to describe
incidents at work that made them feel especially good or
bad. The hygiene factors include:
• Adequate salary
• Appropriate supervision
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• Good interpersonal relationships
• Safe and tolerable working conditions (including
reasonable policies and procedures)
The motivation factors include:
• Satisfying, meaningful work
• Opportunities for advancement and achievement
• Appropriate responsibility
• Adequate recognition
The leader manager's function is to ensure that both
sets of needs are met, some directly and others by
providing opportunities to meet them in a conducive
work environment.
Achievement Need Theory (McClelland)
McClelland claimed that human needs are socially
acquired and that humans feel basic needs for
achievement, affiliation, and power. Need for
achievement is the drive to exceed one's former
accomplishments, to perform an activity more skillfully or
effectively than before. A person with high achievement
need to spend much time thinking about how to improve
personal performance, how to overcome obstacles to
improvement, and what feelings will result from success
and failure. McClelland claims that a person with high
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achievement need to set moderate, realistic goals, enjoy
problem-solving activities, and desires concrete
feedback on performance.
The need for affiliation consists of a desire for
friendship, love, and belonging that causes a person to
spend much time and planning how to establish friendly
personal relations. Persons' with high affiliation need are
sensitive to others' feelings, support others' ideas, and
prefer jobs involving conversational give and take.
Need for power is the desire to control the means of
influencing others and resisting control by others.
Persons with high power need to spend much time
thinking about how to gain authority, dominate
decisions, and change others' behavior. Such persons
are likely to be articulate, demanding, and manipulative
in dealing with peers and subordinates.
Equity Theory (Adams)
Adams's (1965) equity theory of motivation suggests
that an employee continuously compare her or his work
inputs (skill, effort, time) and outcomes (status, pay,
privileges) with those of other employees. The employee
perceives inequity whenever her/his rewards are
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disproportionate to those received by other employees
for the same amount of input. Feelings of inequity
motivate an employee to resolve the inequity by
reducing input, attempting to increase outcomes,
selecting a different comparison worker, or resigning.
Equity does not in any way imply equality; rather, it
suggests that those employees who bring more to the
Job deserve greater rewards.
Expectancy Theory (Victor Vroom)
Victor Vroom's expectancy theory of human motivation
indicates that a person's attitudes and behavior are
shaped by the degree to which they facilitate the
attainment of valued outcomes. According to Vroom's
theory, the amount of an employee's job effort depends
on her or his perception of the relationship between
good performance and specific outcomes.
Transformational Leadership
A transformational leader is one who “commits people to
action, who converts followers into leaders, and who
may convert leaders into agents of change”.
Transformational leaders do not use power to control
and repress constituents. These leaders instead
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empower constituents to have a vision about the
organization and trust the leaders so they work for goals
that benefit the organization and themselves.
Leadership is thus not so much the exercise of power
itself as it is t he empowerment of others. The goal is
change in which the purpose of the leader and that of
the constituent become enmeshed, creating a collective
purpose. Empowered staffs become critical thinkers and
are active in their roles within the organization. A
creative and committed staff is the most important asset
that an administrator can develop. People are
empowered when they share in decision-making and
when they are rewarded for quality and excellence
rather than punished and manipulated. When the
environment is humanized and people are empowered,
they feel part of the team and believe they are
contributing to the success of the organization. In
nursing, empowerment can result in improved patient
care, fewer staff sick days, and decreased attrition.
Nurses who are transformational leaders have staff with
higher job satisfaction and who stay in the organization
for longer periods.
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Nurses Role- as- a Leader
Leaders make things happen! As a leader, your first
priority is to get the Job done. In order to do this, you
must:
1. Know your objectives and have a plan for
reaching them
If you are unclear about your goals, clarify them
with your manager.
On planning, list everything you have to do both
short & long-term goals.
Set priorities. Decide which t asks are the most
important in achieving your objectives.
Decide how much time you will need to complete
each task.
Check to see that resources needed to complete
the task are available.
Use wall calendars, desk calendars daily to do lists
and other aids to help you develop a plan for getting
jobs done.
2. Build a team committed to achieving those
objectives
3. Help each team member to give his or her best
effort.
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Achieving goals depends on teamwork
You simply cannot do everything on your own. As a
leader, it is your Job to build a team that values what it
does and knows that it is valued.
Set clear standards
Let your team know exactly what you expect in terms of
quality and quality of work, time keeping, and following
safety rules. Strive to maintain high but realistic
standards.
Explain the "Why" as well as the "What"
It is important for team members to understand why a
task is necessary and why it must be done in a certain
way and how it will be achieved.
