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 EIGHT
EVALUATING HEALTH ACTIVITIES
Objectives:
At the end of this chapter, the student should be able to:
􀂃 Define evaluation
􀂃 Describe the roles of evaluation
􀂃 Explain the types and levels of evaluation
􀂃 Discuss the steps of evaluation
Evaluation
• Is the process of finding out the value of
something
• Determining the value or worth of objects of
interest against standard of acceptability
• In evaluation we have to ask two broad
questions:
• Are the results those that were intended?
• Are they of value?
Roles of Evaluation
1. As a step ensuring the delivery of
high quality health care
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2. An important tool for controlling
health care expenditures and
ensuring accountability
Levels of Evaluation
• Effort-to assess the resources or capacities
• Performance-to assess the output or outcome of
the program
• Adequacy of performance-the extent to which
performance meets the program objectives
• Effectiveness-the amount of the intended
objectives that have been attained
• Efficiency-the degree to which the program
achieved its result at the lowest possible cost
Steps of evaluation
1. Decide what is to be evaluated?
2. Collect the information needed to provide the
evidence
3. Compare the results with the targets or
objectives
4. Judge to what extent the targets and objectives
have been meet
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5. Decide whether to continue the programme
unchanged, to change it or to stop it
How to evaluate work progress?
Work progress is evaluated in order to measure the
efficiency of the nursing/ midwives team, i.e. to find out
whether the team completed the work which was
assigned to it in order to reach its targets, the work was
of expected quality, was carried out in time and its
budget was not overspent?
Types of evaluation
• Process evaluation- measurements
obtained during the implementation of
program activities to control or assure or
improve the quality of performance or
delivery.
• Impact evaluation- focuses on the
immediate observable effects of a program
leading to the intended outcomes of a
program
• Formative evaluation- measurements and
judgments made on the process of the
program
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• Summative evaluation
Learning activity
1. What is evaluation?
2. Explain the roles and levels of evaluation
3. How can we evaluate work progress?
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CHAPTER NINE
COMMUNICATION
Objectives:
At the end of this chapter, the student should be able to:
• Define verbal communication and non verbal
communication
• List down the components of communication
process using a diagram direction
• Discuss the ten basics for good communication
• Use an assertive style of communication using the
nurses Bill of Rights as identified by Hermann and
differentiate between aggressive and passive style
of communication
• List down common blocks to communication and
discuss on how to improve them
• Use through examples the common patterns of
communication networks.
Communication
Communication by definition is the transfer of
information and understanding from one person to
another. To be a leader, the student must have a basic
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understanding of the communication process, which
consists of a sender, a message and a receiver, all of
which are influenced by an environment. Each of the
components of the communication process is capable of
enhancing or inhibiting the understanding of the
message.
The Message
The message is that which is being conveyed. The
leader must remember that the meaning of words
resides not in the message but in the person receiving
the message. Words mean different things to different
people. Individuals assign their own meaning to what
has been suggested, and their meaning may be different
from what was intended by the leader. The message is
composed of what it is you are trying to convey through
verbal and nonverbal symbols. Since words are more
symbols with meaning residing in people, it is possible
for everyone to hear the same thing and interpret the
message differently. The second aspect of a message is
nonverbal behavior. Nonverbal behavior consists of
facial expressions, pauses, gestures, posture, and tone
of voice that reinforces or contradicts what is being said
in the primary message. The message through both
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verbal and non-verbal means is conveyed by means of
the communication process.
The message
1. Verbal
What you talk about
2. Non -verbal
How it is communicated - facial expression, pauses,
gestures, posture, tone of voice (accepting or rejecting) -
body language
3. Communication climate
Positive-enhances the message or Negative-detracts
from understanding the message.
Fig.9.1 The essential elements of communication
components: the message and communication in which
the message is delivered.
The Communication process
In technical terms, the communication process consists
of six steps: ideation, encoding, transmission, receiving,
decoding, and response (Fig. 9.2). Ideation refers to the
message, the idea or thought to be conveyed to an
individual or a group. Encoding is the manner in which
the message is conveyed and may be other than verbal,
such as a written message or a visual or audible cue.
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Encoding also takes into account the nonverbal
behaviors that accompany the message, such as a
gesture or an expression. Transmission is the actual
expression of the message. For the listener or reader to
receive the message, he or she must have appropriate
listening or other abilities. Decoding refers to the
receiver's under standing or interpretation of the
message. The response, or feedback, should convey to
the leader the degree of understanding held by the
individual or the group. The communication process is
now reversed so that the leader has the task to
understand the new message using the same process.
The nurse leader or manager uses communication skills
in all aspects of organizational life. Different skills are
required to communicate effectively with groups of
professional workers. The professional person is an
educated individual with a very specific contribution to
the work place. Therefore, appropriate manner of
communication process is essential.
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Fig.9.2. The conceptual components of the
communication process. The circle is used to denote the
dynamic and reciprocal properties of the communication
process.
Ten Basics for Good communication
1. Clarify your ideas before communicating to others.
Before speaking to an individual or a group, plan and
organize what it is you are going to say. Analyze
your thoughts carefully, and keep in mind the
objective you wish to meet as well as the
uniqueness of the individual or the group. Provide an
opportunity for questions and answers to enhance
the clarity of the message.
Ideatio Encoding
Respons
Decoding
Transmission
Receiving
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2. Consider the setting, both physical and
psychological. The physical setting can be
conducive or can be serious block to
communication. Take for instance the backdrop of a
busy emergency department currently understaffed.
This would not be a place to discuss an employee's
performance appraisal, but it might be the perfect
setting in which to discuss the shortage of nurses
with the administrator.
The psychological environment is also important. This is
referred to as the communication, or social, climate. If
you as a leader have less difficulty, communicating with
your staff than you would with in a defensive and hostile
(negative) environment.
Positive climate behavioral characteristics
Listening
Empathy
Acceptance
Shared problem solving attitude
Openness
Evaluating
Advice giving
Superiority
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Fig.9.3. The characteristics of both a negative and
positive communication climate.
The leader or the followers or both exhibit these
behaviors.
A psychological and emotional relationship results
between and among the work group and the manager
and may be either supportive or defensive. A supportive
communication climate means that communication
patterns are characterized by a leader who listens; is
empathetic; offers acceptance of individuals; exhibits a
shared, problem-solving attitude; is open; and values
equality in the work place. The members of the group
exhibit the same attitudes and behavior. A defensive
climate, on the other hand, is characterized by a leader's
communication pattern that may be controlling,
punishing, evaluating, advice giving, and reinforced by
leader behavior that says, "I am superior and always
right". The followers, on the other hand, are submissive
or aggressive, and communication is usually nonproductive
and unpleasant.
The value of a positive communication climate is
that it fosters behaviors among the leader and
followers that lead to trustful and cooperative
working relationships. It is a kind of climate that will
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foster innovations in the work place, making change
a possibility.
3. Consult with others when necessary to be exact and
objective. The worst mistake a leader can make is to
communicate incorrect information to the members
of the group. If misinformation is given to an
individual or to the group, the leader should
acknowledge the error and correct the situation. This
demonstrates to the staff and to superiors that the
leader deals with mistakes in a direct, honest and
forthright manner.
4. Be mindful of the overtones as well as the message
itself. Non-verbal cues may be saying something
opposite from the words nature. It may give mixed
messages, making it very difficult for the listeners to
know what you are trying to convey. Non-verbal
behavior should support your message, not detract
from it.
5. Take the opportunity to convey something to help,
value, or praise to the receiver. People need to know
that their contributions are useful and respected.
This is not just limited to subordinates; you also
might wish to acknowledge the helpful contributions
of superiors.
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6. Follow up your communication. You must get feed
back to make sure that the message is understood
as you intend it to be understood. Ask questions and
encourage the receiver to express his or her reaction
by follow up contacts.
7. Be sure your actions support your communication. In
other words, "What I say. I do". If action and
attitudes are in conflict, there will e confusion, and
people will tend to deny what has been said. For
example, if you tell your staff that, they must be on
time for work and then you are late on a regular
basis; your message will not be taken seriously.
8. Be an active listener. Practice what you preach.
Listen to what the person has said as well as the
way in which it was said. Probably one of the least
developed skills in the communication process is
active listening. Listening takes effort and often time
to develop because it demands discipline. It is
difficult to listen to non-stop talkers or to people who
use other communication patterns that get on your
nerves. A true leader must develop the self-mastery
to be silent when someone else is speaking. To do
that you must consider the other person's ideas to
be more important than your own.
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Active listening, however, does not imply agreement on
your part, nor does it imply that you do not have the right
to interrupt the conversation. It does mean that you must
learn the other's point of view by hearing and trying to
understand the message. It only through understands
what the differences are that the potential for positive
solutions exist.
9. Give credit for the contributions of others when
genuinely deserved. It is amazing how powerful
praise can be in establishing positive feelings in
other people. Everyone needs to know when he or
she have done something especially well
10. Be an assertive when expressing your view.
Communication patterns exist on a continuum from
passive to aggressive. Assertiveness is the desirable
style for the nurse leader and manager. Assertive
communication and behavior maintains a balance
between aggressive and passive styles. The
assertive style considers the rights of all persons
involved in the communication process.
The nurse's Bill of Rights, identified by Herman, states
very clearly what these rights are :( Hermann)
• The right to be treated with respect
• The right to be listened to
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• The right to have and to express thoughts, feelings,
and opinions
• The right to ask questions and to challenge
• The right to understand job expectations as well as
have them written
• The right to say "no" and not feel guilty
• The right to be treated as an equal member of the
health team
• The right to ask for change in the system
• The right to have a reasonable workload
• The right to make a mistake
• The right to make decisions regarding health and
nursing care
• The right to initiate health teaching
• The right to make decisions regarding health and
nursing care
• The right to initiate health teaching
• The right to be a patient advocate or to help a
patient speak for himself or herself
• The right to change one's mind
The assertive style is demonstrated by communication
that says directly and clearly, what is on y our mind. It is
also demonstrated by listening to what others say. The
leader uses objective words, uses "I" messages, and
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makes honest statements about the leader's ideas and
feelings. Part of assertive style is the use of direct eye
contact, spontaneous verbal expressions, and
appropriate gestures and facial expressions while
speaking in a well-modulated voice. Assertiveness is
also a process that comes with maturing in role gaining
self-confidence in one's own knowledge and experience.
An assertive style is appropriate and is based on selfrespect
and consideration for other people.
