CHAPTER 7: PLANNING

INTENDED LEARNING OUTCOMES:

At the end of the chapter, the student should be able to - "FAILURE to plan is planning
• Discuss the meaning of Planning; its components and parts. to FAIL"
• Compare good from poor planning.
• Explain the types of plans and its relationship to nursing practice.
• Explain the reasons for planning.
• Describe the elements or scope of planning.
• Discuss the different models of planning in the management of patient care.

Planning is a management function, concerned with defining goals for future organizational performance and
deciding on the tasks and resources to be used in order to attain those goals. To meet the goals, nurse managers may
develop plans such as a unit plan or a nursing care plan.
Planning always has a purpose. The purpose may be achievement of certain goals or targets. Planning helps achieve
these goals or targets by using available time and resources.

DEFINITION OF PLANNING
• Planning -Planning is deciding in advance what to do, how to do a particular task, when to do it, and who is to
do it. It is a cognitive process for decision-making, based on facts and information as opposed to a manager's
preferences or wishes. It must be adaptable and flexible to current realities to ensure that the desired result is
achieved.

• Good Planning - Good planning, involves a continuous process of assessment, establishment of goals and
objectives, implementation and evaluation of change as new facts become known (Douglass, 2006).
• Poor Planning - Poor planning is the failure to set goals, make assessments or provide for implementation or to
anticipate any possible change in circumstances. Some indicators of poor planning are as follows (McLarney,
1964):
o 1. Delivery dates are not met.
o 2. Machines are idle.
o 3. Materials are wasted.
o 4. Some nurses are overworked, others are underworked.
o 5. Skilled nurses doing unskilled work.
o 6. Nurses are fumbling on jobs for which they have not been trained.
o 7. There is quarreling, bickering, buck-passing, and confusion.

PLANS
A plan is a living document which can be changed based on the prevailing circumstances. It is a
predetermined course of action intended to facilitate the accomplishment of a task, work or mission.

CHARACTERISTICS OF A PLAN
A well-developed plan requires, first and foremost, creative thinking and foresight. It characteristics:
1. it must involve the future,
2. it must involve action; and
3. it must have an organizational identification of the action which will be undertaken either by the planner or
someone designated by or for her.

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TYPES OF PLANS
There are several types of plans. These are strategic or long term plan, short term operational plan and
continuous/rolling plans.

1. Strategic Plans - A strategic plan is the sum total or outcome of the processes by which an organization engages
in work analysis, goal setting and strategy formulation for the purpose of organizational growth and
development. A strategic plan is one that asks the vital question: "what are the right things to do?"
a. They are usually around 3-5 years, long in nature and are based on explicit assessments of the
competitive strengths and weaknesses of the organization. This type of plan defines the direction and
growth of the organization.
b. Strategic plans are usually prepared in the upper levels of management and serve as the basis for
operational plans. In a nursing care setting, a strategic plan would be one which calls for increasing
diversity in nursing and more aggressive recruitment.

Steps in Strategic Planning:

A. Assess the environment - This requires a broad area of the organizations current environment. For example:
planning a program that would incorporate increasing emphasis on safety and patient centered care. Hence,
nurses will be made to understand that new models for Clinical Teaching are needed to impress and expect
linkages between education and practice.
B. SWOT Analysis - A tool frequently used to conduct environmental assessments; such as new equipment and
technology, escalating cost and prestige of the company and its impact to society. This stands for:
• S- Strengths- Refers to assessment of internal Example:
environment. • S - New Equipment and Laboratory;
• W-Weaknesses - Unmet goals and objectives of the • W-Escalating Cost;
organization as a result of inadequate planning and • O - Prestige in the Community;
controlling. • T-Unionization
• O-Opportunities - Assessment of external
environment. that provide sources of improvement or
change.
• T-Threats-These are factors that may pose hazards, barriers to improvement or change.

C. Assessment of the Community as Stakeholder - A stakeholder is any person, group or organization that has
vested interest in the program or project under review. All potential stakeholders must be considered to ensure
that their needs are incorporated in the plan.
D. Other Methods of Assessment such as:
• Focus group interaction-consists of small group of individuals selected due to common characteristics.
• Surveys and questionnaires that will be used to gather ideas and opinions.
• Advisory boards that are selected from various constituents affected by a proposed program.
• Review of literature and similar programs in order to identify potential problems, pitfalls and successes.
• Review of best practices that will be used for evidence-based innovations and successes coming from
other organizations.

2. Operational Plans - Operational plans usually pertain to activities in specific departments of an organization.
The plan's main question is "how does one do things right?" It deals with tactics or techniques for accomplishing
these things. They are generally shorter in time frame (e.g. one year), and usually involve the middle and lower
level managers. Although coordinated with each other, operational plans are prepared separately by the managers
of the functional sub-units of an organization. For example, the department budget is prepared by the head nurse
of a pediatric unit. Operations planning focuses on timetables, target quantities and specifies the persons
responsible for the tasks.

3. Continuous or Rolling Plans - A continuous or rolling plan, involves mapping out the day-to-day activities.
This is the task of the staff nurse who has to devise and implement the nursing care plan for the patients, altering
or modifying the plan as necessary depending on the needs and problems of the patients and the unit to where
the plan is applicable.

REASONS FOR PLANNING

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Planning is essential in nursing because:
1. It leads to success in the achievement of goals and objectives.
a. It brings about behavior that leads to desired actions and outcomes.
b. It makes performance of tasks more meaningful.
c. It helps the nurse relate to what they are doing and their professional goals.
2. It provides for effective use of available personnel and facilities.
a. For example, projecting the number of nurses needed to care for a group of patients or ordering
enough supplies for a unit.
3. It helps nurses cope with crises and problems calmly and efficiently.
a. Planning is a well-thought process of predicting future activities, anticipate future problems, and plan
for alternatives to prevent or cope with potential problems.

4. It reduces the element of change.

a. Studying what has been successful or unsuccessful can give the manager a better idea of what to do in
the future.
b. Through planning, one can discover the need for change and innovation, trends and practices to meet
current expectations of stakeholders and the community.
c. Planning can point out opportunities for new or different services.
5. Overall, it is necessary for effective control.
a. This will ensure effective management and capability of workers to meet local and global demands.

RESISTANCE TO PLANNING
Despite the many benefits of planning, many nurse-managers avoid it because of the following:
1. Lack of knowledge of the philosophy, goals and operations of the organization;
2. Lack of understanding of the significance of planning, that success or failure of work activities relate directly
to the quality of a plan;
3. Lack of proper appreciation of use of time for planning; they erroneously perceive that time spent on planning
would be better spent on addressing day-to-day concerns;
4. Lack of confidence and fear of failure;
5. Lack of openness to change that they believe planning may entail;
6. Lack of willingness to engage in new activities that planning produces; and
7. Exigencies of the situation, they prefer to act on immediate problems that give them immediate feedback.

Note: Resistance to planning can be overcome by managers who are willing to be open-minded about planning and
change.

ELEMENTS/SCOPE OF PLANNING
Planning covers the following elements:
1. Forecasting or estimating the future;
2. Setting goals and objectives;
3. Developing strategies and setting the time frame;
4. Preparing the budget and allocation of resources; and
5. Establishing policies, procedures and standards.

1. Forecasting or Estimating the Future - Forecasting is looking into the future. It is weighing the unknown
values in the situation and using them as basis for an educated guess about the future. Prediction is a similar, but
more general term, and usually refers to estimation of time series, cross-sectional or longitudinal data. Risk and
uncertainty are central to forecasting and prediction. In making forecasts, the planner should consider three (3)
things
• The agency where the planner is working
• The community being served by the agency, and
• The goals of care.
Note: The forecasts must be supported by facts or evidences, reasonable estimates of time and resources and
accurate reflection of policies and future plans.

2. Set Goals/Objectives and Determine Results Desired - A plan must set objectives or goals, or in other words
determine beforehand the 'desired result. Goals are broad statements of intent derived from the purposes of the

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 organization. Objectives are specific behavior or tasks set for the accomplishment of a goal. (See Chapters 1 and
5 for a discussion on goals and objectives).
3. Develop and Schedule Strategies, Programs/Projects /Activities; Set the Time Frame - A planner must
develop schedules, strategies, programs, projects and/or activities, and set the time frame for their completion in
order to achieve the objectives and goals of the organization. A strategy is the techniques, methods, or procedure
by which the overall plan of the higher management of the agency achieve desired objectives. Programs are
activities put together to facilitate attainment of some desired goals, such as staff development programs,
outreach programs, discharge teaching programs and the like.

Time Management
The manager's single most important resource is time. Since time is finite, the manager should allocate it as
efficiently as possible, which he can do by setting goals, assigning priorities, and identifying and avoiding all possible
wastes of time. Good time management is founded upon intelligent planning and decision-making, and a thorough
assessment of the tasks which need to be done. It is about efficiency and the determination of the most effective or at
least the best available means of fulfilling a task. It is not enough to just work hard at a given task; time management
means finding the most efficient way to do it.
Although everyone has the same number of hours in a day, the clever time manager is able to accomplish more
than others because he makes better or smarter use of his time.
Mismanagement of time severely ompromises an organization's productivity and results in negative effects
across the board, from the manager to the rank-and-file.
When time is mismanaged, work is rushed and becomes substandard, deadlines are missed, bad choices are
made, employees suffer from fatigue, and even the nurses' personal lives and relationships are adversely affected by the
lack of time or energy to devote to them.