Encourage Involvement
Whenever the situation allows, ask for team member's
ideas and opinions. Team members who are involved in
the decision making process are more likely to feel they
have a stake in achieving goals. However, be sure your
team understands that you are responsible for making
the final decision.
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Build positive working relationships
4. Strive to be fair with all employees at all times.
5. Be understanding. Keep in mind that everyone
makes mistakes occasionally. When you must
criticize, be constructive and tactful.
6. Build an atmosphere of respect among team
members.
7. Put the team first. Make it clear that you are
more interested in the group's achievements
than in the personal gain.
Keep your team informed
Provide as much information as you can as soon as you
can. The news you have to convey may not always be
pleasant. However, your team will appreciate hearing it
directly from you instead of through the grapevine.
Leader use different styles
In general, your leadership style will depend on your
personality, when you feel comfortable with, the abilities
of your team members and the situation at hand. For
example, you may use a:
8. Participative style, when it is appropriate to involve
members of your team in making decisions
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9. Directive style, when a situation requires you to give
specific instructions, such as when training new
employees. Flexibility and good judgment are
essential to successful leadership.
Leaders tend to share some important qualities
While no two leaders are exactly alike, in general,
leaders are:
10. Positive- they believe in themselves and others,
and the contributions they can make
11. Enthusiastic - they're willing to tackle tasks that
others may dismiss as possible
12. Committed to excellence - they're always looking
for new and better ways to do things
13. Self confident- they're willing to make decisions
even when these are unpopular
14. Sincere - when they make a promise, they do all
they can to keep it
15. Open to new ideas - they realize they do not
have all the answers.
What Makes a Leader?
The 20 most important qualities of a leader, as cited by
3,032 Latinos in a recent nation-wide survey. Some
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traits appear similar because they were named in
response to and open-ended question, not chosen from
a prepared list
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1. Honest/Trustworthy/Integrity 50.4% 10. Just/impartial/Fair 2.3%
2. Intelligent/Educated/Experienced 7.5% 11. Strong leader/Assertive 1.7%
3. Respectful/Respects the people 4.6% 12. Skilled communicator 1.2%
4. Serve/Help the community 4.3% 13. Patriot/Loves country 1.2%
5. Loving/compassionate/kind 4.1% 14. Hard working/ethical 0.8%
6. Strong moral values/Ethical person 2.9% 15. Good listener/Accessible 0.6%
7. Good person/Responsible 2.8% 16. Dedicated/Committed 0.6%
8. Courageous/Tenacious 2.7% 17. Charismatic/Visionary 0.5%
9. Humble/Sincere 2.6% 18. Goal oriented/Efficient 0.3%
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Obtaining and Using Power
Power is the ability and willingness to influence
another’s behavior for the sake of producing intended
effects. When power is not linked to a worthwhile goal, it
is used as a personal possession, and becomes evil.
The essence of power is the ability to cope with life’s
demands; to impress one’s will on external events, to
achieve significance in the total schemes of things.
Bases of Power
In order to acquire power, maintain it, and use it
effectively, a manager must recognize power sources
and know the types of power needed to effect change.
There are six bases of social power common in
organizations.
􀂃 Reward power is based upon the incentives the
leader can provide for group members to
influence behavior by granting rewards. For
example, a nurse manager may have
considerable influence in determining a vacation
time of a staff nurse and give incentives or
recommendations.
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􀂃 Punishment, or coercive power, is based in
influencing behavior through the negative things
a leader might do to individual group members or
the group as a whole by withholding rewards or
applying sanctions. Example, Giving undesirable
job assignment or salary cut.
􀂃 Information Power- is based upon “who knows
what” in an organization and the degree to which
they can control access to that information by
other individuals. The nurse manager, for
instance, is has private ground to information
obtained at meetings with the nursing director or
through other informal channels of
communication that either are not available to or
are unknown to members of staff nurses.
􀂃 Legitimate Power- stems from the group
members’ perception that the nurse manager
has a legitimate right to make a request; this
power is based on the authority delegated to the
nurse manager by virtue of his her/his job and
position within kith management hierarchy.
􀂃 Expert Power- is based upon particular
knowledge and skill not possessed by staff
members. Nurse managers, by virtue of their
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experience and, possibly, advanced education,
frequently qualify as the persons who know best
of what to do in a given situation. For example,
newly graduated nurses might look to the nurse
manager for advice regarding particular
procedures or for help in using equipment on the
unit.
􀂃 Referent Power- is based upon admiration and
respect for an individual as a person. For
example, a new graduate might ask the advice of
the nurse manager regarding career planning.