Aggressiveness, on the other hand, is concerned only
with the rights of one position and may be loud,
inappropriate, confronting, or hostile. This style uses
subjective words, makes accusations, and sends "you"
messages that blame others. A confronting, sarcastic,
verbal approach with an air of superiority and rudeness
may be usual. This individual often belittles others while
seeming to take charge of the situation. There is
absolutely nothing to be gained by this style. The
individual may win the battle but will surely lose the war.
The rights of all individuals have not been considered.
A Passive Communication style is one that does not
consider any rights. It may be viewed as being
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uninvolved or unable to share thoughts. This style may
be withdrawn and shy or purposefully withholding.
Women in particular may tend to be quiet in-group
situations, and beginning leaders may have to overcome
some hesitation about speaking to groups. Some
suggestions that can help include recognizing your
value and rights in a situation. Try to make one
contribution in each group situation. Gradually you will
feel more comfortable speaking in groups.
Communication among professionals is an essential
hallmark of health care. Keep in mind that the leader
and followers have a basic right to give and to receive
information in a professional manner. Communication
skills grow and develop over time and are the means by
which leadership is exercised. It is important to
remember that communication does not necessarily
mean agreement or harmony over every issue but is
rather an attempt to achieve understanding of the
message between leader and followers.
Case Study
Dr. Hailu is a well-known and experienced surgeon. At
the very least, he is known to be a "difficult individual".
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He has gained this reputation because he shouts before
he thinks, blames before he knows the facts, and
generally has a short fuse.
Alemnesh Sium, RN, did not know Dr. Hailu's and
unintentionally walked into the unit to transfer a patient.
In typical fashion, Dr. Hailu could not find the laboratory
work on the chart and began a temper tantrum aimed at
Alemnesh Sium. Alemnesh looked him in the eye, told
him to stop shouting, and, when he could be
reasonable, to restate his request. The spectators to this
event were speechless.
Difficult individual's impositions of relative power can be
problematic for a staff. However, appropriate behavior
and the rights of all individuals have to be considered if
good working relationships are to exist.
What kind of communication technique did Alemnesh
Use?
What would you have done?
Blocks to Communication
Blocks to communication refer to obstacles that
somehow prevent the message from being delivered or
understood. Some common reasons for blocks to
communication are poor listening habits, Psychological
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blocks, Environmental distractions, and semantic
barriers (Davis). Blocks to communication are the
reason why people leave meetings with half messages
and incomplete or inaccurate information.
Listening Skills-To improve your listening skills, certain
behaviors must be learned and practiced as you interact
with people. Active listening begins as you give full
attention to the person speaking. This means that you
listen carefully with your mind as well s with your
gestures and facial expressions. Look directly at the
person to whom you are speaking. Direct eye contact
conveys your undivided attention to the speaker. It is a
good idea to indicate your desire for understanding by
asking for clarification, paraphrasing, or summarizing or
by requesting information as necessary. Probably the
most important aspect of active listening and the most
difficult are keeping silent, which is a means of showing
respect for the other person. Active listening will
enhance the understanding of messages by facilitating
communication through appropriate feedback.
Feedback allows the leader to judge the listener's
understanding and can be gained by asking the right
questions. This means phrasing questions within a
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frame or reference and requesting that questions asked
of you be also placed in a frame or reference. As
always, acknowledge the message and affirm that both
you and the speaker have the same understanding. If it
is appropriate, thank the other person for the honesty
and true expression of feelings. Listening is a skill for
which you as a leader will be rewarded because it will
lead to effective behavior.
Psychological Blocks-Consider the following situation.
An individual hears something that produces a profound
emotional reaction. An intense response to a
communicated message very likely will produce a
temporary block to the rest of the message. It is highly
unlikely that constructive communication can continue
until feelings have been defused. The individual stops
listening, focuses on part of the message, and may
close his/her mind to other ideas. Emotions are powerful
forces that may interfere with reason and must be
recognized and respected before constructive
communication may continue.
Environmental Distractions - The problem of
environment is considered to be a block to
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communication when it interferes with the
communication process. People may be trying to have a
serious conversation when a sudden, distracting noise
occurs that directs attention away from the message
and toward the environmental stimuli. For example, the
head nurse is telling one of her staff nurse about his
performance of the last four months and the phone rings
or there is a knock at the head nurse's door. This is
distracting, and both parties will have to compensate for
the interruption before they are ready to continue their
conversation.
Semantic Barriers- Semantics is the study of words.
Since words are symbolic, their meaning is subject to
multiple interpretations. The leader should try to be
aware of the choice of words or phrases used in
conveying a message to avoid misinterpretation or
sending the wrong message to the group. In addition,
the leader should consider the context of words or their
relationship to a particular idea. Using messages in the
proper context will reduce misinterpretation. For
example, a head nurse wishes to convey to the staff that
they have been especially competent and productive
during an extremely hectic period and that she is
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pleased with their performance. The words the head
nurse chooses to use are, "You are guilty of doing and
unbelievable job!" Unfortunately, it is really not clear
what the head nurse is trying to say or for what period of
time or particular activity. In this case there is a great
deal of room for misunderstanding the message.
Communication Networks
Communication patterns, or networks, allow information
to be circulated among the group. These same networks
also affect the ways groups solve the problem. The
actual pattern of the communication network may be as
varied as the number of groups in existence. Common
patterns include downward, upward and downward,
circular, or multi-chaneled. Fig. 9.4 illustrates the
communication networks. In essence, the leader either
talks in downward pattern to the group or there is
sharing both up and down with the participants of the
group as well as communications that are shared
among the participants. The real issue is not whether
every participant shares a two-way communication
channel with every other member but whether the
communication is adequate as measured through the
appropriate performance of the group. Attempts at open
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communication are preferable to restricted
communication patterns.
and upward
Learning Activities
1. Ho you personally prepare for small
group interactions?
2. Select a recent situation in which you
interacted with several people in a formal
group structure. How do you
communicate verbally and non-verbally?
Fig. 9.4 some of the ways communication networks can form
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CHAPTER TEN
GROUP DYNAMICS
Objectives:
At the end of this chapter, the student should be able to:
• Differentiate among primary and secondary groups
in a group dynamics
• Analyze the functions and roles of a group
• Discuss nonfunctional and unhelpful roles in the
group dynamics
• Demonstrate in class the five phases of small groups
using a role play
• Develop a skill of decision making in small groups
using brainstorming and nominal group technique
exercises in a classroom.
• Explain the major guideline to increase team
cohesiveness
• Describe the guideline for making a committee
effective
Group Dynamics
Communication skills are only one aspect of leadership
development, the other is knowledge of Group
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dynamics. Group dynamics include the study of how
people form and function within a group structure. The
group becomes a unit when it shares a common goal
and acts in union to either achieve or thwart the
accomplishment of the goal.
Primary and Secondary Groups - A group may be
defined as a collection of individuals who interact with
each other on a regular basis, who are psychologically
aware of each other, and who see themselves as a
group. Groups are categorized as primary or secondary.
Primary groups are composed of individuals who
interact on a "face to face" basis, and the relationships
are personal. In addition, there are no written, formal
rules or regulations because they are unnecessary.
Examples of primary groups are families or groups of
friends. In the workplace, primary groups also exist in
the form of those who affiliate because of something
held in common. Similarity distinguishes this group. For
instance, the group members may be all women in the
administrative field or all graduates from the same
institution, or they may all be of the same ethnic
background.
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Secondary groups are larger and more impersonal.
These groups are organized around formal rules,
procedures, policies and other regulations. The work
place is composed of secondary groups that are found
in departments or at levels and that form the work
group.
The leader deals with the secondary group in the work
place. Secondary groups may also be categorized as
formal or informal groups. Formal groups are the official
or legitimate work group, while informal groups form for
different reasons. The leader must be able to influence
both groups and thus move the work group toward
meeting its objectives.
An effective work group is characterized by the ability to
meet its goals through a high degree of appropriate
communication and understanding among its members.
This type of group makes good decisions based on
respect for all members' "points of view". Another
characteristic is the ability to arrive at a balance
between group productivity and satisfying individual
needs. The leader does not dominate a group like this;
instead there is flexibility between the leader and
members to use different and individual talents
appropriately. This group is cohesive and can
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objectively review its own work and face its problems in
a way that balances emotional and rational behavior for
a productive group effort. The leader who enhances
cohesion and cooperation will be moving the group
toward completion of its goals.
Characteristics of a Group- One of the characteristics
of the group is a value structure that is created in
groups that comes about because of the influencing
process among and between its memberships. For
example, some groups value their expertise, they value
friendship, or they value higher wages. Another
characteristic of a group is the sharing of norm. Norms
refer to the expected behavior within a group. If the
individual violates these norms, he/she will take the risk
of being an outcast. Norms of a group are powerful
enforcers for human behavior. Compliance to the norms
means a group membership.
Task Behaviors of a Group
Some of the available behaviors that participants in the
group may exhibit are broadly grouped as task or
maintenance behaviors. Task behaviors serve to
facilitate and to coordinate group effort in the selection
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and definition of a common problem and in the
solution of that problem. Behaviors that fall in this
category are:
• Initiating-suggests new ideas, or a different way of
looking at an old problem, or proposing new
activities
• Information seeking- asks for relevant facts and
feelings about the situation at hand
• Information giving- provides the necessary and
relevant information
• Clarifying- probes for meaning and understanding in
whatever the group is considering
• Elaborating- builds on previous comments and
thoughts and thus enlarge the concept under
consideration
• Coordinating- clarifies the relationships among the
various ideas and attempts to pull things together
• Orienting- defines the progress of the discussion in
terms of goals to keep the discussion in the right
direction
• Testing- checks periodically to see if the group is
ready to make a decision or to recommend some
action
• Summarizing- reviews the content of past discussion
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Maintenance functions are carried out through behavior
that maintains or changes the way in which the group is
working together. These behaviors seek to allow the
group to develop loyalty to one another and to the group
as a whole. These behaviors include;
• Encouraging- the giving of friendly advice and help.
Praising and agreeing with others also define this
behavior.
• Mediating or harmonizing- helps others to
compromise or to resolve differences in a positive
way.
• Gate keeping- allows the fair and equal participation
of all members of the group by such comments as."
We haven't heard from Seifu."
• Standard Setting- the action that determines the
yardstick the group will use in choosing its subject
matter, procedures, rules of conduct, and , most
important its values.
• Following- Going along with the group passively or
actively either during a discussion or in response to
the group's decision.