Principles of Time Management. "There is always time for everything if you like to find the time"

There are a number of basic principles that managers can use to cultivate good time-management habits.
1. Planning for contingencies. Think of other options or alternatives, if the desired option is not possible.
2. Listing of tasks. Calendar all activities.
3. Inventory. Looking at task done and not done. 4. Sequencing. Prioritizing activities to be done.
4. Setting and keeping deadlines. Do not procrastinate or else nothing is done.

5. Deciding on how time will be spent. Indicate time allotted for each activity, set time targets.
6. Delegate. A portion of the task can be given to another who can equally accomplish the task on time.

Multitasking results when time is not enough or properly allocated to be able to finish task.

Multitasking is part of daily life. Whether you are driving while talking on the cell phone, sending e-mails during
a meeting or listening to music during work or study, multitasking has become a way of life.
Nurses, doctors, parents, and even students are trying to get more things done in less time. A nurse is asked to do a
lot of things, any one of which may demand her full attention. She often finds. herself juggling tasks. A patient needs to
have an IV inserted. Another patient requires a medication for pain. The head nurse is asking for a report that was due
yesterday. However, multitasking does not really make a person more efficient but maybe able to save time.
These days, nurses have smart phones and tablets to keep all appointments, iPads to keep them company during
graveyard shifts, and laptops/netbooks on which to check their emails whether office-related or personal. With
technology, things seem faster and a lot needs to get done all at the same time. People think they are getting a lot done
at once, but in fact are not. The net effect of multi-tasking is that when several tasks are done at once, some or all of
them end up being performed in a haphazard manner. This can have disastrous consequences. Nurses, therefore, must
learn to prioritize the tasks at hand even if they have to do them one after the other, as this remains the best way to make
sure that they get done properly.
"Anyone who wants to get more work done should be mindful. Anyone who wants to have more time
should be mindful. Mindful means one thing at a time. It is how the brain works, no matter how
people try to convince themselves otherwise."

Tools in Project Management

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 Various tools in project management have been devised such as Gantt Chart, Performance Evaluation and
Review Technique and Critical Path Method allow the manager to set the time frame of the project or activity meant to
achieve the goals of the organization.
Gantt Chart
Gantt charts show task and schedule information. The tasks are
numbered and listed vertically. A bar shows the starting date and projected
completion date of each task. Color or shading is sometimes used to show how
much of each task has been completed. It is both a management tool and a
communications tool.

Performance Evaluation and Review Technique (PERT)

The PERT or the Performance Evaluation and Review Technique is a network system model for planning and
control which involves identifying key. activities, sequences them in a flow diagram and assigning a specific duration
for each phase of work.
A PERT system involves extensive research and development. Multiple time estimates are used for each activity
that allow for variation in activity times, which are assumed to be random, with assumed probability distribution
("probabilistic").

Critical Path Method or CPM

The Critical Path Method (CPM) can calculate time and cost estimates for each activity. This method is used
to create a cost estimate using either "normal" or "crash operating conditions. Normal operating conditions are those
involving the least cost, while crash operating conditions have much less available time than under normal conditions.
CPM is useful where time and cost are significant factors because both can be estimated based on past
experience.
CPM is a tool to analyze a project and determine duration, based on identification of a "critical path" through
an activity network. Knowledge of the critical path can permit management of the project to change duration.

4. Prepare the Budget and Allocation of Resources - Budgeting is defined as a systematic financial translation
of a plan, the allocation of scarce resources on the basis of forecasted needs for proposed activities over a
specified period of time. It is a tool for planning, monitoring and controlling cost and meeting expenses. A nursing
budget allocates resources and nursing programs to deliver patient care during a fiscal year. A hospital budget is
designed to meet future service expectations, to provide quality care at minimum cost. A budget plan for health
care institutions, which is simply a olan for future activities, generally consists of four components:
a. A revenue budget summarizing the income, management expects to generate during the planning
period
b. An expense budget describing expected activity in operational financial terms for a given period of
time.
c. A capital budget which outlines the programmed acquisitions, disposals and improvements in the
institution's physical capacity.
d. A cash budget, consisting of money received, cash receipts and disbursement expected during the
planning period.

Approaches in Budgeting
The two basic approaches in budgeting are the centralized and the decentralized approaches to budgets.
1. Centralized Budget Centralized budgeting is developed and imposed by the comptroller, administrator and/or
director of nursing with little to no consultation with lower level managers.
2. Decentralized Budget - Decentralized budgeting, has the middle level manager involved in the planning and
budgeting process with ARA (authority, responsibility and accountability) placed on the practitioner level.

Components of Total Institutional Budget

The components of total institutional budget are:
1. Manpower Budget - This consists of the wages and salaries of the regular employees and the fees paid to
outside registries through which the institution contracts short-term employees.
2. Capital Expenditure Budget - This involves the large expense of purchasing of lands, buildings, and major..
equipment meant for long-term use.

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 3. Operational Budget - This includes the cost of supplies, minor equipment repair and maintenance as well as
other overhead expenses.

Types of Institutional Budget Depending on Management Philosophy

There are many different types of institutional budgeting, the appropriateness of which to a given milieu may depend
on such things as the philosophy of the incumbent management or the exigencies of a given situation.

1. Open-Ended Budget - An open-ended budget is characterized by a single cost estimate for each program in the
proposed unit. There is no specified amount on budget allocation. "Sky is the limit"
2. Fixed Ceiling Budget - A fixed ceiling budget is one in which the uppermost spending limit is set by the top
executive who then asks managers to develop budget proposals for individual units.
3. Flexible Budget - A flexible budget, in contrast, contains several financial plans for each level of activity or for
different operating conditions. Top management can select the budget or shift the spending level upwards or
downwards, whichever is best for optimum productivity. This type of budget can be adjusted or manipulated.
4. Performance Budget - A performance budget is based on the functions involved in the operation budgeted. In
a nursing care management setting this may refer to direct nursing care, supervision, and quality control, among
other things.
5. Program Budget - On the other hand, in a program budget costs are computed for a program as a whole or the
entire program itself (e.g. a home care program, an outreach program, etc.), rather than for individual activities
or functions.
6. Zero-Based Budget - A zero-based budget justifies in detail the cost of all programs, both old and new, in every
annual budget preparation.
7. Sunset Budget- A sunset budget is designed to "self- destruct" within a prescribed period to ensure cessation of
the funded program at a predetermined date.

Benefits of the Budgeting Process

There are several advantages derived from the budgeting process. Budgeting affords planning, coordination and
comprehensive control of resources.
1. Planning - Budgeting stimulates thinking in advance. It leads to specific planning such as the volume and type
of services, the number and type of personnel as well as the volume and type of equipment and supplies required,
as well as the corresponding cost. The process likewise stimulates action and interaction with all concerned
parties. From the process of budgeting one can learn a good deal about planning.
2. Coordination - Budgeting also encourages coordination among the different persons involved in the process,
from the top to bottom. It has a balancing effect on the total organization, in particular the quantity and quality
of service and the expected revenue. The continuous exchange of information up and down the organizational
ladder is encouraged, and in many instances the team approach is stimulated or developed.
3. Comprehensive Control - A budget fosters comprehensive control for those responsible for managing it. This
is because in assessing whether a budget is realistic or not, an administrator is able to evaluate quality and
initiative in performance. He is able to set standards and compare these standards with actual expenditures and
revenue. Through budgeting the manager is able to define fixed and pre- determined goals through the budget,
and is also able to initiate cost consciousness.

Factors in Budget Planning

Budget planning is determined by the specific type of activity for which it is implemented. Nursing service has
very specific parameters, activities and needs which form the basis of budget planning.
The basic factors to be considered in budget planning are the type of patient/s, the kind or class of the hospital,
the policies on personnel and equipment, standard of nursing care and nursing
supervision.
1. Patient - The nature of the patient's needs is a primary consideration in budget planning. These needs are
determined by the condition of the patient, the length of stay in the hospital and the acuteness of the illness.
Categorizing the patient is made through the type of care given by the physician such as medical, surgical,
maternity, pediatric, and geriatric among others. The method of patient assignment can be functional, case, team
or primary. The severity of the illness serves as the basis for length of stay in the hospital.
2. Hospital or Health Care Facility - The available facilities and resources with which to address the needs of the
patient are also factors in budget planning. In nursing management, these concerns include the size of the hospital,
specifically its bed occupancy and capacity. Bed capacity must be enough to accommodate the possible number

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 of patients. Other aspects of a hospital to be considered include its physical layout, the size of wards or units, the
Nurse's Station, the treatment rooms, and other relevant facilities and resources available such as equipment and
supplies.
3. Personnel - These facilities would be useless without the personnel to utilize them, and so it is important to be
well-acquainted with personnel policies in place, such as the salaries paid to nursing personnel, leave benefits
enjoyed by the personnel, i.e. whether these leaves, are confined to those required by law or include others, and
provisions for staff development programs including instructional, staff and training structures available, e.g.
periodic seminars for staff.
4. Standard of Nursing Care and Supervision - This consists of the cost of training and maintaining personnel and
acquiring equipment that will be needed by the health care facility, based on the volume of patients and the nature
of their needs.
a. It begins with documentation of the nursing care method employed which refers to reports. The manager
Policies determines whether the method of patient assignment shall be functional, on a case basis, on a
team basis or to a primary nurse.
b. She identifies what labor-saving devices and equipment are necessary. There must be a determination
of the amount of centralized service provided, such as sterile equipment, centralized oxygen service and
linen supply.
c. The manager determines the affiliation of nursing students or medical students to the system,
considering that as a rule, inexperienced students need more supervision, equipment and supplies.