Application to Nursing
􀂃 All nurse managers possess some degree of
legitimate power-authority to carry out
organizational decisions and goals.
􀂃 This authority is supplemented by the nurse
managers’ power to reward of coerces
􀂃 Nurse Managers become leaders through the
development of referent and expert power
bases that inspire others’ obedience and
loyalty.
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􀂃 By developing referent and expert power, a
nurse leader need not rely on legitimate
power
􀂃 A nurse manager and nurse leader can use
various sources of power to effect change at
the unit, organizational, and professional
level (Sullivan, 1990).
Reasons for Acquiring Power
A nurse manager should seek power for both selfish and
unselfish reasons. A nurse manager will need
considerable power to survive in the dog eat dog world
of institutional politics. Without strength to move others,
he or she cannot complete with the managerial elite for
scarce funds, scarce personnel and scarce materials.
He or she should also seek power to benefit patients
and subordinates.
Individuals and groups in heath agency may seek power
in order to manipulate others. Power holders at the top
of the hierarchy look for persons with similar values to
be their successors and to ensure the preservation of
cherished values.
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Skills Used in Acquisition
Basic skills for exerting power over others include: peer
skills, leadership skills, information processing skills,
conflict resolution skills and skills in unstructured
decision making.
􀂃 Peer skills are communication and interaction
skills by which a person builds a network of
supporters from whom to obtain help in a crisis.
􀂃 Leadership skills are communication and
motivation skills with which one resolves
problems arising from power, authority, and
dependency phenomena.
􀂃 Information processing skills are skills of
receiving, encoding, grouping, storing, retrieving,
translating, and sending information by which
one interprets the world and transmits
interpretation to others.
􀂃 Conflict resolution skills are skills by which a
person finds agreement between candidates and
persuades disputants to collaborate in the
interest of mutual gain.
􀂃 Skills in the unstructured decision making is the
ability to analyze problems for the cause and
effect relationships, generate possible solutions,
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select the most effective course of action, and
assign responsibility for plan implementation.
Learning Activities
1. Discuss basic points that you consider for an
outstanding nurse leader
2. Kurt Lewin suggests that there are three
leadership styles-Autocratic, Democratic, and
Laissez-faire;
2.1 Which leadership style does your supervisor
exhibit?
2.2 List three of his or her activities as decisions
that illustrate the style.
2.3 How does your supervisors' leadership style
affect your work and attitudes?
3. From the theory of leadership described in this
chapter, describe and discuss actual examples of
leadership demonstrated by persons. Consider:
3.1 A charismatic leader
3.2 A transforming leader
3.3 McGregor's theory X and theory Y
3.4 Likert's authoritative and democratic systems
3.5 Leadership style.
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4. Choose a theory of leadership and describe how you
would implement it in your ideal nursing setting.
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CHAPTER SEVEN
MANAGING RESOURCES
Objectives:
At the end of this chapter, the student should be able to:
􀂃 Explain the mechanisms of acquiring and
retaining human resource.
􀂃 Describe the process of budgeting
􀂃 Discuss the points to be taken in controlling
and maintaining equipment.
􀂃 How do managers maximize their time?
Human Resource Management
Human resource management is the process of
acquiring and retaining the organization's human
resource.
Acquisition of human resource includes human
resource planning, recruitment, selection and orientation
Retention activities include performance appraisal,
placement, training and development, discipline and
corrective counseling, compensation and benefit
administration, safety, and health.
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A. Acquiring Human Resource
1. Human resources planning
Human resource planning precedes the other acquiring
activities. Health service organizations determine
staffing needs through human resources planning.
Because organizations are dynamic, these needs
change. The work force must be considered in the
context of a changing environment: present staff must
be retained and new employees recruited to meet
changing needs. Staff needs in Health Service
Organizations are driven by
1. Organizational growth: occurs through
increased demand for services, higher
occupancy, facility expansion and the addition of
new services or intensifying services.
2. Employee turnover: through resignation,
discharge and retirement
Human resource planning involves five steps
1. Profiling-to profile the personnel need of the
organization at some future point
2. Estimating-Projecting the type and number of
personnel needed
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3. Inventorying-human resource audit of present
employees
4. Forecasting-anticipating changes in the present
work force in terms of entries and exits
5. Planning-Assumptions made by following steps
1-4 to ensure the right number of personnel with
appropriate prerequisite knowledge and skill
Human resource Sources
1. Internal Sources-filling vacancies by transferring
or promoting from within. Advantage
• It is cost effective, reduces recruiting and
relocation costs
• Usually quicker, and
• Enhances employee morale
Disadvantage
Seniority rules policy rather than best
qualification
2. External sources -new employees may be
recruited from outside through advertising
vacancies, visits to colleges and universities,
contacts with public and private employment
agencies and participation in professional
organizations
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Advantage
2. Recruitment
Recruitment is the process of attracting qualified people
to apply for a job. It involves searching for and attracting
prospective employees either from within the
organization or outside the organization. It is the
process of making applicants available for selection.