• Relieving tension- diverts attention from unpleasant
to pleasant matters. Often this behavior smoothes
the way for constructive communication.
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The third and last category of group roles is the one,
which is nonfunctional and unhelpful to the group. Group
members to satisfy their own particular needs use
individual roles. These roles do not help the group to
accomplish its task or to facilitate good member
relationships. The roles in this group category are listed
below:
• Aggressor: Attacks or disapproves of
others' suggestions, feelings, or values.
• Blocker: Resists, without good reason, or
becomes extremely negative to others
suggestions.
• Recognition seeker: Calls attention
repeatedly to own accomplishments and
diverts the group's attention.
• Self-confessor: Uses the group's time to
express personal, non-group oriented
feelings or comments.
• Play boy-Playgirl: Plays around and
displays other behavior that indicates
he/she is not involved in the group
process.
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• Dominator: Tries repeatedly to assert
own authority and often interrupts other
group members.
• Help seeker: Tries to elicit sympathy from
other group members.
Phases of Small Groups
Orientation Phase: The beginning period in the small
group process is called the orientation phase. During
this phase, individuals spend time assessing their
purpose for joining the group and figuring out where
they fit in the group. Orientation phase is also called the
forming phase. Members engage in testing the other
members and the leader to determine what is
appropriate and acceptable behavior within the group.
Members spend time at this point trying to identify the
nature of the task and the ground rules.
Conflict Phase: During this phase, members become
less interested in orientation issue, such as how they
are fitting into the group, land more interested in control
issues, such as how they are influencing the group.
Each member wants to be perceived by others as a
competent group member with something to offer
others. In addition, frequent discussions typically occur
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about what task needs to be completed, which rules of
procedure will be followed, and how decisions will be
made in the group. Here leaders can assist group
members to satisfy their needs for control or influence
within the group during the conflict phase.
Cohesion Phase (Norming Phase): This phase is the
developmental phase and members of a task group may
become aware of time pressures and realize that they
need to start moving toward consensus in order to meet
their objectives. Members of a therapy group may
become more understanding of one another differences
and more able to accept these differences in the group.
Still others may observe the splits and factions of the
previous stages and feel the need to move closer rather
than farther away from others. Essentially, members
want to develop more unity during this phase. During
this phase, there is greater expression of the ideas,
opinions, and observations on task issues.
Leadership during this phase poses fewer problems
than during other phases because of the positive
feelings and the unified sense of directions in the group
at this time. The leader can put the group on "automatic
pilot" during this phase as members work in harmony on
group objectives. The leader provides guidance and
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direction only as needed during this phase and
essentially assumes a non-dominant role.
Working Phase (Performing phase): This phase is
similar to the cohesion phase but it involves more time,
greater depth, and increased disclosure among group
members. At this point members feel secure to express
both positive and negative emotions in task groups, yet
communication usually remains positive, even to the
point of members joking and praising each other. The
group spirit and the feeling of unity among members are
often high during the working phase.
Termination Phase: This phase usually occurs when
the goals of a group have been fulfilled or when the
allotted time has run out and the members begin to
consider the implications of lending the group. During
the termination phase, leaders need to summarize the
work of the group, emphasize goal achievement, and
help group members find a sense of closure as they
confront their feelings about the approaching end of the
group and the members' relationships.
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Orientation Conflict Cohesion Working Termination
Sale topics
Goblet
issues
Little self
disclosure
"In or Out"
discussions
Disagreement
s and
debates
Discussions
about rules
and
procedures
"Top or
bottom"
discussions
Supportive
comments
Greater self
disclosure
Suppression
of negative
feelings
"Close or far"
discussions
Positive
comments
Consensus
statements
Problem
solving
comments
In-depth self
disclosure
Summary of
discussions
Expression
of feelings
Closure
statements.
Table 10.1. Typical kinds of communication in different
Phases of Groups
Techniques for Decision Making in Small Groups
There are three useful procedures for a small group of
people that helps them to arrive at a decision for a
problem. These include Brainstorming, the nominal
group technique and the Delphi method. Each
procedure provides a different but practical approach to
group decision-making.
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Brainstorming
Brainstorm is a discussion technique developed by
Osborn (1957) to stimulate the production and
generation of creative ideas in groups. Brainstorming
enhances by allowing them to express their ideas freely
without being inhibited by the fear of criticism. The
assumption that underlies brainstorming is that if group
members feel uninhibited about expressing their ideas,
more ideas and better ideas will emerge from the group.
The brainstorming technique is relatively easy to use in
small group discussions.
The rules for brainstorming technique include:
1. Generate numerous ideas about an issue
2. Welcome free thinking and facilitate open
expression of ideas
3. Withhold any evaluation or criticism of the ideas
that are expressed
4. Build and improve on ideas already expressed
For brainstorming to work effectively; group members
must not judge or criticize the ideas expressed by
others. This nonjudgmental approach is often difficult to
master because most people are conditioned to
evaluate the pros and cons of a new idea as soon as it
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is introduced in a group. Criticism, is however
counterproductive of the overall goal of brainstorming
because members who fear criticism will most likely
express conventional solutions and withhold wild or
innovative ideas.
Nominal Group Technique
This technique is designed to promote the expression of
many high quality ideas from members who initially work
independently and then share their ideas with the group.
Unlike the free willing expression of ideas in
brainstorming, this technique uses a more systematic
procedure that ensures that each member will have the
opportunity to present an idea to the group for
consideration. The overall goal of the nominal group
technique is to arrive at a group decision that represents
a pooled judgment that is based on the independent
ideas of all group members.
The steps for nominal group technique include:
1. Group members, without any discussion,
independently write down their ideas about a
problem or task
2. Each group member presents an idea to the
group without discussion. This process continues
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around the table until all ideas have been
expressed. The ideas are summarized and listed
on either a chart or a chalkboard
3. Members discuss each of the recorded ideas for
the purpose of clarification and evaluation
4. Members independently give their own priority
ranking of ideas. These independent rankings
are added together and averaged. The final
group decision emerges from the pooled
outcome of the independent rankings.
The format utilizes both the independent thinking of
members (example, writing down ideas) and group
interaction, (example, discussing the ideas) in order to
arrive at a joint decision. The nominal group technique is
used when individuals can be brought together at one
location and when the problem requires a relatively
quick solution. In health care, this method can be used
for determining program priorities or for identifying
needed program content in areas such as staff
development.
As a decision-making procedure, the nominal group
technique has several advantages. First, when
members are given opportunity to write down their own
ideas independently, their ideas tend to be more
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problem centered and of higher quality. Second, the
technique allows all members an equal opportunity to
express their views and also an equal opportunity to
vote on the group decision. This technique prevents a
group discussion from being dominated by a few
influential members. On the negative side this technique
can be time consuming and somewhat difficult to
implement in all situations.
Delphi Method
The Delphi method of decision-making was initially
developed by Dalkey and his associates (1963, 1969)
who used this method to gather data from groups of
experts for the purpose of making forecasts about future
events. More recently, in health care, the Delphi method
has been employed to determine priorities in such areas
as nursing research and cancer nursing. In this method,
participants are usually in different geographical
locations and they do not meet for face-to-face
interaction as they typically do in the brainstorming and
nominal group technique procedures. The Delphi
method structures the group communication process so
that a large group of individuals can work together as a
whole and solve a complex problem.
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Steps in the Delphi Method of Group Decision Making
include:
1. Group members are sent a questionnaire which
asks them to identify important questions or
issues on a specific topic
2. Members responses are compiled and a second
questionnaire is administered which asks
members to assess and prioritize the list of
responses derived from the first round
3. Step 2 is repeated in subsequent rounds. Each
time the priorities of members are summarized
and narrowed down to those, which are the most
important. The results are returned to each group
member for further ranking and evaluation.
4. In the last phase, a final summary and ranking is
provided to each member of the group. This
represents a synthesis of the series of sequential
rankings completed in all prior rounds.
The major disadvantage of the Delphi method are that it
does not allow for the development of emotions and
feelings in the group, and it does not allow for face to
face feedback and clarification. Overall, however, the
Delphi method is a very useful, though time consuming,
decision-making technique.
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Team Work
A team is defined as two or more people who interact
and influence each other toward a common purpose
Types of teams
1. Formal Team: is a team deliberately created by
managers to carry out specific activities, which help the
organization to achieve its objectives.
Formal team can be classified as
a. Command team: is a team composed of a
manager and employees that report to the
manager.
b. Committee: a formal organizational team
usually relatively long lived, created to
carry out specific organizational tasks
c. Task force or project team: A temporary
team to address a specific problem
2. Informal team: emerge whenever people come
together and interact regularly. This group has a
function of:
a. to hold in common the norms and values of
their members
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b. give to their members status, security and
social, satisfaction
c. help their members communicate
d. help solve problems
e. act as a reference groups
3. Super teams: a group of workers drawn from
different departments of the organization to solve
problems that workers deal with their daily performance
4. Self managed team: are super teams who manage
themselves without any formal supervision
Characteristics of a team
Awareness of the characteristics of a team helps to
manage effectively the group.
Effective teams are built on:
• Communication
• Trust
• Shared decision-making
• Positive reinforcement
• Cooperation
• Flexibility
• Focus on common goals
• Synergy
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Teams that are effective can achieve more together
than they would as individuals all working alone
Stages of team development
Teams move through five stages to develop
a. Forming: during the initial stage the team forms and
learns the behaviour acceptable by the group
b. Storming: as the group becomes more comfortable
with one another they begin to assert their individual
personalities
c. Norming: the conflicts that arose in the previous
stages are addressed and hopefully resolved. Group
unity emerges as members establish common goals,
norms and ground rules.
d. Performing: it is a stage by which a group begins to
operate as a unit
e. Adjourning: it is a time for a temporary group to wrap
up activities
Team cohesiveness
Team cohesiveness is the degree of solidarity and
positive feelings held by individuals towards their group.
The more cohesive the group the more strongly
members feel about belonging to it. Highly cohesive
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teams have less tension and hostility and fewer
misunderstandings than less cohesive groups do.
Studies have found that cohesive teams tend to produce
more uniform output than less cohesive groups.