Tools in Budgeting and Management of Resources

There are a number of tools used in the budgeting and management of resources:
1. The budgeting process of the organization.
2. Determine the number of full-time equivalent of nurses necessary to staff the unit.
3. Compute the salary and non-salary budget including salary increases and other various factors.
4. Monitor the variances over the budget period and identify negative variances responding promptly and
appropriately.
5. Understand the extraneous factors such as changes in technology or direct or indirect cost that may be assigned
to their budget.
6. Encourage the staff to monitor resources used including time and supplies.

5. Establish Policies Procedures and Standards

Policies are defined as standing plans used repeatedly, or guides or basic rules that govern action at all levels in
the organization. They stem from the goals of the organization. Examples include personnel policy, nursing service
policies and the like.
Procedures are defined as a more specific guide to action than policy, where each step is listed in the POLICIES
process of doing the procedures while standards indicate the minimal level of achievement acceptable to meet the set
objectives.

MODELS OF PLANNING
Models of planning vary according to the needs and profile of the organization. Some of these models are:-
1. "Basic" Strategic Planning
• This model is suited to small organizations with a high volume of work.
• This requires longer time frame
• The early operation period of the organization, like the first year, would be a good time to use the model in order
to familiarize the organization with the concept and conduct of planning.
• Subsequent planning may be done with more details, phases and activities.
• Organizations which follow this approach may adjust their strategies to identify additional goals to develop
operations or administration of the organization.
• Planning is usually carried out by top-level management, who identifies the:
Purpose or mission statement.
a) Goals to be accomplished to fulfill the purpose or mission statement.
b) Specific approaches or strategies needed to reach each goal.
c) Specific action plans to implement each strategy for achieving goals.
d) Consistent monitoring and updating of the plan.

2. Issue-Based or Goal-Based Planning

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Issue-Based or Goal-Based Strategic Planning consists of the following activities:
a) External/internal assessment to identify "SWOT" (Strengths and Weaknesses and Opportunities and Threats).
b) Strategic analysis to identify and prioritize major issues or goals.
c) Designing major strategies or programs to address these issues or goals.
d) Designing or updating the organization's vision, mission and values.
e) Establishment of action plans based on the organizations. objectives, resource needs, roles and responsibilities
for implementation.
f) Documentation of issues, goals, strategies or programs, and whenever applicable, an updated mission and
vision, action plans in a Strategic Plan document, and SWOT.
g) Development of the yearly Operating Plan document from year one of the multi-year strategic plan.
h) Development and implementation of the Budget for year one allocation of funds needed to fund year one.
i) The conduct of the organization's year-one operations.
j) Monitoring/reviewing/evaluating and update the Strategic Plan document.

3. Alignment Model
• This particular model is geared towards ensuring that the organization's resources are aligned with its mission
and vision in order to ensure effective operation. It is a useful strategy for organizations that need to fine tune
their operating strategies or which may need to rework their current approach. An organization with internal
issues may also find benefit in this model.

4. Scenario Planning
• Scenario planning involves identifying possible scenarios or situations that the organization may face. This
model is useful in identifying strategic issues and goals and may be used to ensure truly concrete solutions to
problems.

5. "Organic" or Self-Organizing Planning

• Organic or self-organizing, requires repeated reference to common cultural values within the organization.

6. Functional Planning
• This model deals with, both the actual activities of the organization and the administrative or internal matters
thereof as well, such as work, costs and resources.
• This plan usually works in the context of an overall plan and as such has to be weighed against competing
priorities from other programs and internal initiatives for organizational advancement like process
improvements and training.
• A functional plan defines tasks which may be assigned to individuals; produces clear final outputs to other
similarly oriented organizations; tracks internal operations; allows for additional program requirements; allows
for managing competing priorities from multiple programs; may be affected by non-project related work;
includes change; and work includes a process for assessing plan status.

7. Cross-Sectional Planning
• Cross-sectional planning focuses on managing the external effects on outputs of a function. It brings together
the activities of various functional groups in support of a single project like a team working together. Unlike
functional planning, which is oriented towards moving work within a single organization, cross-sectional
planning is geared towards moving work from one functional organization to another.

8. Operational Planning
• Operational planning requires one to look at the development of the decisions being made as they relate to the
overall effectiveness of work on the health care facility.
• An operational plan defines how one will implement the action agreed upon and monitoring these plans, what
the needs are, how will one use available resources, how one will deal with risks, and how one will ensure
sustainability of the project's achievements.
• An Operational Plan incorporates all other plans, past and present, to come up with a wholistic implementation
of the plan. The key components are integrated with the other parts of the overall Strategic Plan.

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 Chapter 8: Organizing

"The most useful asset of a

person is not a head full of knowledge
INTENDED LEARNING OUTCOMES: but a heart full of love"
At the end of the chapter, the student should be able to
• Explain the concept of organization, categories, characteristics, designs, principles and structures.
• Analyze the different categories of organizations and its implications to leadership and management.
• Design an organizational chart specific to the area of assignment.
• Discuss organizational or staff culture and patterns in relation to patient care classification.
• Explain the meaning of job description and employee discipline in relation to organizational goals.

After planning the tasks and devising the most efficient and cost-effective methods for getting things done, it is then
up to the manager to establish a formal structure to provide for the coordination of resources to accomplish the objectives
of the group. The manager then becomes an organizer.
Unless he organizes the work of his subordinates, they will be getting into one another's way and stepping on one
another's toes. The way he organizes the work affects even the effort his team members put into their job. This will in
turn affect the delivery of health service.
Organization is one of the steps in the nursing management process. In fact, it is the backbone of management. A
manager cannot do without organization and there can be no management without organization.

THE ORGANIZATION
There are current definitions of organization but the way it was phrased at the time it was formally studied still
holds true. Some of these definitions are as follows.

DEFINITIONS
1. Organization is the form of every human association for the attainment of a common purpose (Mooney, 1939),
2. It is also an act of putting into systematic relationships those elements and activities essential to the satisfaction
of the purpose.
3. Organization serves as a facilitating agency in the achievement of a purpose (Moehlman, 1940).

Organization, then, is both a function and a framework or a process and structure. It is both a human
activity and at the same time, it is a group of people. It is deliberately designed and exists because of an
objective which is geared towards efficient and effective goal attainment.

4. Organization is a form of identifying roles and relationships of each staff in order to delineate specific tasks or
functions that will carry out organizational plans and objectives.
5. It is the process of identifying and grouping the work to be performed, defining and delegating responsibility
and authority, and establishing relationships for the purpose of enabling the people to work most effectively
together in accomplishing objectives (Allen, 2008).

Organization, then, is both a function and a framework or process and structure. It is both a human activity and at
the same time, it is a group of people. It is deliberately designed and exists because of an objective which is geared
towards efficient and effective
goal attainment.
As a process, it refers to the building of a structure that will provide for the separation of activities to be
performed, and for the arrangement of these activities in a framework which indicates their hierarchical importance and
functional association. The organization process is a logical process. It is one by which the manager brings order out of
chaos, removes conflicts between people over work responsibility, and establishes an environment suitable for
teamwork,
The process involves:

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 1. Identification and definition of basic tasks of Individuals. at work such as staffing and creation of job
descriptions;
2. Delegation of authority and assignment of responsibility to each member of the team for the
accomplishment of activities; and
3. Establishing relationships of people by providing a system of vertical and horizontal communications
through hierarchical relationships to bind and coordinate all the activities to be done.
As a structure, it is borne out of the process. It is deliberately constructed. It evolves out of the logical process.
The organization of a group does not happen by accident; it is designed. As in engineering or architecture, so it is in
management, form follows function. The organization must be built around the basic activities of nursing practice. It
must reflect the:
1. Objectives and plans of the unit or area of assignment,
2. Lines of authority, responsibility and accountability (ARA),
3. Environment within which it is to function, and
4. Quality of available manpower to run it.

CATEGORIES OF ORGANIZATION
There are two major categories of organization: the formal organization and the informal organization. The first
is the result of the logical process and the second is borne out of consideration of behavioral patterns. special

1. Formal Organization
The formal organization is a system of well- defined jobs, each with a measure of authority and accountability.
The whole responsibility and organization is consciously designed to enable the people of the enterprise to work most
effectively together in accomplishing its objectives. The formal organization is well-defined, bounded by delegation and
relatively stable.
The formal organization is derived from the set of factors considered vital by scientific management. It is
governed by the set of principles crystallized by Taylor, Fayol and Gantt among others.
Sound organization facilitates administration, growth and diversification, optimizes the use of technological
resources, enhances the value of the individual as a person, and provides an environment for creative work.
There is another form of organization which exists side by side with the formal organization but is not visible.
What one sees in the organizational chart is usually different from what actually happens in the organization. This is the
informal organization, not easily reproduced in a chart but whose presence is simply felt by those within the organization.

2. Informal Organization
The informal organization refers largely to what people do because they are human personalities, and to their
actions in terms of needs, emotions, and attitudes and not in terms of procedures and regulations. In the informal
organization, people work together because of their likes and dislikes. This is reflected in the unofficial ways in which
a nurse creates a small group of collaborators officially denied to her.
People in the organization cross formal barriers and form the informal organization. For example advise is
sought from persons whose positions do not normally entitle them to have their views considered or when groups or
cliques arise that have no formal standing in the organization and yet have an impact on the attitude. and procedures, or
when informal discussions and consultations, perhaps with the ironing out of divergent views, occur before proposals
are formally presented to management.
Under these circumstances, management does not have ant option to destroy the informal organization but
should instead harness it for constructive ends.