You can select only from those people who apply for a
job, the odds of finding a strong candidate are less than
if you have many applicants to choose them.
3. Selection
Selection is the process of choosing for employment. It
is to choose among the applicants using job qualification
as a guide. The essence of selection is to determine
whether an applicant is suited for the job in terms of
training, experience and abilities
Sources of information for selection
1. Application forms and
2. pre employment interviews
3. Testing
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Selection Model
Step 1. Analysis of the vacant job(s)-Using job analysis
procedures the vacant job(s) are studied to find the
knowledge skills and abilities needed for job success.
Many problems in personnel selection stem from the fact
that there is often inadequate understanding of the job
and its requirements. The best person is best only
insofar as he/she optimally meets these requirements
Step2: Selection of criterion and predictor: this step
involves two procedures. First, based on the job
analysis, a criterion of job success is chosen. As always,
the criterion must be a sensitive indicator of work quality.
Secondly, a predictor must be chosen
Step 3: Measuring performance-After the criterion and
predictor have been chosen, the worker's performance
is measured on both variables.
Step 4: Assessing the predictor's Validity-determine if
differences in predictor scores correspond with
differences in criterion scores, that is, does the predictor
have validity?
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Step 5: Determining the predictor's Utility-is to
determine how useful it will be in improving the quality of
the work force
Step 6: Reanalysis-Any personnel selection program
should be periodically reevaluated to see if changing
employment conditions have altered the predictorcriterion
relationship
The Classic Selection Model
3. Orientation
After selection, induction and orientation occur.
Orientation programmes include information about the
organization, organizational structure, philosophy and
objectives of the organization, rules and regulations,
universal precautions enrolling new employees in
benefit plans, issuing an identification badge are
typically carried.
Advantage
􀂃 Builds employees sense of identification with the
health service organization
􀂃 Helps the gain acceptance by fellow workers
􀂃 Give them a clear understanding of the many
things??? they need to know
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􀂃 Enables the new employee to become familiar
with the entire organization as well as their own
work area and department
B. Retaining Employees
The Retaining activities include, performance appraisal,
training and development, discipline and compensation
administration.
Personnel Training
A personnel training is the formal procedure which an
organization utilizes to facilitate learning so that the
resultant behavior contributes to the attainment of
organization's goals and objectives
Personnel training should contribute to the goals of both
the organization and the individual. Training is a
management tool designed to enhance organization's
efficiency. However, in the process of attaining
organizational goals, many individual goals can also be
attained.
Assessing training needs
Assessing training needs usually involves a three-step
process
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1. Organizational analysis- is the study of an entire
organization-its objectives, its resources and the
way in which it allocates resources to attain its
goals. Organizational analysis can take several
forms. One form is that of a personnel audit for
manpower planning. A personnel audit is an
inventory of the personnel assets of an
organization and a projection of the kinds and
numbers of employees who will be required in
the future. A second approach to organization
analysis involves indicators of organizational
effectiveness. These are examined to see if
training could improve the organization's
performance
2. Operational analysis-is the orderly and
systematic collection of data about an existing or
potential task or a cluster of tasks that define a
job. It examines the task or job requirements
regardless of the person holding the job. It
determines what an employee must do to
perform the job properly. Operational analysis is
most directly concerned with what training should
cover
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3. Personnel analysis-is directed toward learning,
whether the individual employee needs training
and what training he/she needs. It is concerned
with ascertaining how well a specific employee is
carrying out his/her tasks and with determining
what skills must be developed, what knowledge
acquired, and what attitudes cultivated if the
employee is to improve his/her job performance.
A large portion of person analysis involves
diagnosis. We want to know not only how well
people are performing but also why they are
performing at that level. Personnel analysis
involves appraising an employee’s performance,
objective records and diagnostic achievement
tests.
Methods and Techniques of Training
After determining an organization's training needs and
translating them into objectives, the next step is to
design a training program to meet these objectives. This
is not an easy task, because each training method has
its strengths, weaknesses, and costs. Ideally, we seek to
choose the one that meets our objectives in a cost
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efficient manner. There are many training methods
available.