Ways to improve team cohesiveness
1. Introduce competition
2. Increase interpersonal attraction
3. Increase interaction
4. Create common goals
Guidelines for effective committee functioning
1. Goals should be clearly defined, preferably in
writing
2. Specify committees authority
3. Determine the size of the committee
4. Select a chairperson on the basis of the ability to
run the meeting efficiently
5. Distribute the agenda and all supporting
materials before the meeting
6. Start and end meeting on time
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Conflict within teams
Conflict may arise within teams when they go along in
their activities. Some of the conflicts are essential for
effective functioning of the team. Some of the common
conflicts in teamwork are:
1. The paradox of identity-the feeling of people in a
team that the group diminishes their identity
2. The paradox of disclosure: disclose only what
they think acceptable to others because of fear
of rejection
3. The paradox of thrust: for a trust to develop in a
group members must trust the group
4. The paradox of individuality: feeling of members
that their individuality is threatened by the group
5. Paradox of authority: diminishing individual
power by putting it at groups disposal
6. The paradox of regression: : the groups pressure
on individual progress may lead to regression
7. Paradox of creativity: treat to the groups creative
potential
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Determinants of work group effectiveness
1. Task independence: the extent to which a
group’s work requires its member s to interact
with one another
2. Sense of potency: collective belief of a group that
can be effective
3. Outcome independence: the degree to which the
work of a group has consequences felt by all its
members
Checklist for Evaluating Meeting Effectiveness
Standards
􀂃 The meeting started on time
􀂃 A quorum existed
􀂃 The meeting agenda is on a schedule
􀂃 The chair acts as and equal member of the
group, taking no special considerations.
􀂃 The chair follows the agenda
Dull items are scheduled early, star items last
Important items have a starting time
The agenda avoids “any other business”
Meetings are scheduled for one hour before
lunch or one hour before end of workday
The chair is well prepared for the meeting
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The chair referees, paces, summarizes and
clarifies discussion
The meeting concludes with definitive
decisions and a commitment to them
Useful information is circulated with the
minutes
􀂃 The chair allows adequate time for
discussion
􀂃 The chair facilitates participation by all
members
􀂃 Items requiring further study are referred to
smaller groups as projects. Timetables for
results are established.
Technical assistance is provided to facilitate meeting
success.
Learning Activities
1. Observe the group dynamics in one of your
classes or groups. What do you see in terms
of roles played by the different participants?
What is your role?
2. Compare from your own individual
experiences positive and negative
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communication climates. Discuss the
characteristics in each.
3. Try to find people in your experience that fit
the various roles played by group members.
Do they consistently use the same behaviors,
or do they alter, as the situation requires?
Share with the class your observations, and
discuss the relative effectiveness of the
different behaviors in influencing the group.
4. What are the major types of teams?
5. How can managers increase team
cohesiveness?
6. How can committees be made more
effective?
7. How can managers deal with conflicts within
their team?
8. What are the determinant factors of team
effectiveness?
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CHAPTER ELEVEN
CONFLICT RESOLUTION
Objectives:
At the end of this chapter, the student should be able to:
• Identify aspects of your professional role that
predisposes to conflict with nurse administrators or
physicians
• Analyze an ongoing conflict in your organization and
identify the manifest conflict, the felt conflict,
antecedent conditions and internal and external
factors influencing the conflict;
• Differentiate the three common methods of conflict
resolution
• Elaborate the different ways of conflict management
and identify the most preferred of conflict
management;
Conflict Resolution
Conflict is inevitable in human organizations. In health
care organizations the potential for conflict is heightened
because within these settings individuals must address
life and death issues; they have to function both
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independently and interdependently within a system
containing considerable role ambiguity and complex
lines of authority. Health care workers also need to be
highly skilled both in technical areas and in human
relationships. Other organizations may demand similar
qualities from individuals, but seldom to the same extent
that they are required of professional in health care.
These demands on health professionals make conflict
unavoidable.
What is Conflict?
Conflict is an expressed struggle between at least two
interdependent parties, who perceive incompatible
goals, scarce rewards, and interference from the other
party in achieving their goals. They are in a position of
opposition in conjunction with cooperation. Conflict
produces a feeling of tension, and people wish to do
something to relieve the discomfort that results from
tension.
Five characteristics of a conflict situation may be
identified: (1) at least two parties are involved in some
form of interaction; (2) difference in goals and/or values
either exists or is perceived to exist by the parties
involved; (3) the interaction involves behavior that will
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defeat, reduce, or suppress the opponent, or gain a
victory; (4) the parties come together with opposing
actions and counteractions; and (5) each party attempts
to create in imbalance, or favored power position (Filley,
1975).
Types of Conflict
Interpersonal Conflicts
Interpersonal conflicts are those that arise between two
individuals, and these are the most frequent type,
because people are constantly interacting and therefore
differing. Two staff nurses who disagree about the
approach to use with a depressed patient are involved in
a conflict, as are two children who want to play with the
same toy.
Inter-group conflicts
Inter-group conflicts can occur between two small
groups, two large groups, or between a large group and
a small group. A small group may be a family or a group
of 10 or fewer persons, or it may be a group that is a
small in relation to another group.
Regardless of a size of the groups involved, inter-group
conflict has certain predictable consequences. Within
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each group cohesiveness increases, but members
become more task oriented and less concerned with the
needs of individual members. Group leadership tends to
become more autocratic, but members nevertheless
accept it. The groups become highly structured, so that
a unified front will be presented to the opposition. If the
groups are required to meet, they will see and hear only
those aspects of the other group that support their
opinions.
These consequences of conflict are both positive and
negative. The increased cohesion and structure will
probably increase production, but the stereotyping and
hostile behaviors toward the other group are likely to be
destructive to the persons involved. Conflict
management strategies should therefore be used to
ensure that the conflict will have a healthy outcome.
Personal Group Conflicts
Conflicts between an individual and a small group or
between an individual and a large group are called
personal –group conflicts. In this type of conflict an
individual is at odds with a group. The nurse who does
not finish giving her patient’s bath before she goes to
lunch will be in conflict with the rest of the staff if they
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believe that all baths should be completed by noon. This
type of conflict is very difficult for the individual because
he or she typically feels overwhelmed and powerless in
the situation. The odds are all against the individual.
Intrapersonal Conflicts
Conflict may also be intrapersonal (i.e., within a person).
The individual feels tension because of a disagreement
within him-or herself. Intrapersonal conflict may result
from having to make a choice between two things of
generally equal value (positive or negative), from
ambivalence about doing or not doing something, or
from problems related to decision making between two
or more of the individual’s roles. A nurse leader who is a
mother may experience intrapersonal role conflict when
she must choose between going to apparent teacher
conference about her child or going to a professional
nursing meeting.
Management of intrapersonal conflict must come from
the individual involved. Several options are available,
but the individual must first decide what is most
important, and then work to change the environment or
his or her attitudes, or else use a systematic decision
making process to identify a solution.
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Conflict Resolution Theory
Filley (1975), Proposed a model of conflict resolution
represented in Fig. 11.1, which provides a framework
that helps explain how and why conflict, occurs and,
ultimately, how one can minimize conflict or resolve it
with the least amount of negative aftermath? Filley
argues that the conflict resolution process moves
through six steps: (1) antecedent conditions, (2)
perceived conflict, (3) felt conflict, (4) manifest behavior,
(5) conflict resolution or suppression, and (6) resolution
aftermath.
Antecedent Conditions (Preexisting) - certain
conditions exist which can lead to conflict, though they
do not always do so.
Conflict may develop from a number of antecedent
sources, including:
􀂃 Incompatible goals
􀂃 Distribution of scarce resources when individuals
have high expectations of rewards
􀂃 Regulations, when an individual’s need for
autonomy conflicts with another’s need for
regulating mechanisms
􀂃 Personality traits, attitudes, and behaviors
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􀂃 Interest in outcomes
􀂃 Values
􀂃 Roles, when two individuals have equal
responsibilities but actual boundaries are
unclear, or when they are required to
simultaneously fill two or more roles that present
inconsistent or contradictory expectations.
􀂃 Tasks, when outputs of one individual or group
become inputs for another individual or group, or
outputs are shared by several individuals or
groups..
Perceived Conflict - two or more individuals logically
and objectively recognize that their aims are
incompatible.
Felt Conflict- Individuals experience feelings of threat,
hostility, fear or mistrust.
Manifest behavior- overt action or behavior takes place
- oppression, competition, debate, or problem solving.
Conflict Resolution or Suppression- the conflict is
resolved or suppressed either by all parties' agreement
or else by the defeat of one party.
Resolution Aftermath- Individuals experience or live
with the consequences of the Resolution
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Fig.11.1 The conflict process
Manifest behavior
Manifest behavior refers to the behavior and action of
individuals in response to conflict. These are the signs
of conflict that are observable to bystanders. Individuals
manifest primarily two kinds of behaviors in response to
perceived and felt conflict: (1) Conflictive behaviors
(negative) and (2) Problem solving behaviors (Positive).
Conflictive behavior is characterized by the conscious
attempts of one person to compete, dominate, and win
over a second behavior. For example, conflictive
Antecedent condition
Felt
conflict
Perceived
Conflict
Manifest
behavior
Conflict resolution or
suppression
Resolution aftermath
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behavior would be manifested by a health professional
in an interdisciplinary meeting who consciously tries to
block the innovative program suggested by another
health professional. The dominating professional may
try tactics such as discrediting the proposed program or
diverting the discussion to a completely different topic in
order to prevent program adoption. Problem solving
behaviors, on the other hand, are conscious attempts to
find mutually acceptable alternatives- to find approaches
to problems that have positive outcome for both parties.
Conflict Resolution or Suppression
In conflict situations, individuals can either suppress
conflict or engage in activity, which will lead to its
resolution. Behavior directed toward the resolution of
conflict can be characterized by three different
communication strategies: (1) Win- Lose, (2) Lose-
Lose, or (3) Win -Win.
Win -Lose Strategies- The win- lose strategy of conflict
resolution is quite common, and most of us have used it
at one time or another. It is not the optimal way of
resolving conflict because one of the participants loses.
This strategy is characterized by attempts of one
individual to control or dominate another so as to obtain
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his/her own goal(s) even at the expense of another’s
goal(s).
Lose – Lose Strategies- the lose –lose approach to
conflict is obviously one we would all like to avoid when
possible. Most people do not intentionally select a loselose
strategy, but they end up with this outcome when
other strategies, such as when a win-lose strategy, fail.
In lose-lose conflicts both parties try to win over the
other but both end up losing to each other. Neither
person’s goals are achieved and the relationship is
weakened. Attempts by individuals to dominate over
each other result in mutually destructive communication
between the participants and negative outcomes.
Case Study
A school of nursing was seeking a new director.