CHARACTERISTICS OF AN ORGANIZATION
Organizations are separated from other types of associations by the following characteristics.
1. Division of work where each box represents an individual or sub-unit responsible for a given task.
2. Chain of command with lines indicating who reports to whom and by what authority.
3. Types of work segments, shown by clusters of work groups differentiated from one another.
4. Levels of management indicating hierarchical relationships.

ORGANIZATIONAL DESIGN
Organizational design is a process used to improve the probability that an organization will be successful. It is
a formal, guided process for integrating the people, information and technology of an organization. The use of the term
organizational structure' is limited to the framework within which people act, the basic plan which the manager draws
up to help in achieving the objective.

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 Such framework is achieved by the organizational chart.

WHY IT IS BEING USED - Organizational design is used to match the purposes of the organization with the operations
undertaken, and to improve collective efforts of members to ensure success.

HOW IT IS DONE- Organizational design is guided by an external facilitator whose thinking. Managers and members
work together to define the needs of role is to assure a systematic process and to encourage creative the organization
and create policies to meet those needs.

HIERARCHICAL SYSTEMS - The triumvirate of authority, responsibility and accountability are arranged in a
hierarchy, which is often known as bureaucracy. In such systems, rules, policies and procedures are uniformly applied
to exert control over member behaviors. Activity is organized within sub- units (bureaus or departments) in which people
perform specialized functions, such as accounting, ward Staff, ICU Staff, and the like. People who perform similar tasks
are clustered together.

REASONS FOR ORGANIZING

People choose to organize when they recognize that acting alone limits their ability to achieve their goals, and
that by acting as a group, they may come up with collective efforts to overcome individual limitations.

1. The Best Way for an Organized Group to Succeed - The benefit of organization is maximized when the group
achieves patterns of activity that are both complementary and interdependent, which result in the achievement of the
intended outcomes. Each member of the group contributes to the success of the
group.

2. The End Result of Effective Organizational Design - The final product is an integrated system of people and
resources working together tailored according to specific direction of the organization.

PRINCIPLES OF ORGANIZATIONAL DESIGN

These principles on which sound organizational design is founded are the following
1. Division of labor promotes departmentalization and specialization, which results in a more efficient
performance of a unit.
2. Unity of command, whether it follows a line of command or vests it in one superior ensures a unity of vision.
3. Authority and responsibility determine the line and staff authority, which delineates the distribution of power.
4. Span of control determines the extent of control in each level, area or unit within the system, as well as whether
it is centralized or decentralized.
5. Contingency factors the environment and technology or knowledge of team members, which deals with task
variability and problem analyzability

Remember!
• Division of labor
• Unity of command
• Authority and responsibility
• Span of control
• Contingency factor

ORGANIZATIONAL STRUCTURE
Organizational structure is a process in which a group is formed including its authority, responsibility and
accountability (ARA), span of control and lines of communication. It is a formal structure, the official arrangement of
positions or working relationships that will coordinate efforts of workers of diverse interest and abilities.
It is a formal system of task and reporting relationships that controls, coordinates, and motivates employees so
that they cooperate to achieve an organization's goals.
The task of a manager is to create an organizational structure and culture that:
1. Encourages employees to work hard and to develop supportive work attitudes, and
2. Allows people and groups to cooperate and work together effectively.

PATTERNS OF ORGANIZATIONAL STRUCTURE

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 Organizational layers in the structure are communicated by means of an organizational chart with hierarchy or
chain of command which represents a formal top down reporting structure. There are two patterns of organizational
structure: tall or flat or centralized or decentralized.

1. Tall or Centralized Structure

• Tall or Centralized structure, the centralized authority (Figure 25) Is:
a. Responsible for only a few subordinates, so there is a narrow span of control; and
b. Because of the vertical nature of the structure, there are many levels of communication.
• There are distinct advantages to the Centralized System.
c. It makes use of people with specific specialization or expertise, and allows close communication
between the workers.
d. Supervisor can screen the flow of communication from top-down level.to and from each unit or
department.
• The disadvantages of this system are the following:
e. Often times the most skilled individuals end up doing nothing while actual tasks are done by those less
capable,
f. Communication from bottom to top is often difficult, and messages may not get to the top, and
g. Workers tend to be very "boss-oriented" because of the close contact with their supervisor.

2. Flat or Decentralized Structures

The Flat or Decentralized structure is characterized by few levels or few layers in the reporting structure and a
broad span of control, where decision-making is spread among many people. Communication from lower levels
to higher levels is easy and direct. The principal advantage of Decentralized system over a more old system is
a. The lower likelihood of messages being lost or distorted; the organization can respond to faster
problems or new opportunities,
b. Workers develop their own abilities and autonomy and come to see the organization as humanistic,
resulting in greater job satisfaction, and
c. The principle of shared governance" produces maximum potential for professional growth.
• The disadvantages of this system include:
a. The fact that supervisors spend less time with each worker, and
b. The supervisors themselves may lack expertise in the variety of operations and may end up making
inappropriate decisions.

TYPES OF ORGANIZATIONAL STRUCTURE

The different types of organizational structure are line, staff, functional, ad hoc, matrix, flat, shared governance
and lateral.

1. Line Organization/Bureaucratic/Pyramidal

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 • A Line Organization have many layers in the chain of command. Authority, power and communication, is
bureaucratic and highly centralized. Figure 28 shows that each position has general authority over the lower
position in the hierarchy. This is commonly found in large health care facilities.
• There is a clearly defined superior - subordinate relationship. A traditional hierarchical organization is pyramid
shaped where all decisions emanate from the top down to the subordinates.
• Authority, responsibility, accountability and power are concentrated at the top.
• The structure acquires its form from the fact that as one goes up the administrative ladder, the worker's power
increases as well as its authority and responsibilities.

2. Flat Organization
• Flat Organization is a decentralized type. There is a flattened scalar chain and fewer levels of position (Figure
26). A flat structure is one used for less complex organizations, with authority decentralized and with several
managers supervising large work groups.
• A flat structure, also known as horizontal organization, refers to an organizational structure with few or no levels
of intervention between management and staff. The more experienced and well- trained nurses become
productive when they are directly involved in the decision making process, rather than closely-supervised by
many layers of management. Through this, feedback is immediately reported and time management issues are
lessened.
• However, a flat structure is applicable only in smaller organizations or individual units within larger
organizations. When the organization grows bigger, the pyramidal or traditional hierarchical structure takes
place.
• The flat structure can be advantageous as it encourages good feedback. Communication is more rapid like a
ping-pong ball bouncing on the table.
• On the other hand, this can be disadvantageous as this requires a painstaking building of personal relationships
between and among workers and which can be easily destroyed by negative feedback.

3. Staff Organization
• Staff organization is by nature purely advisory to the line structure with no authority to place recommendations
into action.

4. Functional Organization
• Functional organization (Figure 28) permits a specialist to aid line position within a limited and clearly defined
scope of authority.

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5. Ad Hoc Organization
• Ad Hoc Organization is a modification of the bureaucratic structure and is used as a temporary basis to facilitate
completion of a project within a formal line organization. It is a means of overcoming inflexibility of line
structure.

6. Matrix Organization
• Matrix Organization is designed to focus on both products and function. It has both the vertical and horizontal
chain of command. This combines both the best of both worlds to make an efficient organizational structure.
This structure is the most complex organizational structure.
7. Shared Governance Organization
• Shared Governance Organization is one of the most radical and idealistic type of organizational structure
developed in 1980's as an alternative to traditional pyramidal/centralized structure.
• This can be done through constant communication between the top, middle and lower management. Workers
may participate in problem solving and decision making particularly on issues or problems which concerns
them.

8. Lateral Organization
• Lateral organization people in a system function together for a relationship among the people with no authority
and accountability common goal through coordination and collaboration. There is equal between them.

ORGANIZATIONAL RELATIONSHIPS
• Organizational relationships depicts the nature and status of workers in an organization. It includes the members
of the community reporting, delegating tasks and exercise of power, responsibility and accountability,
organizational relationships are basically characterized as formal and informal.
1. Formal Relationships - Formal relationships are represented by uninterrupted lines between units, showing
who reports to whom.
2. Informal Relationships - Informal relationships represented by a broken or dotted line, where no direct power
relationships and responsibilities are merely coordinated. The Organizational Relationship Chart (Figure 29)
illustrates the command structure or relationships among human roles, organizations, or organization types that
are the key players in a health care facility.

These relationships can include:

1. Supervisory reporting,
2. Command and control relationships,
3. Command-subordinate relationships, and
4. Coordination relationship between equals.

Nurses should feel free to define any kind of relationships necessary and important within their organization to
support the goals. of the organization.. For example, dynamic teams or task forces may be created with only limited
lifespan and assigned missions, and could have needlines assigned to them.

ORGANIZATIONAL CULTURE

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 • Organizational Culture is the personality of the organization comprised of the assumptions, values, norms and
tangible signs of the corporation, as well as its attitudes, feelings, beliefs, norms and customs.
• Corporate culture can be looked at as a system, in which inputs include feedback from the group. Organizational
culture is less tangible and difficult to measure.

DIFFERENT TYPES OF ORGANIZATIONAL CULTURE

• The types of organizational culture provide a reason for the employee to be satisfied or unsatisfied with the
organization as well as the people comprising the organization. The culture can be tough-guy macho, work hard-
pay hard, bet your company, culture and process.

1. The Tough Guy Macho Culture - Feedback is quick and the rewards are high. This often applies to fast moving
financial activities such as a brokerage.
2. The Work Hard/Pay Hard Culture - The work hard culture is characterized by few risks being taken, all with
rapid feedback. People work hard on the grounds of their assigned tasks and are appropriately compensated on
their work output.
3. The Bet your Company Culture - The bet your company culture involves high stakes but delayed feedback.
Big stakes decisions are taken, by the company with less rewards and it may be years before the results are
known.
4. The Process Culture - The process culture is formed in organizations where there is little or no feedback.
People become bogged down with how things are done not with what is to be achieved.