Performance Appraisal
Performance appraisal is a systemic review of an
individual employee's performance on the job, which is
used to evaluate the effectiveness of his/her work
Purpose:
• Provide information upon which to base
management decisions regarding such
matters as salary raises, promotions,
transfers, or discharges
• Helps to assist employees in their personal
development
• Performance appraisal information will help
to assess the effectiveness of hiring and
recruiting practices
• Supply information to the organization that
will help to identify training and development
needs of the employees
• Helps in the establishment of standards of
job performance often used as a criterion to
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assess the validity of personnel selection and
training procedures
Employee’s work should continually be assessed in a
formal or informal basis. A formal appraisal is more
accurate, fair and useful to all concerned
Common Problems in Performance Appraisal
• Performance appraisal may be viewed as
demanding too much from supervisors. Especially in
large number of span of control. It is difficult for a
first line supervisor to know what each of 20, 30 or
more subordinating is doing
• Standards and rates tend to vary widely, with some
raters being tough and others more lenient.
Leniency Errors-some raters are hard graders and
others easy graders. So raters can be characterized
by the leniency of their appraisals. Harsh raters give
evaluations that are lower than the true level of
ability. This is called severity of negative leniency.
The easy rater gives evaluations that are higher than
the true level called positive leniency. These errors
usually occur because the rater has applied personal
standards derived from his/her own personality or
pervious experience
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• An appraiser may replace organizational standards
with personal values and bias. Halo errors-are
evaluations based on the rater's general feelings
about an employee. Thus, the rater generally has a
favorable or unfavorable attitude toward the
employee that permeates all evaluations of the
person. Typically, the rater has strong feelings about
at least one important aspect of the employee's
performance. This is then generalized to other
performance factors, and the employee is judged
(across many factors) as uniformly good or bad.
Raters who commit halo errors do not distinguish
among the many dimensions of employee
performance
• Because of lack of information, standards by which
employees think they are being judged are
sometimes different from those superiors actually
use
• The validity of ratings may be reduced by the
supervisor's resistance to making the ratings,
because of the discomfort they feel when having to
confront the employee with negative ratings and
negative feedback. Example, central tendency
errors: refers to the rater's unwillingness to assign
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extreme -high or low -ratings. Everyone is average,
and only the middle part of the scale is used
Characteristics of an Effective Performance
Appraisal
• Relate performance appraisal to the job description
• Understanding the criteria for evaluation
Tools of performance appraisal
• Rating scales-the tool consists of a behavior or
characteristics to be rated and of some type of scale
that will indicate the degree to which the person
being evaluated demonstrates that behavior
• The checklist- it describes the standard of
performance and the rater indicates by placing a
checkmark in a column if the employee
demonstrates the behavior
• Management by objective- it focuses on the
evaluator's observations of the employee's
performance as measured against very specific
predetermined goals that have been jointly agreed
upon by the employee and the evaluator.
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Appraisal methods designed to avoid rater bias
a. The field review method- this method allows the
ratings of several supervisors to be compared for
the same employee
b. The forced choice rating method-the evaluator
choose from among a group statements those
that best describe the individual being evaluated
and those that least describe this person
The critical incident technique-the supervisor observes,
collect, and record instances of the employee carrying
out responsibilities critical to the job. These are used to
prepare the evaluation or serve as the evaluation itself
to be viewed with the employee during the feedback
interview. These written accounts of behavior tend to
focus on performance rather than personality traits
II. Budgeting
• Is a plan for the allocation of resources and a
control for ensuring that results comply with the
plans
1. Prerequisite for budgeting
• Sound organizational structure
• Job descriptions
• Goals and objectives
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• Formal budgeting policies and procedures
The budgeting process should provide for
1. Plans of anticipated activity
2. A mechanism for measurement of work
effort on timely basis
3. Accountability by someone for variances
from budget
4. An awareness of costs by all participants
in the budgeting program
2. Major types of budgets
• Operating/recurrent- estimates of operating
expenses, estimates of operating revenues and
estimates of activity
Example: personnel salaries, supplies, light water,
drugs, repairs and maintenance
• Plant/Capital-estimates of expenditure for
adding, replacing or improving buildings or
equipment for the budget period
Example: buildings, major equipment
3. Other types of budget
Cash Budgets
Cash budgets are planned to make adequate funds
available as needed and to use any extra funds
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profitably. They ensure that the agency has enough, but
not too much, cash on hand during the budgetary
period. This is necessary because income does not
always coincide with expenditures.