Administrators at the college strongly desired to have an
“in-house” person assume the position, since that
person would already be familiar with the program and
would have faculty support. Two faculty members said
that they would like the position and both tried to line up
faculty support. In their attempt to gather faculty support,
strong disagreements developed between the two
candidates and two distinct factions developed within
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the faculty. Both factions of faculty members threatened
to quit if the person of their choice was not selected. In
the end, neither in-house candidate was appointed as
director of the program; instead a person from the
outside who was less qualified had to be hired for the
position. The tension and conflict that were generated
within the two quality groups produced what could be
called a lose-lose, destructive outcome.
Win- Win Strategies
Individuals who employ win-win strategies approach
conflict in ways that are significantly different from the
strategies used by individuals who take win-lose or loselose
approaches toward conflict. The win-win strategy is
an approach that allows both individuals to feel they
have accomplished all or part of their goals. This
strategy tries to satisfy mutual needs, to solve problems
creatively, and to develop relationships. There is no
attempt by one party to win over or control another party
in this approach.
Finding win-win conflict solutions mean suppressing but
not sacrificing our own needs in order to listen for the
needs of others. Whether it is a conflict over a policy or
procedure or conflict for control or esteem, win-win
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strategies mean both parties communicate in ways that
allow each of them to satisfy at least some of their
needs. Win-Win solutions strengthen relationships. They
make individual feel better about how they are related to
others. Overtime, the strengthening of relationships has
the advantage of helping individuals in future conflict
resolution.
Example: -
Development of a joint appointment program in which
staff could spend part of their time working for
governmental school of nursing and part of their time
working for the private school. This type of programs
where there is scarcity of instructors would benefit both
institutions as well as the individual staff members.
Resolution Aftermath
The final aspect of conflict in the Filley conflict model is
resolution aftermath. During this phase, participants
experience feelings directly related to the outcomes of
the resolution process. If the conflict is resolved in a
positive fashion, the participants will have good feelings
about themselves, about each other and the situations.
This was the case in win-win strategies. On the other
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hand if the conflict is resolved in an unproductive style,
participants will have negative feelings about
themselves, each other, and the relationship. This is
common in win-lose or lose-lose situations, where
participants may feel less cooperative, more distrustful
and very prone to further conflicts (Filley, 1975).
Obviously, the preferred goal of conflict resolution is to
arrive at solutions that result in positive feelings,
productive interactions, and cooperative relationships
among the participants.
Conflict Management /Styles of Approaching
Conflict/
We have discussed the nature of conflict, different kinds
of conflict, and theoretical perspectives on conflict and
strategies for resolving conflict. Now we would like to
address the questions, do individuals have different
ways of handling conflict? In addition, how do the styles
employed by individuals affect the outcomes of the
conflicts?
Researchers have found that individuals approach
interpersonal conflict utilizing five styles: (1) avoidance,
(2) Competition, (3) accommodation (4) compromise,
and (5) collaboration. This five-category scheme for
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classifying conflict was developed by Kilmann and
Thomas (1976) and is based on the work of Blake and
Mouton (1964). In the next section, each of the five
conflict styles will be discussed in more detail. As you
read the descriptions of these styles, perhaps you can
identify which style of the conflict management you must
commonly use in your communication with others. Is
that style productive or counter productive? Of all the
styles described, is there one or more that you could
develop to enhance your conflict handling skills?
Avoidance
Avoidance is a style characteristic of individuals who are
passive and who do not want to recognize conflict.
These persons generally prefer to ignore conflict
situations rather than confront them directly. In conflict
producing circumstances, these individuals are not
assertive about pursuing their own interests nor are they
cooperative in assisting others to pursue their concerns.
In health care settings, avoidance is not and uncommon
conflict style. In fact, there times when avoidance may
almost be necessary. For example, on department in a
hospital may frequently be in conflict with another
department that is always slow in responding to
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requests. If the request is directly related to the survival
of a patient, the interdepartmental conflict becomes less
important than just getting the service immediately- and
avoiding conflict may be the best way. Health care
practitioners are frequently dealing with life and death
decisions for patients; consequently they often need to
suppress their own concerns or conflicts with other staff
members’ in order to perform the necessary services. In
these critical situations, avoidance of conflict may
facilitate the health care delivery process.
In general, however, avoidance is not a constructive
style of confronting conflict. Health professionals who
are continually required to avoid conflict experience a
great deal of stress. They bottle up their feelings of
irritation, frustration, or anger, inside themselves,
creating more anxiety, instead of expressing them or
resolving the situation. Furthermore, avoidance is
essentially a static approach to conflict: It does nothing
to solve problems or to make changes that could
prevent conflicts. In health, care organizations, the
problems that exist will seldom be alleviated or resolved
of avoidance is employed in conflict situations.
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Competition
Competition is a conflict style characteristic of
individuals who are highly assertive about pursuing their
own goals but uncooperative in assisting others to reach
their goals. These individuals attempt to resolve a
struggle by controlling or persuading others in order to
achieve their own ends. A competitive style is based on
a win-lose conflict strategy.
Competition is spreading in our culture and can produce
solutions to conflicts that are more effective and more
creative than if competition were not present. For
example, in a community in which school of nursing are
competing to provide specific training, the quality of
trainings will be higher, and the costs to the public will
eventually be lower than if there were no competition. In
the area of cost containment, a competitive approach to
conflict can generate innovative cost solving solutions to
complex problems. Similarly, on the interpersonal level,
when two professionals compete to provide quality care,
the
Outcomes can be very positive for clients. In effect,
competitive approaches to conflict can challenge
participants to make their best efforts, and this can have
positive results.
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Generally, though, competitive approaches to conflict
are not the most advantageous approach to conflict
because they are more often counterproductive than
productive. In failing to take other’s concerns into
account, we do others damage. When we attempt to
solve conflict with dominance and control,
communication can easily become hostile and
destructive. Too much competition among health
professionals can direct energy away from patient care
objectives toward unnecessary inter-professional
struggles. Too much competition between health care
facilities can lead to a duplication of services within
communities (example, two CAT scans, two dialysis
units, etc.) and duplication increases healthcare costs.
Competitive approaches to conflict create unstable
situations as one party is constantly striving to attain or
maintain dominance over the other party. Finally,
competition creates discomfort; and competition
individuals fail to recognize the concerns and needs of
others.
Accommodation
Accommodation is a conflict style that is unassertive but
cooperative. An accommodating individual attends very
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closely to the needs of others and ignores her or his
own needs. Using this style, individuals confront
problems by deferring to others.
Accommodation is one way for individuals to move away
from the uncomfortable feelings of struggle that conflict
inevitably produces. By yielding to others, individuals
can lessen the frustrations that conflict creates. By
yielding to others, individuals can lessen the frustrations
that conflict creates. In accommodating, an individual
essentially communicates to another, “You are right, I
agree; let’s forget about it.”
The problem with accommodation is that it is in effect a
lose-win strategy. Individuals who accommodate may
lose because they fail to take the opportunity to express
their own opinions and feelings. Their contributions are
not fully considered because they are not actively
expressed or forcefully advocated. This style is primarily
a submissive style, which allows others to take charge.
To illustrate accommodation, consider the following
conflict between a nurse and a physician regarding the
use of pain medication with a terminally ill cancer
patient. The physician believes that pain medication
should be given no sooner than every four hours. In
contrast, the nurse believes that the patient should be
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allowed to request pain medications as necessary and
should not have to adhere to a rigid four-hour schedule.
After only brief discussion of their differences, the nurse
decides to give in-to accept the physician’s approach to
the situation. The nurse in this situation suppresses
his/her values regarding pain management in order to
maintain a friendly nurse –physician relationship and in
order to prevent further conflict.
From a positive perspective, accommodation can be
useful I situations in which preserving harmony is
necessary. For ex. If two professionals differ on an issue
but one professional is deeply interested in the particular
issue while his/her colleague is less involved in the
issue, then it can be useful for the professional who
finds the issue less important to go along with the
concerned professional in order to maintain good
personnel relations. In general, accommodation can at
times be an effective means of eliminating conflict. As a
rule, however, accommodation is not a preferred conflict
style.
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Compromise
Fig. 11.2 A diagrams depicting the relationship between
assertiveness, cooperativeness, and styles of approaching
interpersonal conflict.
As. Fig.11.2 Indicates, compromise occurs halfway
between competition and accommodation, which means
it, includes both a degree of assertiveness and a degree
of cooperativeness. In using compromise to approach
conflict, an individual attends to the concerns of others
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as well as to her or his own concerns. On the diagonal
axis of fig. 11.2, Compromise occurs midway between
avoidance and collaboration. This means that persons
using this approach do not completely ignore
confrontations but neither do they struggle with
problems to the fullest degree. This conflict style is often
chosen because it is measure and provides a quick
means to find a middle ground. It partially satisfies the
concerns of both parties.
Compromise is a positive conflict style because it
requires that individuals attend to others’ goals as well
as their own. Compromise reminds us of the golden rule:
“Do unto others as you would have them do unto you.”
The problem with compromise is that it does not go far
enough in resolving conflict. As two persons give in to
one another’s demands, both individuals also pull back
from fully expressing their own demands. Both
individuals suppress personal thoughts and feelings in
order to reach solutions that are not completely
satisfactory for either side.
In health care, the compromise strategy may sometime
be seen in the communication among health
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professionals in interdisciplinary team meetings. One
person may quickly agree with another person in order
to resolve a problem so that each of them can get back
to other responsibilities. Although this may be efficient
and conserve time, innovative solutions are sacrificed in
favor of quick solutions.
Collaboration
Collaboration, the most preferred of the conflict styles,
requires both assertiveness and cooperation. It involves
attending fully to others’ concerns while not sacrificing or
suppressing one’s own concerns. Although collaboration
is the most preferred style, it is the hardest to achieve.
Collaboration requires energy and work among
participants. To resolve incompatible differences
through collaboration, individuals need to take enough
time to work together to find mutually satisfying
solutions.
The results of collaboration are positive because both
individuals win, communication is satisfying,
relationships, are strengthened, and future conflicts can
be resolved more easily. An effective style such as
collaboration and productive strategy such as win-win
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approach both require that participants attend closely to
one another’s opinions and proposals and interact in
ways that result in solutions acceptable to all parties.
Effective communication is the pivotal element that
prevents difference among individuals from escalating
and facilitates constructive resolution to conflict
situations.
Learning Activities
1. Observe the interaction, which a conflict
occurs. Determine the type of conflict and the
strategies used to manage the conflict.