STAFFING
• Staffing is the process of assigning competent people to fill the roles designated for the organizational structure
through recruitment, selection and development.
• Apart from recruitment, selection and hiring, this process includes induction and orientation of the new staff on
the goals, mission, vision, objectives and philosophy of the organization. These steps are cyclical in nature and
non-exclusive (Figure 30).

STEPS IN STAFFING
• Staffing follows a predictable patten before a nurse can be hired: preparing to recruit, attracting staff, recruiting
and selecting staff through interview, induction, orientation, and job offer.

1. Determine the Number and Types of Personnel Needed- The number and type of personnel needed is a
decision that a manager can reach best not alone but in consultation with the staff and co-workers. This can be
done through interviews or daily observations of needs of clients.
2. Recruit Personnel - Recruitment of personnel must be carefully and thoughtfully done either through word of
mouth or formal advertisement in different channels such as newspaper classifieds, radio, television, online
internet sites or manpower agency. The recruitment step is an opportunity to attract the best and the brightest
applicants to fill in the personnel needed in the organization.
3. Interview - All interviewers must be ready with the background of the prospective employee. Resumés or
curriculum vitae with pictures of the faces of the applicants usually help in identifying the interviewees.
Interviews should be scheduled properly and conducted in an environment that would help bring out the best

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 and worst in the applicant depending on the objectives of the interviewer. The interviewer though should always
keep sight of the qualities and experience desired in the position to be filled up. Both the interviewers and
interviewees should prepare in advance for the questions and answers that will be asked during the interview.
4. Induct or Orient the Personnel - Such orientation allows both parties to see whether they would be able to
work with each other, understand the organizational culture and learn the background of the organization. This
allows parties to back-out before any offer can be made.
5. Job Offer - For instance, when the personnel will be given an offer and the applicant accepts the offer and is
therefore hired. The would-be employee endures a pre-employment testing and the physical examination before
any contract is signed by all parties. The selection of the employee and placement happens when all pee
employment requirements are accomplished. This is the only time that the person officially becomes an
employee.

STAFFING PATTERN
• A staffing pattern is a plan that articulates how many and what kind of staff are needed by shift and day to staff
a unit or department.
• There are several ways of developing a staffing pattern. It can be generated by determining the nursing care
hours needed for a specific patient or patients and then generating the Full Time Equivalents (FTEs) and staff-
to-patient ratio needed to provide that care. In most cases, a combination of methods is used to validate the plan.
• Developing a staffing pattern is a science and an art. Some of these considerations in the development of a
staffing pattern are the following:

1. Benchmarking - Benchmarking is a management tool for seeking out the best practices in one's industry so as
to improve performance and be competitive with other productive companies in terms of quality of services
rendered. (Swansburg, 2012).
2. Regulatory Requirements - The local requirements will be followed as mandated by R.A.
3. Skill Mix - Skill mix is another critical element in nurse staffing. It is the percentage or ratio of professionals
to non-professionals, e.g. RN staff to other direct care staff and other non-professionals.
4. Staff Support - Staff support in place is necessary for the operations of the unit or department. For instance,
the organization must have a systematic process to deliver medications to the department and unit personnel
have to pick up patient medications and narcotics and be accountable in dispensing these drugs. The less support
available to the staff, the more nursing hours have to be built in the staffing pattern to provide quality care to
patients.
5. Historical Information - Historical information must be kept intact to ensure effective absence of equipment
and supplies. Since lack of these will require ways of doing tasks. Being knowledgeable about the presence or
more time for nurses doing non nursing activities hence patient needs cannot be met appropriately.

FACTORS AFFECTING TIME REQUIREMENT OF NURSING CARE

• There are a number of different factors which determine how much time is needed in a nursing care environment.
1. Acuity of the patient's illness;
2. Degree of patients' dependence on the caregivers;
3. Communicability of the ailment; and
4. Rehabilitation needs of patients and special treatments and procedures. In short, the needs of the patient as
determined by their illness effectively determine how much time and care the nursing service most devote.

PATIENT CLASSIFICATION SYSTEM

• To this end, it is important to devise a means of categorizing patients on the basis of certain needs that can be
clinically observed by the nurse.
• A patient classification system (PCS) is a measurement tool used to articulate the nursing workload for a specific
patient or group. of patients over a specific period of time.
• The measure of nursing workload that is generated for each patient is called patient acuity. As the patient
becomes complicated, the acuity level rises, meaning the patient requires more nursing care. The reverse is also
true. Patient care is classified according to:
1. "Self care" or minimal care patients are capable of carrying activities of daily living (ADL), e.g., hygiene,
meals, exercises, etc.
2. Intermediate or moderate care requires some help from the nursing staff with special treatments or certain
aspects of personal care, c.g., patient with IV fluids, catheter, respirator.

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 3. Total care patients are usually those who are bedridden and who lack strength and mobility to do average
daily living, c.g.. patients on complete bed rest, immediate post-operative, with contraptions, among others.
4. Intensive care patients are those who are critically ill and in constant danger of death or serious injury,
e.g., comatose patients, bedridden patients.

NURSING CARE MODELS

• A model for nursing care is the framework for nursing care- delivery in any setting, or design that meets the
particular needs of a group of health care givers and clients. Each nursing diagnosis model has its own specific
values. The delivery of care includes patients' needs, formulating a plan of care, implementing the plan, and
evaluating the patient's responses to interventions.

1. The Case Method or Total Patient Care

• This is actually the original model of nursing care delivery, in which a registered nurse is responsible for all
aspects of care of one or more patients (Figure 31).

• KNS work directly with the patient, family, physician and other health care staff in implementing the plan of
care within her shift. This sa complete care model which includes treatment, medications and arsing care plan
(NCP),
• The RN gives total care within her shift, and her point of entry is anytime during the course of patients' illness.
She provides holistic often times to more than one client for a specific period of time.
• The goal of this system is to have one nurse give all care to the same patient(s) for the entire shift. This delivery
system is typically used in areas requiring a high level of nursing expertise, such as in entical care units or post-
anesthesia recovery areas.

There are several advantages found in Case Method:

• The nurse can better see and attend to the total needs of clients and the continuity of care can be facilitated with
case.
• The client's interaction and rapport with the nurse are well- developed, and the client's needs are monitored
carefully. with the result that both the client and his or her relatives feel secure.
• The disadvantage of this system is that RNS spend some time doing tasks that could be done more cost-
effectively by less-skilled persons. This adds to the expense of using a total patient care delivery system.

2. The Functional Method

• Functional nursing, also called "task nursing" was developed in response to a national nursing shortage in the
1940s in the USA around the time of World War II. As a result of the loss of RNs, the composition of nursing
staffs in hospitals changed; staffs composed almost entirely of RNs, gave way to widespread use of licensed
practical nurses (LPNs) and unlicensed assistive personnel (UAPs) to deliver nursing care.
• The needs of a group of patients are broken down into tasks, which are assigned to RNS, LPNs, or UAPS or
nursing aides so that the skill and license of each caregiver is used to the best advantage.
• This method is task and procedure oriented. It is used when there are too many patients in proportion to available
RN. The RN learns to work fast because activities are repetitious, and her technical skills amplified. It is a
technical approach to patient care and dependent function of nursing practice. Nurses are assigned to selected
functions such as vital signs, treatments, medication, among others.

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The advantages of Functional Method are:
a. Nurses who are oriented this way become skilled in performing assigned tasks;
b. Individual aptitude and experience improves;
c. Less equipment is needed;
d. Time is saved; and
e. Task-oriented approach improves both productivity and organization.

Often, in this approach (Figure 33), patients can not identify who their nurse is.

3. Team Nursing
• In team nursing (Figure 33) which evolved from functional nursing, a group of nursing personnel provides total
patient care to a group of patients. In some instances, a team may be assigned to a certain number of patients,
while in others, the assigned patients may be grouped by diagnoses or provider services.
a. The RN leads a group of many health workers, including students.
b. This group is centered through participation efforts.
c. The personnel work together to identify, plan, implement and evaluate comprehensive client-centered nursing
care toward a common goal of providing quality client care.
d. It is oriented towards the decentralization of a nursing unit and of the Head Nurse's authority.
e. Comprehensive nursing care with authority, responsibility and accountability becomes the responsibility of the
entire team.

There are several advantages to be found in team nursing relative to other methods.
a. The constant group work fosters a feeling of participation and belonging.
b. The workload is balanced and shared with the division of labor for each team member..
c. Each member of the team has the opportunity to learn from other team members or team colleagues.
d. There is also a variety in the daily assignment.
e. It also helps maintain interest in client's well being and is cost effective.
f. The patient is able to identify who their nurses are due to the continuity of care.
g. Barriers between nurses and clients can be minimized since care is well coordinated.
h. Everyone gets to contribute to the care plan.

Primary Nursing Care

• Primary nursing (Figure 34) was designed to place the RN back at the patient's bedside. Decentralized decision-
making by staff nurses accountability (ARA) for nursing care allocated to staff nurses at the is the core principle
of this method with authority, responsibility, and bedside.

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 a. This method represents total nursing care directed by a nurse on a 24-hour basis, from the moment of admission
to discharge with ARA.
b. It is accomplished through decentralization, autonomy and independently competent nursing care.