Labor or Personnel Budgets
Personnel budgets estimate the cost of direct labor
necessary to meet the organization’s objectives. It
includes recruitment, hiring, assignment, lay off, and
discharge of personnel. The nurse manager decides on
the type of nursing care necessary to meet the nursing
needs of the estimated patient population. How many
nurses are needed during what shifts, what months, and
in what areas? The current staffing patterns, number of
unfilled positions and last year’s reports can provide a
base for examination and proposals. Patient occupancy
and the general-complexity of cases affect staffing
patterns. Personnel budgets also are affected by
personnel policies, such as salary related to position
and number of days allowed for educational and
personal leave. Overtime costs should be compared
with the cost of new positions. Employee turnover,
recruitment, and orientation cost must be considered.
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Flexible Budgets
Some costs are fixed and do not change with the
volume of business. Other costs vary proportionately
with changes in volume. Some variable expenses are
unpredictable and can be determined only after change
has begun: thus the need for flexible budgets, to show
the effects of changes in volume of business on
expense items. Periodic budget reviews help managers
compensate for changes. Relationships between the
volume of business and variable costs may be predicted
by a historical analysis of costs and development of
standard costs.
Strategic Planning Budgets
Long-range budgets for long-range planning are often
called the organization’s strategic plan and are usually
projected for 3 to 5 years. Program budgets are part of
the strategic plan that focuses on all the benefits and
costs associated with a particular program.
Business plans are detailed plans for proposed services,
projects, or programs. The contain information to
assess the financial feasibility of the plan. The business
plan states the objectives of the project and links them
to the organization’s strategic plan.
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STANDARD COST
Standard cost may be developed to predict what labor
and supplies should cost.
Multiplying the standard cost by the volume predicts the
variable cost. Supervising community health nurses can
predict the standard number of clinic visits and the
number of birth control pills that will be required by each
family planning client who has chosen birth control pills
as a method of contraception. Multiplying the number of
pills needed by each client by the number of clients
using birth control pills, nurse mangers can predict the
inventory needed and the cost. They also can predict
the number of clinic visits needed and plan staffing.
ZERO-BASED BUDGETING
Many budgeting procedures allocate funds to
departments based on their previous year’s
expenditures. Then the department managers decide
how the funds will be used. This procedure usually
allows for enrichment and enlargement of programs but
seldom for decreases or deletion of programs.
Obsolescence is seldom examined, and this leads to
increased costs.
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With zero-based budgeting, no program is taken for
granted. Each program or service must be justified each
time funds are requested. Managers decide what will be
done, what will not be done, and how much of an activity
will be implemented. A decision package is prepared.
The package includes a list of the activities that make up
a program, the total cost, a description of what level of
service can be performed at various levels of funding,
and the ramifications of including them in or excluding
them from the budget. The manager may identify the
activity, state the purpose, list related activities, outline
alternative ways of performing activities, and give the
cost of the resources needed.
After decision packages are developed, they are ranked
in order of decreasing benefits to the agency. They can
be divided into high, medium, and low-priority categories
and reviewed in order of rank for funding. Resources
are allocated based on the priority of the decision
package. The cost of each package is added to the cost
of approved packages until the agreed-on spending
level is reached. Lower ranked packages are then
excluded.
A major advantage to zero-based budgeting is that it
forces managers to set priorities and justify resources.
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SUPPLEMENTARY BUDGETS
Some budgetary flexibility may be obtained through a
supplemental monthly budget. A basic or minimal
budget is planned, usually for a year’s time, to outline
the framework for the agency’s plans, establish
department objectives, and coordinate departments.
Then a monthly supplementary budget is prepared
based on volume of business forecast for the month.
Moving Budgets
The moving budget may be used when forecasting is
difficult. The moving budget plans for a certain length of
time, such as a year. At the end of each month, another
month is added to replace the one just completed.
Thus, the budgetary period remains constant. The
projections progress a month at a time but always for a
fixed period such as one year. It is an annual budget
revised monthly. As Sene is completed, Sene budget
for the forthcoming year is added to the moving budget.
4. The budget period
Most health care agencies budget on a monthly
basis for a 1-year period. The budget year often
begins July 1 and ends June 30.
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5. Advantages of Budgeting
Budgets plan for detailed program activities.
• They help fix accountability assignment of
responsibility and authority.
• They state goals for all units, offer standard of
performance, and stress the continuous nature of
planning and control process.
• Budgets encourage managers to make a careful
analysis of operations and base decisions on careful
consideration.
• Consequently, hasty judgments are minimized.
Weaknesses in the organization can be reveled and
corrective measures taken.
• Staffing, equipment, and supply needs can be
projected and waste minimized.
• Financial matters can be handled in an orderly
fashion, and agency activities can coordinated and
balance.
6. Budgeting Process
Financial planning responsibilities need to be identified
before budget preparation begins.
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Steps
1. The first step in the budget process is the
establishment of operational goals and policies
for the entire organization.