Propose alternative approaches to resolve
the conflict.
2. Case Study: You are called to a ward to
resolve a conflict between an RN and
assistant nurse. As you approach them you
hear the following dialogue:
RN: I asked you to get Mr. Nuru ready to go to X-ray,
and you ignored me. The technician was here and left
because you have not prepared the patient.
Ass. nurse: I was busy with Wro. Hanna and could not
leave her. Why didn't you get Mr. Nuru ready? You
actually knew about it.
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RN: It was your job. I assigned Mr. Nuru to you.
Ass.N. I do my own work and part of yours. You are the
RN. You are supposed to be the leader on this ward.
RN: Do not get sarcastic with me. I do not have to put
up with it. I am going to call the supervisor and report
you for your rudeness.
Ass.N. My rudeness! Go ahead and report me! I will tell
the supervisor what a lazy nurse you are!
Outline a plan to deal with this conflict. You may use the
following format.
2.1. What is (are) the cause (s) of the conflict?
2.2. Decide on aims, strategies, and specific skills for
resolving the conflict and list them.
3. Describe a recent instance of a conflict in
which you are involved. Was it resolved
satisfactorily? Can the group help in finding a
better solution? Discuss.
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CHAPTER TWELVE
MANAGEMENT OF CHANGE
OBJECTIVES:
At the end of this chapter, the student should be able to:
• Describe the importance of change and appreciate
its nature
• Explain key factors in management of change
• Discuss the source of resistance to change and the
ways this resistance can be overcome
• Play a leading role in initiating and managing change
in your organization of work environment
• Discuss Lewin's 3-step model of change
management.
Management of Change
Change is defined as "the process of alteration or
transformation of individuals, groups, and organization
undergo in response to internal factors."
Purpose of change
• To meet changing clients needs
• To meet changing market conditions
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• To respond to internal pressures
• To take advantage of new opportunities
• To respond to competitive pressure
Factors that cause change
A number of internal and external forces, often
interacting to reinforce one another, stimulate changes
in organization. Pressure for change may arise from a
number of sources within the organization, particularly
from new strategies, technologies, and employee
attitudes and behavior. For example, a top manager's
decision to seek a higher rate of long term growth will
affect the goals of many departments of the
organization. Unexpected opportunities may arise that
permit the innovators inside the organization to develop
new ways of doing things. This can stimulate
organizational change.
An enormous variety of external forces, from
technological advances to competitive actions can
pressure organizations to modify their structure, goals,
and methods of operation. Outside pressures come from
changes in the organizations technological settings,
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economic, political, legal, social, and competitive
environments.
Managing Change in an Organization
Change can be planned or unplanned. The latter just
happens in the natural course of events. Planned
change, on the other hand, is the result of consciously
designed preparation to reach a desired goal or
organizational state. An effective management of
change involves change agents, performances gaps,
levels and targets of change, systems approach, and
content and process.
a. Change Agent - In every situation in which a change
is desired, some person or group must be designated as
the catalyst for change. That person or group is called
the change agent. The change agent is the individual
who is responsible for taking a leadership role in
managing the process of change. The individual, group,
or organization that is the target of the change attempt is
called the client systems. Managers or staff at various
levels in organizations can serve as change agents.
Consultants brought in from outside can also be change
agents. Their role is to recognize the need for altering
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the status quo and to plan as well as to manage the
implementation of the desired changes.
b. Performance Gaps - It is the difference between the
status quo and the desired new standard of
performance or desired organizational state. The
change agents think in terms of performance gaps.
c. Levels and Targets of change - Change agents
must identify the level at which their efforts will be
directed. Effects can be made to change individuals,
groups, and entire organizations. Each represents a
different level, or unit of change. Besides, change
agents’ focus on targets to alter in attempting to close
performance gaps and reach desired objectives. These
targets of change include people, technology, Jobs and
workflow, organizational structure and processes,
culture, and management. The following examples
illustrate how managers can change some of these
targets.
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Target Example
Individual • Fire a person and replace him/her
with some one else.
• Change knowledge, skill, attitude,
or behavior
Technology • Replace existing technology with
a more modern machine or way
of doing work
Structure • Change from functional structure
to a product division structure
• Add a new department or division,
or consolidate the existing ones
Processes • Change the pay system from
hourly wages to salaries
Culture • Implement a program to
encourage valuing quality and
service
Management • Encourage participation in the
diagnosis and solution of
problems by people at lower
levels to replace a top-down
approach
d. Systems Approach- since various elements of an
organization are all part of an inter- dependent system,
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a change in any single target often leads to changes in
the others. For example, when intensive care unit
introduces ECG machines to improve diagnosis of
patients, a series of changes followed. First, nurses
have to learn on how to monitor the ECG and all have to
learn the concepts and its interpretation.
E. Content and process: - Two key concepts in
managing change are content and process. Content is
the what aspect of change, and process is the how
dimension of change. For example, assume a manager
is concerned about decreasing productivity among the
clerical staff. She thinks the cause might be excessive
talking among staff members. In order to discourage
talking among the clerical staff, she may decide to move
their desks farther apart or place partitions between
them. This is a content change.
How this manager introduces and implements the
change is the process. For example, she may decide to
announce the change by memo or in a staff meeting, or
she might have the desks moved during the night so
that the clerks find out about the change when they
come to work the next day.
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Programming Change
The realization of organizational change requires
effective planning or programming. A change program
should incorporate the following processes.
1. Recognizing the need for change – The need
for change is sometimes obvious, as when
results are not inline with expectations, things
clearly are not working well, or dissatisfaction is
apparent.
2. Setting Goals – Defining the future state or
organizational conditions desired after change.
3. Diagnosing the present conditions in relation to
the stated goals.
4. Defining the transition state activities and
commitments required on meeting the future
state.
5. Developing strategies and action plans.
Lewin’s 3 Step model of the change Management
Sociologist Kurt Lewin (1951) envisioned that any
potential change is interplay of multiple opposing forces.
These forces are broadly categorized under two major
fields: the driving forces and restraining forces. The
driving forces are the factors that encourage or facilitate
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the change, while the restraining forces are the factors
that obstruct change. If these opposing forces are
approximately equal, there will be no movement away
from status quo. For change to occur the driving forces
must be increased and/or the restraining forces must be
reduced. This requires thorough understanding and
analysis of the forces likely to resist change as well as
those creating the need for change. Lewin called this
process “force field analysis”. He noted that force field
analysis is an important diagnostic and problem solving
technique. It involves:
1. Analyzing the restringing forces or driving forces,
which will affect the transition to the future state.
These restraining forces will include the
reactions of those who see change as
unnecessary or constituting a threat.
2. Assessing which of the driving or restraining
forces are critical
3. Taking steps both to increase the critical driving
forces and to decrease the critical restraining
forces.
Kurt Lewins further studied the process of bringing
about effective change. He noted that individuals
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experience two major obstacles to change. First, they
are unwilling (or unable) to alter long-established
attitudes and behavior. Second, their change of
behavior frequently last only a short time. After a brief
period of trying to do things differently, individuals often
return to their traditional behavior.
To overcome obstacles of this sort, Lewin developed a
three – step sequential model of the change process.
The model involves “unfreezing” the present behavior
pattern, “Changing” or developing a new behavior
pattern, and then “refreezing” or reinforcing the new
behavior.
Fig. 12.1, the three step of change process
Unfreezing
Raised state
of tensions,
dissatisfacti
on with
status quo;
climate
adapted to
minimize
resistance.
Changing
Changes
advocated
and
implementati
on begins;
changes
tested/adapt
ed for
desired
results
Refre
Behavior
desired att
values int
and rei
Refreezing
Behavior
stabilized;
desired
attitudes
and values
internalized
and
reinforce
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1. Unfreezing- it involves making the need for
change so obvious that the individual, group, or
organization can readily see and accept it. It is
the process of creating a climate ready for
change. In this stage, the management realizes
that the current strategy is no longer appropriate
and the organization must breakout of (unfreeze)
its present mold. As such, it tries to make other
people (employees) realize that some of the past
ways of thinking, feeling, and doing things are
obsolete. It convinces individuals and groups that
present conditions or behavior are inappropriate.
2. Changing- once the members have been
prepared to accept change, their behavioral
patterns have to be redefined. There are three
methods of reassigning individuals' new patterns
of behavior. These are:
a. Compliance – It is achieved by strictly
enforcing the reward and punishment
strategy for good or bad behavior. The
fear of punishment or actual reward
seems to change the behavior for the
better.
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b. Identification – Identification occurs
when the members are psychologically
impressed upon to identify themselves
with some given role of models, whose
behavior they would like to adopt and try
to become like them.
c. Internalization – Internalization involves
some internal changing of the individual’s
thought processes in order to adjust to a
new environment. Members are left alone
and given the freedom to learn and adopt
new behavior in order to succeed in the
new set of circumstances.
As a whole, in this stage, new behavior is
developed and change is effected through a
conscious process as individuals seek to
resolve the anxieties that surfaced during
unfreezing stage.
3. Refreezing – It means locking the new behavior
pattern into place by means of supporting or
reinforcing mechanisms, so that it becomes the
new norm. It is the process of institutionalizing
the new state of behavior or work by rewards
(praise, etc).
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Making the change process Effective
The important aspects of Kanter’s Ten Commandments
have been summarized as follows (Lovell, 1994).
1. Analyze the organization and its need for
change- any change process should start with a
meticulous understanding of how the
organization works; what are its strength and
weakness, what are its relationships with the
environment and what are its needs to change.
2. Create a shared vision and common
Direction- One of the key first steps is to unite
the organization around a vision of the future.
3. Separate from the past- This is a similar idea to
Lewin’s (1947) unfreezing process. This is an
absolute detachment from the past. The
organization must identify what aspects of its
operations are no longer relevant.
4. Create a sense of urgency
A sense of urgency seems to be important for the
organization to unfreeze and develop support for the
changes. Sense of urgency is accelerated as a result of
crisis. But preferably organizations should be productive
in their change strategies and change before crises
occur.
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5. Support a strong leader (transformational leader)
Several studies demonstrated that a strong leader is a
factor to vision creation, motivating the organization
behind the vision and rewarding who strive towards its
realization.
6. Line up political support
Although leader ship is a very important prerequisite for
propelling change, it is not enough in its own.
Successful change needs a broad-base support from all
the stakeholders, including those who will lose, as well
as those who will profit from change.