The advantages of this method are:

a. The nurse sees the client and family as one system and ARA is increased.
b. The nurse uses a wide range of skills knowledge and expertise and develops creativity.
c. This, in turn increase trust and satisfaction by the clients.
d. There is excellent communication between the primary nurse and associate nurses.
e. Primary nurses are able to hold associate nurses accountable for implementing the nursing care as prescribed.

The disadvantage of this method is that, because of transfers to different units, critically ill patients may have several
primary care nurses, disrupting the continuity of care inherent in the model.

5. Progressive Client Care - In the Progressive Client Care method, different areas or units provide various levels of
care. Clients are evaluated, transferred and assigned to units with nurses having expertise with respect to the level or
intensity of care needed. There is increased reliant behavior, and staff is trained to provide the best of care.

6. Managed Care Method- The Managed Care method involves unit- based care that is organized to achieve specific
patient outcomes within her stay in the
unit.

7. Practice Partnership - Practice Partnership Model, an RN and an assistant-UAP LPN, or less experienced RN agree
to be practice partners. They work together with the same schedule and the same group of patients. The senior and junior
staff members share patient care responsibilities (Sullivan, 2006). Practice partnership (Figure 35) is an efficient way of
using a mixture of skills and professional and non-professional staff with differing levels of expertise. The relationship
between the senior and junior partner is designed to create synergistic energy as the two work in consonance activities
but delegates less specialized activities to the junior partner. with patients needs. The senior partner performs selected
patient care Compared to team nursing, practice partnerships offer more continuity of care and accountability for patient
care, while compared to primary nursing, partnerships are less expensive for the organization and more satisfying
personally for the partners.

The two main disadvantages of this model are that:

a. It tends to decrease the ratio of professional nurses to non-professional staff, and
b. There is the potential for the junior member of the team to assume more responsibility than may be appropriate to
his/her level.

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8. Case Management Method
• Case Management Model for identifying, coordinating, and monitoring the implementation of services needed
to achieve desired patient care outcomes within a specified period of time (Zander, 2008).
• In the Case Management method, (Figure 36) care is directed by i case manager focused on achievement of
outcome and appropriate time frame and resources. The nurse focuses on an entire episode of liness, and the
method is therefore episode-based rather than unit- based
• The Case Management Method is used to organize patient care according to diagnoses or other related groups.
The manager in this method does not provide direct patient care but rather supervises the care provided by the
RNs or the non-RNs. Patient cooperation is vital to the success of this method.

9. Modular Method
• In the Modular Method, the RN provides direct nursing care with assistance of aides. This is a modified team
& primary nursing method where RN provides leadership, support and instruction.

FORMULA TO DETERMINE STAFFING PATTERNS

There are several formulae for determining staffing patterns.

1. Full Time Equivalent (FTE) - This is a formula that uses nursing care hours and annual hours of work provided by
one Full-Time Equivalent (FTE). It is a measure of the work commitment of a full-time employee. A full-time employee
works 5 days a week or 40 hours per week for 52 weeks a year. This amounts to 2,080 hours of work time. The formula
is:

2. Forty-Hour Week Law- This formula is based on the National League of Nurses (NLN) or R.A. 5901 otherwise
known as the Forty Hour Week Law. Based on National League of Nurses (NLN), the formula is:

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d. 40 hour/week - For personnel working in hospitals
with 100 bed capacity or over or which are located in a 1 M population.

e. 48 hour/week - For personnel who work in agencies with lesser bed capacity or which are located in communities
with less than 1M population.

JOB DESCRIPTIONS
• Job descriptions are specifications of duties, conditions and requirements of a particular job prepared through a
careful job analysis. They are also called performance descriptions.
• They are used primarily for purposes of:
a. Recruitment,
b. Placement and transfer,
c. Guidance and direction,
d. Evaluation of performance,
e. Reduction of conflict and frustration,
f. Avoidance of overlapping of duties,
g. Facilitating working relationships with outside bodies such as professional associations, and
h. Serving as basis for the employees' salary range.

Job descriptions include

1. Job title, namely the position and the necessary qualifications,
2. Job relationships, such as the degree of supervision, line and staff responsibilities and reporting mechanisms
imposed on the worker, and
3. Performance or Job description, which is a catalogue of the assigned tasks and responsibilities of the worker.

EMPLOYEE DISCIPLINE
• Among the most challenging problems that a manager may face is what to do when employees fail to perform
to expectations.
• Some managers would rather ignore such underperformance but there are certain principles they can apply and
steps they can take to help improve staff performance and morale.

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 • Employee discipline is the process of generating employee compliance to institutional rules and regulation.

Purposes:
1. It creates order and smooth transition during shifts and breaks.
2. It helps nurses to perform their tasks better and they are able to care for their clients without guesswork.
3. It also provides a direction for the delinquent employee.

Employee discipline policies and regulations must be properly communicated to the stakeholders. This makes it
easier for the manager to implement work policies and procedures.

PRINCIPLES OF DISCIPLINE
• In any situation, whether in a work or home environment, there are several rules on the application of discipline:
The following rules are
1. Discipline should be done privately, promptly and consistently.
2. It should be progressive in nature.
3. In the work environment especially, it should be preceded with counseling.
4. Disciplinary procedures should be instituted with extreme caution.

DISCIPLINARY PROBLEMS
• Disciplinary problems tend is to occur when there methodological weakness, such as when the manager lacks
skill in interviewing or documentation, or when there is a procedural omission, such as poor application of
discipline.

Steps to Address Disciplinary Problems

1. Coaching
• Coaching is a day-to-day process of helping employees improve their performance. This is done through
interaction which. encompasses need analysis, staff development, interviewing, decision making, problem
solving, analytical thinking active listening, motivation, mentoring, and communication skills. The goal is to
eliminate barriers and problems or such as excessive absenteeism or frequent personal phone calls and improve
performance based on policies and standards of a professional nurse.

2. Confrontation
Confrontation is a communication technique used to address specific issues such as violation of a policy or procedure.
Confronting an employee over such issues involves a number of steps:
• The nurse manager should determine whether the employee is aware of the policy.
• The employee should have received policy information at orientation, and an updated policy manual should be
readily accessible to all employees.
• The policy should have been enforced strictly and consistently.
• The nurse manager should then describe the behavior that constitutes the violation in a manner that relays the
concern to the employee regarding the issue, while avoiding making the interaction a personal issue.
• The manager should solicit the employee's reason for the behavior, allowing sufficient time for the employee to
respond.
• The manager should convey to the employee that she cannot continue breaking an established policy.
• The manager should explore alternative solutions to the problem so that negative outcomes will be avoided.
• The manager and employee should agree on a course of
• action.
• They should set up a reasonable date to follow-up in order to check if she is adhering to established policy.

3. Disciplinary Conference
• Disciplinary Conference is a means of applying discipline, it uses a combination of directive and non-directive
technique, in order to minimize stress during the interview.

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STEPS OF PROGRESSIVE DISCIPLINE
• Progressive discipline means the managements' adherence to the principle of due process, and fair treatment of
subordinates. The measures taken should be graduated according to the frequency (first time, second time, etc.)
and severity of the offense. The different measures are:
1. Counseling,
2. Verbal reprimand,
3. Written reprimand,
4. Short suspension,
5. Longer suspension, and
6. Discharge/dismissal.

• The nurse should at all times adhere to "due process" and ensure fair treatment of her subordinates. This creates
a feeling in the subordinates that they are heard and that special treatment will not be provided to anyone.
• The 1987 Constitutions' Bill of Rights provides that "No person shall be deprived of life, liberty or property
without due process of law."

TOOLS FOR TERMINATING STAFF

• Contrary to popular belief, it is not easy for managers to discipline or terminate non-performing employees. It
is either because of personal beliefs or inadequate understanding of the termination process. The following is a
guide to terminating an employee:
1. Inform the human resource department and administration
1. beforehand,
2. State the offending behavior and the reason for termination,
3. Explain the proposed termination process,
4. Termination must have the approval of higher authorities,
5. Remain calm,
6. Arrange for employee to be escorted out, and
7. Report back to the human resource department and administration.
CHAPTER 9: DIRECTING

INTENDED LEARNING OUTCOMES: "The best day in your life is the one
At the end of the chapter, the student should be able to - on which decide your life is your
• Explain the meaning of directing relation to leadership and management. own"
• Analyze the characteristics of good directing.
• Discuss the tools of directing. you
• Analyze the elements of directing and the role of the nurse in the implementation process.
• Identify the reasons for conflicts, its types and resolutions.
• Analyze the value of critical thinking process.
• Describe team building and its characteristics.
• Analyze the different levels of communication.
• Draw implications of directing to leadership and management.

After planning and organizing the next crucial task the manager must now face is directing. It is through
directing that the manager encourages her personnel to accomplish their assigned tasks towards achieving the
objectives that were laid down for the organization while planning and organizing the operations.
Directing goes beyond giving orders and instructions; it is the final major step taken by the nurse manager to
ensure that the organization's goals are accomplished. To do this, she must ensure that she has assigned the work
properly, that is to say, that she has. gotten the right person for each task that needs to be accomplished.
To able to work well, the employee must, in addition to the skill required of her, have a genuine interest in the
task that needs to be accomplished, especially if the task is a difficult one that may require sustained effort over a
period of time.
Furthermore, it is important that the employees chosen by the manager are able to get along harmoniously
because directing employees invariably depend on the relationships existing among where continued interaction
among the various employees in the them. This is of particular importance in a nursing care environment system is
inevitable and in fact necessary for the organization to
function properly.