2. The top management should approve a longrange
plan of 3 to 5 years that reflects the
community’s future health needs and other
community health care providers’ activities.
Because the situation changes over time,
flexibility is built into the plan.
3. Then operational goals must be translated into
quantifiable management objectives for the
organizational units.
4. The department heads use the organizational
goals as a framework for the development of
department goals.
5. A formal plan for budget preparation and review
including assignment of responsibilities and
timetables must be prepared.
6. Historical, financial, and statistical data must be
collected monthly so that seasonal fluctuation
can be observed.
7. Departmental budgets need to be prepared and
coordinated. During this phase, units of service,
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staffing patterns, salary and non-salary
expenses, and revenues are forecasted so that
preliminary rate setting can be done.
8. Next, departmental budgets are revised, and the
master budget is prepared. At this point,
operating, payroll, non salary, capital, and cash
budgets can be incorporated into the master
budget.
9. Then the financial feasibility of the master budget
is tested, and the final documents is approved
and distributed to all parties involved.
10. During the budget period, there should be
periodic performance reporting by responsibility
centers.
7. Cost Implication to Budgeting
Cost Containment
The goal of cost containment is to keep costs within
acceptable limits for volume, inflation, and other
acceptable parameters. It involves cost awareness,
monitoring, management, and incentives to prevent,
reduce, and control costs.
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Cost Awareness
Cost awareness focuses the employee’s attention on
costs. It increases organization awareness of what
costs are, the process available for containing them,
how they can be managed, and by whom. Delegating
budget planning and control to the unit level increases
awareness. Managers should be provided a course
about budgeting and be oriented to the agency
budgeting process before being assigned the
responsibility. They should have a budget manual that
contains budget forms, budget calendar, and budget
periods.
Cost Monitoring
Cost monitoring focuses on how much will be spent
where, when, and why. Identifies, reports, and monitors
costs. Staffing costs should be identified recruitment,
turnover, absenteeism, and sick time are analyzed, and
inventories are controlled. A central supply exchanger
chart prevents hoarding of supplies and allows
identification of lost items.
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8. Costing Out Nursing Services
There are several benefits to costing out nursing
services.
• Charging our nursing services makes it possible
for the customer to pay for what he or she gets.
The patient pays for the care rendered.
• Customers start to realize that direct care has a
price value. This helps them comprehend costs
of health care and, ideally, to value it
• Hospitals can receive compensation for what
they provide, to help maximize profits.
• Nursing can be viewed as a revenue-generating
center rather than a cost.
• Charging a fee for services helps enhance the
professionalism of nursing through the traditional
pattern of reimbursement for services.
• Costing out nursing services stimulates
productivity by visualizing productivity measures
to enhance the use of human resources, contain
costs, and maintain quality.
• Using a cost accounting system to assess and
change the nursing department helps establish a
reputation for innovation and leadership. Quick
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responsiveness to changes will help agencies
survive in a rapidly changing environment
The most commonly used methods for determining
nursing service costs are per diem, or cost per day,
of service; costs per diagnosis; costs per relative
intensity measures (RUMs); and patient
classification systems (costs per nursing workload
measures).
Per Diem
Per Diem methods are the oldest methods used for
both rate setting and reimbursement. Average
nursing care cost per patient day is calculated by
dividing the total nursing costs by the number of
patient days for a specific period. Nursing costs are
usually considered as salary and fringe benefits for
staff and administrative nursing personnel. These
costs can be calculated for individual cost centers,
subdivisions, or the entire nursing service. Per Diem
relates nursing costs directly to length o stay but
does not identify patient needs, acknowledge
differences in diagnosis, specify nursing services
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needed, justify care given, or provide information for
management decisions.
Costs per Diagnosis
Information about the patient mix is often used to
reduce the variability in nursing care requirements.
The medical diagnosis is frequently used to identify
groupings. DRGs use this method. Some people
recommend using nursing diagnosis or nursing care
standards for grouping patients according to their
nursing care needs. It seems logical that nursing
diagnosis could better predict nursing care needs
than DRGs based on medical diagnosis.
Costs per RIMS
RIMs were developed in New Jersey to allocate
nursing resources in such a way as to address the
complaints that DRGS inadequately represent
variability of nursing care requirements. A RIM is 1
minute of nursing resource use. RIMS are coasted
and allocated to DRG case-mix categories through
three steps: (1) The cost of a RIM is calculated by
dividing the total nursing costs for a hospital by the
total minutes of care estimated or nursing resources
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used to provide care to all patients. (2) The number
of minutes used by the total hospital population,
including adjustments for downtime, such as sick
leave and vacation time, is calculated. (3) The cost
of care for each patient is determined by multiplying
the RIM by the minutes of care required by the
patient as estimated by an equation. The RIMs
development studies used data from New Jersey
Hospitals to measure the time used by nursing
personnel performing nursing and non-nursing
activities during the entire hospitalization.