7. Craft an implementation plan
While visions are of paramount importance in effecting
changes, the organization needs clear information about
what will be done to achieve it. A road map has to be
prepared, giving clear direction and a route to take.
8. Developing enabling structures
The old structures and methods of working are unlikely
to be satisfactory to support and sustain the change
process on their own. Enabling structures are systems
and structures, which support the transformation
process during the transition from the old to the new
state. They include new institutional names, new logos
and uniforms and office relocations and renewal.
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9. Communicate, involve people and be honest
Wherever or whenever possible, there should be open
communications and the involvement and trust of people
in the organization.
10. Reinforce and institutionalize the change
Managers need constantly to demonstrate their
commitment to the change. They should reward the new
desired behaviors and ensure they become part of
normal day to day operations.
Resistance to change and gaining support
1. Reasons for resistance
Change is neither always accepted nor always rejected.
Some people desire change and welcome new
experiences as a break from monotony, on the other
hand, there are a good number of people who resist
change for various reasons than one. Management may
recognize the need for change, but most employees
may resist the process.
No matter what the resistance might arise, the change
must occur continually in order to adjust to dynamic
forces that are continuously at play. The society will
become stagnant if no changes took place. The reasons
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for resistance to change must be studied carefully, but
four main reasons are common.
1. Parochial self interest
• Threat to core skills and competence
• Threat to status
• Threat to power base
2. Misunderstanding and lack of trust
• Lack of information
• Misinformation
• Historical factors (poor timing)
• Low trust of organizational climate
• Poor relationships (quarrelsome)
3. Contradictory Assessments
• No perceived benefits
• An assessment that the proposed change is
wrong/ill thought out
• Strong peer-group norms, which may shape
such contradictory assessments
4. Low tolerance of change
• Fear of unknown
• Fear of failure
• Customer bound (inertia-unwillingness to
disturb status quo)
• Reluctance to let go
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A variety of reasons thus exist for resistance to change.
The change itself or the methods of implementation may
be opposed. But if managed correctly, the opposition
can be minimized or completely eliminated.
Managing resistances to change
If the change is to be implemented successfully, it
needs full acceptance and cooperation from employees.
More specifically, Kotter and Schlesinger (1979:110)
have put forward six valuable ways of overcoming
resistance to change. The techniques include:
1. Education and communication - Management
should educate employees about upcoming
changes before they occur. It should communicate
not only the nature of the change but its logic. The
process include one-on-one discussions,
presentations to groups (variety of conferences),
brochures, or reports and memos.
2. Participation and Involvement - If management
involves those who might resist change with the
design and implementation of the change,
resistance may be prevented.
Considerable research has demonstrated that, in
general, when employees participate in the
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decision to change, they are committed to
implementing it. Therefore, employees should also
be involved in the change's design and
implementation.
3. Facilitation and support - Management should
make the change as easy as possible for
employees and be supportive of their efforts. This
could be achieved through providing training new
skills, or giving employees' time off after a
demanding period of change, or simply listening
and providing emotional support.
4. Negotiation and Agreement - When necessary,
management can offer concrete incentives for
cooperation with the change. Rewards such as
bonuses, wages and salaries, recognition, Job
assignments and perhaps restructured to reinforce
the direction of change.
5. Manipulation and co-optation - This process
involves making covert-attempts to influence
others. One common form of manipulation is cooptation.
Co-optation involves giving an informal
leader (a resisting individual) a desirable role in the
design or implementation of a potential change.
For instance, management might invite a union
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leader to be a member of an executive committee
or ask a key member of an outside organization to
join the company's board of directors. As a person
involved in the change, he or she may become
less resistant to the actions of the co-opting group
or organization.
6. Explicit and Implicit coercion - Some managers
apply punishment to those who resist change. With
this approach, managers use force to make people
comply with their wishes. For instance, a boss may
force employees to go along with a change by
threatening them with dismissed, with being
passed over for promotion, with unattractive Job
assignment, or through other negative
suggestions.
Learning Activities
1. Analyze a change that has occurred. Was the
change planned or unplanned? Who was the
change agent? What strategies did the change
agent used?
2. Interview a nurse leader about changes that
have occurred in the past month. How was the
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nurse leader and her group involved in the
change process?
3. Propose a plan for change. Describe the
anticipated resistance and methods to manage
the resistance.
4. Identify a needed change in your health care
setting. What are the driving and restraining
forces that will enable or prevent that change?
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CHAPTER FORTEEN
PROJECT PLAN MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:
• Develop a complete project plan of its interest using
all the steps of project planning.
Project Plan Management
Studies have consistently shown that planning and goal
setting can improve program performance. A total plan
provides the structure for implementing the program,
serves as a guide for effectively using human, material
and financial resources, and creates a common
understanding of program goals and objectives among
staff.
Organizing and Developing a Written Plan
A good plan should describe the type of project that you
intend to implement, the expected results, the plan of
activities for setting up and implementing the project, the
way that progress will be tracked, the reporting system,
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and the cost of carrying out the project. The plan should
contain distinct sections that clearly describe:
• The existing problem or need that the project will
address and the proposed project;
• The goals and objectives of the project, and the
time frame for achieving the objectives;
• A general activity plan for the term of the project,
including how the activities will be carried out,
who will be responsible for each activity, and
when each major activity will be completed;
• A plan for monitoring progress and evaluating
the results of the project;
• A reporting plan and schedule, including how the
project will manage its finances;
• A projected budget for at least the first year of
the project, land a summary budget for the life of
the project.
Explaining the Purpose of your Initiative
Each new initiative or project should be created to
respond to documented needs or problems in the
community or region your program serves. Thus, the
first part of the plan should justify the need for the
project. This part of the plan can be divided into two
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sub-sections; the problem statement and your proposed
solutions.
The Problem Statement
This is a statement of the specific problem or need to be
addressed by the project. It should include some basic
data (baseline data) that help to explain the problem,
including the following information:
• A description of the extent, scope, or severity of
the problem, so that the proposed results can be
put in the perspective;
• A description of the geographic area and
demographic characteristics of the population in
the area in which the problem exists;
• An analysis of the causes of the problem;
• The results of the previous efforts, by your
program or other programs, to solve the
problem.
An example of Problem Statement:
Within the region of Somalia there is a large per-urban
population of 250,000 that at the present time does not
have any access to family planning services. Ten
government clinics are located within and near this area
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but they offer only some other services on maternal and
child health services. At 52 births per 1,000 populations,
the birth rate in this peri-urban area is roughly two times
than in other areas within the state.
The Proposed Solution- in this section of the plan you
should explain the design of your project, emphasizing
those aspects of your approach that you think best
address the problem you have described. The
description of the project design should answer the
following questions:
• What approach will you use, and why have you
chosen this approach over other possibilities?
• What other local programs are addressing this
problem and how does your proposed approach
complement their activities?
• What changes do you expect will result from this
project?
• How does this project fit in your organization’s
overall strategic plan?
• What sources of support are likely to be available
to you for continuing the project in the future?
• In what ways is the project designed so that it
can be replicated in other areas?
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An example of a Proposed Solution:
Within the Peri-urban area of Somalia region there are
10 MCH clinics staffed by government nurses. This
initiative, “Project Expand: Somalia”, would use existing
government clinics to introduce family planning services
to these peri-urban areas. A family planning trained
physicians and nurses in each of the existing clinics
would provide Family Planning services. In addition, a
network of local promoters (TTBA and extension health
workers) would be formed to disseminate family
planning information, distribute contraceptives, and refer
clients to clinics for clinical methods. By building on the
accessibility of the existing government clinics and
linking community outreach activities with clinic services,
this project is expected to significantly decrease the birth
rate in the peri-urban area of Somalia region. It is
expected that this model will be replicable in other urban
areas in Ethiopia.
Being Specific about what the New Initiative will
Accomplish
A well-designed project should have both overall goals
and specific objectives. The goals and objectives set
forth the intended results to be achieved by the project
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and the degree to which the problem described will be
resolved. Once the objectives have been determined, a
set of activities that describe how each objective will be
achieved should be specified in the activity plan that
follows.
Goals: The overall goals should describe, in a broad
way, the long-term changes that will result from your
project's work on the problem outlined in the problem
statement. Normally one or two general statements
describing the proposed long-range benefits to the
target population are sufficient to describe the overall
project goals.
Example of an overall goal: To reduce the birth rate in
the peri-urban community of Somalia-region, by
providing clinic-and community-based family planning
services.
Objectives: for each overall goal that you develop,
there should be several specific, measurable objectives.
These objectives relate to the problem statement and
describe anticipated results that represent changes in
knowledge, attitudes, or behavior of the project clients or
participants. Your objectives should be SMART.
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Specific - to avoid differing interpretations
Measurable - measurable, observable, or otherwise
documentable. It allows for monitoring and evaluation.
Appropriate - to the problems, goals and strategies
Realistic - achievable, challenging, and meaningful
Time bound - with a specific time period for achieving
them
Examples of specific objectives:
• To select, recruit, and train a network of 60 family
planning promoters by the end of the first year of the
object.
• To attract 4,000 new family planning acceptors
during the first year of operation of the project, and
an additional 9,500 during the second year of the
project.
To be serving 20,000 family planning clients by the end
of the third year of the project.
Developing Detailed project Activities
The plan of activities constitutes the core of your plan
and should describe the major activities needed to
accomplish each project objectives. To fully develop the
plan, you should list the key activities that must be
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carried out in order to achieve each objective. One or
more individuals should be assigned to each activity and
these people will be responsible for overseeing or
carrying out the activity. The plan of activities can be
divided into two sub-sections: a detailed description of
project activities and a project activity timeline.
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Sample-project Activity Timeline
Project Activity Year-1
1 2 3 4
Year-2
1 2 3 4
Year-3
1 2 3 4
Person(s)
Responsible
Select and recruit project personnel
5 nurses
3 outreach supervisors
20 promoters
X X
X X
X X X
Head Nurse/
Metron
Order contraceptive supplies and IEC
materials X X X X X X X X X
Project
Coordinator
Develop monitoring and reporting
forms X X
"
Evaluate project progress and impact X X X X Head Nurse/
Metron
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Tracking the progress toward Meeting Objectives
Plans for monitoring and evaluating your project should
be included in the initial project design.