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 DIRECTING
• Directing is the act of issuing of orders, to accomplish the assignments, instructions organization's goals
and objectives. It involves the process of getting the organization's work done. It entails explaining what is
to be done, to whom and by whom, at what time, how and why it is to be done.
• All directions must be consistent with departmental policies to help personnel perform their duties safely
and efficiently.
• ARA and leadership styles are ultimately related to the manager's ability to direct.

CHARACTERISTICS OF GOOD DIRECTIONS

1. Directions must be clear, concise, consistent and complete.
2. Apart from being understandable, the person giving directions must explain the rationale well and make certain
that it is understood.
3. The words used in giving directions indicate their importance. For example, the words "must," "shall" and "will"
indicate that the directions are mandatory. The word "may" denotes that action is recommended, while the word
"should" places between mandatory the directive somewhere recommended action.
4. The person giving directions must speak distinctly and slowly. Directions must come across as requests not
commands, using a specific tone and set of words. She should give directions in logical manner and prioritize
the tasks directed to be done by importance and time.
5. It is important, furthermore to,
• Avoid giving too many directions at one time;
• Personalize directions;
• Always check to make sure directions have been followed; and
• Provide feedback for actions done.

TOOLS IN DIRECTING
There are many tools available to a director in a nursing environment. The primary tool is the nursing care plan
as a whole. Of course, the director may also use policies, standards, standard operating procedures, rules and
regulations.

NURSING CARE PLAN

A nursing care plan outlines the nursing care to be provided to a patient. It is a set of actions the nurse will
implement to resolve patient problems identified by assessment. The creation of the plan is an intermediate stage of
the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the Nursing Care Plan

1. It is primarily concerned with patient needs and problems such as signs or objective data, symptoms or
subjective data gathered by the nurse through her contact with the patient.
2. It focuses on nursing actions which are designed to solve or minimize the patients' existing problem and
prevent potential risks.
3. It is a product of a deliberate systematic process based on scientific principles and standards of nursing
practice.
4. It relates to the future actions and interactions.
5. It is based upon identifiable health and nursing problems.
6. Its focus is holistic. Considering all aspects of care, be it physical, emotional, psychological, sociological
or spiritual among others.
7. It aims to meet all the needs of the patients or service user in terms of promotive, curative, rehabilitative
and restorative process of care.

Elements of the Nursing Care Plan

The nursing care plan may consist of a NANDA nursing diagnosis with related factors, subjective and objective
data that support the diagnosis, with specified outcome goals and objectives to be achieved including deadlines and
nursing intervention.

ELEMENTS OF DIRECTING
• Directing has seven elements. These are: 1) delegation; 2) supervision; 3) staff development; 4)
coordination; 5) collaboration; 6) communication; and 7) evaluation.

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 1. DELEGATION
• Delegation is the act of assigning to someone else a portion of the work to be done with corresponding
authority, responsibility and accountability (ARA). An assignment is a task done without authority, while a
delegation is a task done with ARA. It is also a skill to be learned and mastered, beginning with learning
what cannot be delegated and what will be delegated and to whom should it be delegated.
• Delegation is one of the core concepts of management leadership. The person delegated to do the tasks
remains accountable for the result of the delegated work. It encourages subordinates to make decisions and
create changes as deemed necessary.

What cannot be delegated

• Certain matters cannot be delegated, such as the overall ARA, the final evaluation of staff performance, for
correcting and disciplining staff, including such activities which the nurse to whom the task is delegated
and does not know how or does not want to do because it is unpleasant. Delegated tasks must be based on
policies, job description and capabilities of workers.

Why is there a Need to Delegate

• Delegation can save money and time.
• Helps in building skills of subordinates.
• Motivate people to perform higher level tasks.
• Train people to prepare for greater responsibilities.
• Allow next in line staff to do the job in the absence of the manager.
• Groom successors since nobody is indispensable.

Why Managers do not Want to Delegate

o Mistakes in delegation can be costly. In cases where an employee fails to deliver the expected task; may
require additional time, manpower and resources.
o Failure to delegate wisely increases management costs and contributes to personnel dissatisfaction.
Inability of the employee to do the right thing may cause emotional and psychological burden on the
staff thereby creating fear in accepting delegated task.
o Fear on the part of the management to fully comprehend the task to be accomplished may inhibit the
manager to delegate the task.
o Fear of losing control of the staff. Inability of the staff to do the task correctly may induce conflict among
them.
o Fear of failing to get others do the work. This is anchored on the assumption that the one delegated to do
the task will accomplish everything leaving others with nothing to do.
o Fear of criticism. Based on command responsibility, when task delegated are not done as expected.
o The manager who enjoys the personal satisfaction gained from doing the work herself will likewise not
be inclined to delegate the work. This refers to micromanagement where the manager provides too much
inputs and performs the tasks personally.

Common Delegation Errors

a. Underdelegating - This stems from the managers' false assumption that delegation may be interpreted as the
lack of ability on his or her part to do the job correctly or completely. The manager manifests his desire to do
the job by himself. He has trust issues and thus lacks trust in his subordinates. He is insecure, that he fears that
subordinates will resent the work delegated to them. Underdelegating also occurs when the manager lacks
experience in the job. Thus, there is the excessive need to control and be perfect.
b. Overdelegating- At the other extreme end is overdelegation. It unnecessarily burdens the subordinates with
tasks that are either inconsequential or irrelevant to the delivery of the goal. The culprit is usually poor
management of time and insecurity in the part of the nurse manager in her ability to perform tasks.
c. Improper Delegating - A manager should be able to determine the talents and capabilities of his subordinates..
Delegation of tasks and responsibilities beyond which the person cannot perform properly, is improper
delegation.

2. SUPERVISION
• Supervision is the process of guiding and directing the work to be done. It entails motivating and encouraging
the staff to participate in activities to meet goals and objectives and personal development and in helping the
staff to do their work better.

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Principles of Good Supervision
• To most workers, the supervisor is presumed as "the management" because of her constant presence and close
association with them. For this reason, the supervisor is in a position to exert strong influence in motivating
individuals under her supervisory jurisdiction. In other words, the supervisor can incite in her employees ideas
and emotions which may affect their morale and their operational efficiency. This means a supervisor:
o Can produce attitudes. which are both positive and negative in character;
o Produces positive attitudes when an employee is conscious of the benefits to herself which she
attributes to the influence of the supervisor; and
o Produces negative attitude when the reaction of workers is resistance to discipline or actual fear of
demotion or discharge.

• The following are some principles of good supervision for supervisors and managers in general to remember.
o Good supervision is focused on the improvement of work rather than upgrading the worker.
o It is based on lines of authority, organizational philosophy, vision/mission, the job description,
policies and standards, the needs of the individual.
o Good supervision focuses on development of the three area of skill:
▪ Conceptual enhance knowledge through adequate information and feedback.
▪ Technical - refinement of skills through in-service trainings and seminars.
▪ Interpersonal develop communication skills through constant dialogues and conferences.
• It is cooperatively planned by both management and staff, and accepts both challenge or change.
• It uses a democratic process to facilitate:
o Effective communication;
o Continuous improvement of staff;
o Respect for the individuality of each staff member; and therefore
o Bring about harmonious relationship and a conducive social, psychological and physical
atmosphere.
• The ultimate goal of good supervision is to provide safe, effective, quality care.

Responsibilities of Supervisors
• Supervisors have the duty to teach and motivate the staff, as well as facilitate their work performance. They
should delegate work responsibilities and be available for consultation. They should also perform
assessment and evaluation of work performance, including environmental conditions work and supervision.

3. STAFF DEVELOPMENT
• Staff development is a planned experience to help employees perform effectively and efficiently, and to
enrich their competence in practice, education, administration and research. It is retraining them for better
performance in areas of skill, knowledge and attitude (SKA).

Functions of Staff Development

• Staff development serves several functions, some of the more critical of which are:
o Maintain staff efficiency and effectiveness; Staff work performance based on goals and objectives:
o Create quality employees; who can better serve the needs of the clients and the organization, who
can assume greater responsibility, help motivate others to perform better and can cope up with crisis
and changes.
o Meet the staff's needs and address their problems, such as deficiencies in knowledge, skills and
attitude.
o Motivate them and improve their self-confidence, knowledge and skills strengthen capability of the
staff to initiate more activities, improve performance, boost self confidence and assurance for
productivity.
o Help prepare them for greater responsibilities, such as promotion to higher posts as in management
administrative position; the staff have to participate in planning, orientation, continuing education,
in-service, patient education, advisory and research.

In - service Training and Continuing Education

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 • In-service training is education for employees to help them develop their skills in a specific discipline or
occupation. In-service raining takes place after an individual begins her work responsibilities. Most
typically, in-service training is conducted during break in the individual's work schedule. education
• A nurse, as in most professions, must actively participate in professional continuing education programs.
Continuing program is a specific learning activity generally characterized by the issuance of a certificate or
continuing education units (CEU) for the purpose documenting attendance at a designated minor or course
of instruction.
• The Board of Nursing encourages requirements on members who hold licenses to practice. These continuing
education. requirements are intended to encourage professionals to expand their knowledge base and stay
up-to-date on new trends and developments.
• These requirements may be satisfied through college or university coursework, attendance in graduate
course work, extension courses or conferences and seminars attendance.

4. COORDINATION
• This activity links the different components of an organization and leads them toward goal achievement. It
creates harmony on all activities to facilitate success of work. In a well-coordinated organization, everything
has been delegated to guard against leaving loose ends.

5. COLLABORATION
• The manager and the health care staff together with the other members of the health care team all participate
in the decision making process. Sometimes they join forces with another as, the medical group. or larger
group, like another health care team or one fulfilling a different role for this purpose.