Costs per Nursing Workload Measures
Patient classification systems were developed to
allocate nursing staffing before DRG-based
reimbursement. Some to calculate the cost of the
nursing component of room rate has used nursing
workload data. Cost accounting methods allow
calculations for whole patient care units and for
individual patients; consequently, t is possible to
generate a separate charge for nursing services for
individual patients. These methods are also used to
allocate nursing costs to DRGs or cost centers.
Unfortunately, there is limited irretrievability of data,
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because few hospitals record patient classification
data for individual patients in the patient record or on
a database, data collection and analysis are
expensive, and practice may not adhere standards.
III. Material management
• Material management is the integrated function
of purchasing and allied activities to achieve the
maximum coordination and optimum expenditure
in the area of materials.
• One of the objectives of materials management
is to have the right materials at the right place at
the right time. This depends on effective policies
of forecasting, inventory, and materials
distribution.
Materials/equipment can be divided into:
1. Expendable/consumable/recurrent-are
those materials/items that should be
regularly kept in stock for production
purposes or maintenance of the plant and
are used within a short time.
2. Non-expendable/capital/non-recurrent:
are those materials/items that are
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required only for specific purposes or jobs
and which are not to be automatically
recouped, lasts for several years, and
needs care and maintenance.
Managing equipment
Ordering-obtaining equipment from
stores of shops
Storing- recording, labeling and holding
equipment in a stock or store room
Issuing- giving, labeling and holding
equipment in a stock or store room
Controlling- monitoring expendable
equipment, maintaining and repairing
non-expendable equipment.
Important points in controlling and
maintaining equipment:
• Convincing staff that equipment
must be cleaned, inspected and
kept in good order. Defects must
be reported immediately.
Equipment must always be
returned to its correct place after
use.
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• Use inspection check list and
inspection schedule
• Detecting discrepancies and
explaining them
Good management takes care of equipment by:
􀂃 Motivating staff to feel
responsible for the
equipment they use
􀂃 Ordering supplies when
needed
􀂃 Storing supplies safely
􀂃 Controlling the use of
supply
Accurate records save time and contribute to the
economy, efficiency and smooth functioning of the
health service
In most of the government sectors in Ethiopia, receiving
and issuing of
Materials/equipment/items are carried out using the
following models
􀂃 Model 19- model confirming delivery of
items/drugs
􀂃 Model 20- Model for requesting items/drugs
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􀂃 Model 21- Model for approving item delivery by
person in authority
􀂃 Model 22- Model for issuing items/drugs
IV. Managing Time
Time is a non-renewable resource.
Maximize Managerial Time
1. Set goals- determines the short, medium and
long-range goals. Which goals must be
completed before others? Which will take the
longest to achieve? Setting priorities helps
resolve goal conflict.
2. Once you have determined and ranked your
goals plan strategies to achieve them
3. Plan schedule
4. Improve reading
5. Improve memory
Planning time arrangements
􀂃 Events are arranged in daily, weekly,
monthly or yearly time periods.
􀂃 The periodicity depends on the frequency
or regularity of particular events.
􀂃 Time plans are written in various common
forms known as :
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Timetable: daily or weekly regularly recurring events.
Schedule: intermittent or irregular or variable events,
and where they take place.
Roster: duties planned for different staff members, for
different times in turn.
Preparing a health unit time table
􀂃 List all activities that happen regularly each
week.
􀂃 Then arrange them in an appropriate timetable
grid.
Preparing health unit schedule
􀂃 A schedule is required when a different activities
or the same activity in a different place is spaced
at intervals over time.
􀂃 To make a schedule, each different activity or
each different place is listed and passed through
the dates in turn, the whole cycle is repeated.
Preparing duty roster
􀂃 A duty roster is a time plan for distributing work
among staff members
􀂃 Duty rosters are needed for three purposes:
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1. To distribute work fairly and evenly outside
normal working hours, e.g. night duty,
weekend duty, holiday duty
2. To distribute uninteresting or difficult work,
and interesting or varied work.
3. To divide extra duties among the whole staff.
Learning activities
1. What are the mechanisms of acquiring and
retaining human resource in nursing?
2. What are the procedures and process to be
followed in forecasting the budget of the
nursing department?
3. How do we maximize the best use of nursing
equipment in an organization?
4. What are the principles of effective time
management?
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