Monitoring - is the process by which project activities
and the budget are regularly reviewed. Monitoring helps
to ensure that the activities planned in the work plan are
being completed and that the costs are in line with the
budget. The monitoring plan should include at least the
following information:
• A list of the project personnel who will be
involved in monitoring the project, and their
specific monitoring responsibilities
• How and when project managers will monitor
activities
• A plan for the development of criteria that will be
use to monitor project activities, including
measures of service quality
• A plan for the development of forms that will be
used for monitoring activities
An example of a monitoring plan
The project coordinator assigned to the project will
monitor the progress of activities and the costs incurred
in carrying out these project activities. On a quarterly
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basis, the project coordinator will compare the
completed activities and the expenditures against
planned activities and the budget, by making site visits
to clinics and outreach worker sites. Clinic heads will be
responsible for monitoring the activities of the promoters
on a quarterly basis by making visits to selected
outreach worker sites with the supervisors assigned to
each area. The medical director will monitor the quality
of care provided by the nurses on a quarterly basis by
making site visits to the clinics and by conducting
random exit interviews with clients. Early in the first
quarter of the project, the project coordinator and the
medical director will develop specific monitoring criteria
for the project and will revise existing government
monitoring and reporting forms for use in the project.
The forms will be designed to collect basic family
planning data, to track potential discontinuers so that the
outreach workers can provide timely and effective follow
up visits, and to assess client satisfaction with clinical
and outreach services.
Evaluation - The evaluation of the project should
analyze the implementation process (that is whether the
planned activities were carried out and completed) as
well as the impact (or long-term effect) that the project
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has had on the target population. By developing this
section of the plan, you will define and let other project
personnel know in advance what aspects of the project
will be evaluated, and how and when the evaluation(s)
will be conducted.
Your evaluation plan should specify the following:
• How the evaluation criteria will be developed
• Who will perform the evaluation and when the
evaluation(s) will occur
• How evaluation data will be collected and
submitted, including how qualitative data, such
as information on user satisfaction, will be
collected
• How and when evaluation data will be analyzed
and reported
• How the evaluation findings will be used
To establish the evaluation criteria, base the criteria on
specific project objectives. Because these objectives are
SMART, they are measurable and observable, and can
be easily converted into evaluation criteria.
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Example:
Evaluation criteria Target
(yr 1.)
Actual
No. %
Target
(yr 2)
Actual
No. %
. Number of
family planning
acceptors
served by the
clinics
2,000 7,000
. Number of
family planning
promoters
oriented and
trained
60 60
Reporting Your Achievements
You should have forms for reporting on both
programmatic achievements and financial activities. If
you do not already have reporting forms, you will need
to develop new forms, or modify existing forms used by
your program or other similar programs.
Programmatic reporting provides detailed information
on the activities under taken in the project. The
narrative reports should refer to the stated objectives,
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activity plan, and evaluation criteria to be used in
analyzing project progress.
Financial Reporting - shows how much money has
been expended during a specific reporting period and
for what purpose, and whether the money that was
spent was in line with the budget.
Sample project proposal outline
I. Project summary
II. Why this new Initiative?
A. Problem statement
B. Proposed solution
III. Organizational Qualifications
A. Organizational Experience
B. Key personnel
IV. Goals and objectives
A. Goals
B. Objectives
V. Detailed Activities
A. Project Activities
B. Project Activity timeline
VI. Project Sustainability
VII. Tracking Progress
A. Monitoring
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B. Evaluation
VIII. Reporting
A. Financial
B. Programmatic
IX. Budget
A. Detailed project Budget (year I)
B. Project Budget Summary
Learning Activity
Develop a complete project plan of your interest
using all the steps of project planning.
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CHAPTER FIFTEEN
QUALITY
ASSURANCE/IMPROVEMENT
Objectives
At the end of this chapter, the student should be able to:
􀂃 Define, and elaborate down the quality
assurance process
􀂃 Discuss the methods used in monitoring the
nursing care for the quality assurance
􀂃 Identify clinical indicators of quality care
􀂃 Discuss on the concepts of total quality
management.
History of Quality Assurance
The process of systematic evaluation of heath care is
not new; quality assurance activities date back to
Florence Nightingale. She urged that all nursing care
being rendered be evaluated. During the Crimean War,
Nightingale reported statistics on the mortality of British
soldiers in comparison to civilians before and after some
of her innovative nursing practices. She reported that
the patient outcome mortality rate decreases by 2
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percent in a six-month period at one military hospital
(Nutting and Dock, 1907). She communicated her
findings and received public support. The government
interest in health care accountability resulted in the
regular evaluation of hospital care; these efforts
eventually contributed to similar health care being
delivered to soldiers and civilians.
In the late 1940s and early 1950s, the general public
became more aware of organizing, planning, and
evaluating methods of health care services. In 1952, the
Joint Commission on Accreditation of Hospitals was
founded. It provides standards for accreditation. The
American Nurses Association (ANA) in 1959 published
its Functions, standards and Qualifications for Practice,
and the National League for Nursing published What
people can Expect of a Modern Nursing Service. All of
these efforts helped to form professional and public
expectations about adequate care.
Definitions
In order to understand the quality assurance/
improvement guidelines that are distributed by
legislative, voluntary, and professional bodies, the nurse
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manager should be familiar with the following definitions
(Gillies, 1994).
Accountability is the obligation to provide an estimate
for one’s actions to the persons who delegated authority
for that action. The conscious nurse exhibits
accountability toward her/his employer, the patient, and
government agency that pays for the patient health care.
A nursing care Outcome is the end result of a nursing
intervention, a measurable change in the state of a
patient’s health that is as a circumstance by nursing
action.
A criterion is the value free name of a variable that is
known to be a reliable indicator of quality. Example,
nurses educational preparation affect the quality of
patient care decisions.
A standard is the desired quantity, quality, or level of
performance that is established as a criterion against
which worker performance will be measured. A nursing
department might establish a standard that requires 100
percent of nurse managers to earn a bachelor’s by a
target date.
A norm is current level of performance of a selected
work group with reference to a given criterion. Example,
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a norm for writing nursing diagnosis in the ward for each
patient within 12 hours of admission is 50 percent.
An Objective is a goal toward which effort is directed.
To be effective, an objective should be expressed in
observable, measurable terms and should include target
date for fulfillment. For example, “By January, 1995, all
head nurses will be certified trainers of cardiopulmonary
resuscitation.”
A Critical clinical indicator is a quantitative measure
that can be used as a guide to monitor and evaluate the
quality of important patient care activities.
The effectiveness of a particular nursing intervention is
the extent to which desired outcomes are attained
through the use of the intervention. The efficiency of a
particular nursing intervention is determined by
computing the intervention’s cost benefit ratio, or the
relationship between monetary value of resources
expended and monetary value of results achieved.
Quality Assurance describes all activities related to
establishing; maintaining and assuring high quality care
for patients.
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Quality Assurance Process
Quality assurance process is the systematic process of
evaluating the quality of care given in a particular unit or
institution. It involves setting standards, determining
criteria to meet those standards, data collection,
evaluating how well the criteria have been met, making
plans for change based on the evaluation, and following
up on implementation for change.
Setting Standards- The nursing profession should have
to design standards of nursing practice that are specific
to the patient population served (for example, the
American Nurses Association has set up a Standards of
Nursing Practice based on nursing process). These
standards could serve as the foundation upon which all
other measures of quality assurance are based. An
example of a standard is: Every patient will have a
written care plan.
Determining Criteria- After standards of performance
are established, criteria must be determined that will
indicate if the standards are being met and to what
degree they are met. Just as with standards of care,
criteria must be general as well as specific to the
individual unit. One criterion to demonstrate that the
standards regarding care plans for every patient are
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being met would be: A nursing care plan is developed
and written by a nurse within 12 hours of admission.
This criterion, then, provides a measurable indicator to
evaluate performance.
Data Collection- The actual collection of data is the
third step in quality assurance. Sufficient observations
and random samples are necessary for producing
reliable and valid information. A useful rule is that 10
percent of the institutional patient population per month
should be sampled. The devised tool to collect data
should leave as little room for interpretation by the data
collector as possible. Data collectors need to be taught
the purpose of quality assurance along with the
principles of data collection.
Data collection methods include patient observations
and interviews, nurse observations and interviews, and
review of charts. Flow sheets and Kardexes are also
resources from which to assemble information about
past and present conditions.
A policy should outline guidelines of the reporting of
quality assurance data so it is clear who in the
organization needs to receive quality assurance
information. The policy should also state at what level in
the organization the analysis of the different criteria is to
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take place, to whom these analyses and
recommendations are to be reported, who is responsible
for implementing the recommendations, and who is
responsible for follow up. Unless definite policies are
established, the system may fail and changes in nursing
practice are not likely to occur (Sullivan, 1992).
Evaluating Performance
Several methods can be used to evaluate performance.
These include reviewing documented records, observing
activities as they take place, examining patients, and
interviewing patients, families, and staff. Records are the
most commonly used source for evaluation because of
the relative ease of their use, but they are not as reliable
as direct observations. It is quite possible to write in the
patient’s chart activities that were not done or not to
record those things that were done. Further, the chart
only indicates that care was provided; it does not
demonstrate the quality of that care. For example, care
plan could be checked nursing diagnosis, interventions
planned, and discharge planning.
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Monitoring Nursing Care
In addition to the individual patient care activities
described, another component of quality assurance is
the ongoing monitoring of nursing care. Several
methods are used to monitor nursing care. These
include the nursing audit, peer review, utilization review,
and patient satisfaction.
Nursing Audit can be retrospective or concurrent. A
retrospective audit is conducted after a patient’s
discharge and involves examining records of a large
number of cases. The patients’ entire course of care is
evaluated and comparisons made across cases.
Recommendations for change can be made from the
perspective of many patients with similar care problems
and with the spectrum of care considered.
A concurrent audit is conducted during the patient’s
course of care; it examines the care being given to
achieve a desirable outcome in the patient’s health and
evaluates the nursing care activities bearing provided.
Changes can be made if they are indicated by patient
outcomes.
Peer Review- occurs when practicing nurses determine
the standards and criteria that indicate quality care and
then assess performance against these. In this case,
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nurses are the “experts” at knowing what the indicators
of quality care and when such care has been provided.
Patient Satisfaction. It is using a questionnaire and
asking the patient to fill out before leaving the institution.
Such questionnaire includes care given in a timely
fashion and other variables in the environment that
contribute to recovery rather than standards of
professional care.
Critical Indicators (Rate based) Surgical Unit
• Postoperative pneumonia
• Paralytic ileus
• Wound infection
• Haemorrhage
• Urinary tract infection
• Phlebitis
• Fever
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