6. COMMUNICATION
• Communication ensures common understanding via various routes. It is a process by which a message is
sent, received and understood as intended. The goal of proper communication is to narrow the gap between
the intended and the received message. As managers, nurses have to frequently communicate directions and
these directions have to be reasonable and understandable so subordinates are likely to comply. Thus,
communications are more than trying to make people understand; they aim at changing people's behavior.
• To achieve good communication, a nurse-manager must be that communication is not only confined to
verbal dictation. There are only non-verbal cues which form part of verbal communication as opposed to
verbal communication which they evolves talking
• As such, a nurse manager must realize that there sites when she has to ask for help and when she es, she
must know the questions to ask. A nurse- sager must also know how to formulate directions and any
information she wants to give her subordinates. Quite often, when a nurse-manager thinks she has and
herself clearly be it orally or written, in reality her subordinates are either confused or have misinterpreted
her. She must learn to listen well, Le., concentrate on what the other person is so as to hear it as accurately

as it is being told.

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 • To be effective communicators, supervisors, head nurses, nurse- managers must realize the value of the free
flow of information and able to chimate in which truthfulness and frankness can be sable between a
subordinate and her superior.
• Some of the ways to communicate involve informal talks, planned appointments, telephone calls, inter
office memos, letters, pens, informal staff meeting, planned conferences, mass meetings or general
assemblies, bulletin board notices, posters, exhibits, displays, and visual aids (Corrado, 1994).Today, the
use of emails, online chats, blogs, social media", constitute alternative Communication.

Barriers to Effective Communication

• The barriers to effective communication can be physical, social or psychological, semantics, and
a. Physical Barriers. These are environmental factors that prevent or reduce the opportunities for
communication for example, distance and noise.
b. Social/Psychological Barriers. They are blocks or inhibitors to communication that rise from the
judgments, emotions and social values of people for example; stress, defensiveness. trust, fear,
c. Semantics. These are words, figures, symbols, penmanship, interpretation of messages through signs
and symbols. Symbols may have a variety of meaning and the symbol is chosen from among the many.
d. Interpretations. These are defects in communication skills of verbalizing, listening, writing, reading and
understanding.

Dimensional Flow of Communication in Nursing Service

• In the nursing service, there are several different
kinds of directional flow of communication among
the members of the organization (See Figure 37).
Upward communication proceeds from the
subordinates to the superiors. Horizontal
communication takes place among peers; members of
the health team. Outward communication proceeds
from the team to the patient's family, community
workers, friends. Downward vertical communication proceeds from an authority or manager to his
subordinates. Diagonal communication, on the other hand, flows throughout different hierarchical levels.

Management Levels in Nursing Service Like most organization,

• Like most organization, a nursing service organization is comprised of several management levels. The
different levels and the roles of those occupying them determine the flow of communication within the
organization.
• At the top level of management are the director and the administrator of nursing services. Nurse supervisors
and area managers comprise the middle level. First line managers consist of the head nurses, unit managers,
senior staff nurses, while at the operating level are the staff nurses, student nurses, nursing attendants.

7. EVALUATION
• A desired result of any employee behavior is effective job performance. An important role of the manager
is to determine performance in advance and state desired outcome of what has been done.
• The purpose of evaluation is to determine how far or how many of the organization's objectives were
accomplished.

Purposes of Evaluation
The purposes of evaluation are to:
• Provide constructive feedback;
• Determine progress and worthiness of individual nurse for greater responsibilities; and
• Serve as basis for promotion and increase in salary or other similar rewards.
Evaluation is also meant to:
• Recognize and further develop strengths;
• Minimize weaknesses of the staff;
• Provide security for patients, personnel, agency and the community; and
• Develop a fair employment practice and performance appraisal process that is in accordance with the law.

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 Different Types of Evaluation
• There are several kinds of evaluation in nursing care situations: a) outcome or product evaluation; b) process
evaluation; and c) structure evaluation.
o Outcome or product evaluation, which takes note of the response of patients after nursing care is
done.
o Process evaluation, nursing actions are examined, to determine if client goals have been met or have
not been met.
o Structure evaluation, the goal is to obtain feedback on the systems in terms of financial and material
resources, nursing personnel, policies and procedures.

Legally Sound Performance Evaluation

• It has often happened that employees have sued their organizations over employment decisions based on
questionable performance appraisal results. Although it is nearly impossible to be certain that an appraisal
system is legally defensible, there are several steps to assure that an appraisal system is non-discriminatory.
1. It should be in writing and carried out at least once a year.
2. The information should be shared with the employee.
3. The employee should have the opportunity to respond in question the results of the appraisal. The manager
should have adequate opportunity to either directly observe the employee's job performance during the
course of be evaluation period or, in the event of lack of adequate contact, be able to gather information
from other sources.
4. Anecdotal notes on the performance should be kept roughout the evaluation period. These notes should be
shared with be employee during the course of the appraisal period.
5. The evaluator should be trained to carry out the appraisal process, including;
a. What constitutes reasonable job performance.
b. How to complete the form, and
c. How to carry out the feedback interview..

• As much as possible, the appraisal should focus on employee behavior and results rather than on personal
traits or characteristics such as initiative, attitude and personality.

CONFLICT
• Conflict is a natural, inevitable condition in organizations and is often a prerequisite to change in real or
perceived differences in goals, values, ideas, people and organizations. Conflict is a consequence of estudes,
beliefs, feelings and actions. These can our on several levels, namely:
1. Intrapersonal or within one individual
2. Interpersonal or within two or more individuals
3. Intragroup or within one group
4. Intergroup or between two or more groups

These different types of conflict may cause organizational dysfunction. There are both positive and negative results
of conflict, and some of these are:
1. Conflict can provide greater sensitivity to an issue which stimulates the interest and curiosity of others;
2. Conflict can increase creativity by acting as a stimulus for developing new ideas or identifying methods
for solving problems;
3. Conflict can help people recognize the legitimate differences within an organization;
4. Conflict can also be a powerful motivator to improve performance and effectiveness; and
5. Disagreements can make parties aware of costs versus benefits of a particular service or technique.

TWO MAIN TYPES OF CONFLICT

1. Competitive Conflict - This occurs when two or more groups attempt the same goals and only one group can
attain them. It is defined by a victory for one side and a loss for the other. The process by which such conflict is
resolved is determined by a set of rules.

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 2. Disruptive Conflict - This takes place in an environment filled with fear, anger and stress. There is no mutually
acceptable set of rules and the goal of each party is the elimination of its opponent.

CONFLICT RESOLUTION

1. Dominance and Suppression The use of win- lose strategy is a method that represses rather than settles
conflict, creating a win-lose situation in which the loser is left feeling angry and antagonistic.
2. Restriction is an autocratic, coercive style that often leads to an indirect and destructive expression of
conflict.
3. Smoothing Behavior is a more diplomatic way of suppressing conflict wherein one persuades the opponent
to give in to the other side.
4. Avoidance Behavior creates a situation in which there seems to be differences existing between one another.
An individual withdraws or walk away from the source of conflict.
5. Majority Rule resolves conflict by majority vote.
6. Compromise or Consensus Strategy is a method where? each side agrees upon solutions that meet
everyone's needs.
7. Integrative Problem-solving is a constructive process in which the parties involved recognize that conflict
exists and openly try to solve the problem.
8. A Win-Win Strategy focuses on goals and attempts to meet the needs of both parties.
9. A Lose-Lose Strategy is one in which neither side wins; the settlement reached is unsatisfactory to both
sides.
10. Confrontation is regarded as the most effective means of resolving conflict in which it is brought out in the
open and attempts are made to resolve it through knowledge and reason.
11. Negotiation is a technique where conflicting partics give and take on various issues and arrange solutions
that may offer best to both parties.

The Ten Commandments for Negotiators (Levenstein, 1984):

• Clarify the common purpose.
• Keep the discussion relevant.
• Get agreement on terminology.
• Avoid abstract principles; concentrate on facts.
• Look for potential trade-offs.
• Listen.
• Avoid debating tactics; use persuasive tactics.
• Keep in mind the personal element.
• Use logic judiciously.
• Look for solutions that satisfy the other person's real interests.

CRITICAL THINKING PROCESS IN PROBLEM SOLVING AND DECISION MAKING

CRITICAL THINKING
• Nurses constantly face numerous alternatives to solve problems and make decisions. These are part of the
usual nursing care activities and are not easy tasks.
• Critical thinking is a cognitive process of examining underlying assumptions, interpreting and evaluating
arguments, exploring and analyzing alternatives thereby developing a reflective criticism for the purpose of
reaching a justifiable reasoned conclusion and correct judgment. Critical thinking consists of the following
competencies:
1. General critical thinking competencies. This process includes scientific method, problem-solving and
decision-making processes.
2. Specific critical thinking competencies. This includes those clinical situations such as diagnostic
reasoning, clinical inference, and clinical decision-making.
3. Specific critical thinking competencies are used in making nursing decisions. This includes the use of
the nursing process in stating nursing diagnosis and formulating treatment plan.

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 • It is a higher-level cognitive process that includes creativity, problem solving and decision making. It is
broader and involves considering a range of alternatives and selecting the best one for the situation.

• There are four suggested questions to consider when examining a problem or making a decision.
1. What do you know about the current issues?
2. How are evidences interpreted?
3. How are the arguments to be evaluated?
4. What are possible alternatives ? and why?
5. What is the best alternative?

• Critical thinking skills are used throughout the nursing process. Learning to be a critical thinker requires
commitment but the skills can be learned over time.

CHARACTERISTICS OF AN EXPERT CRITICAL THINKER

Expert critical thinkers have distinct characteristics (Ignatavicius, 2001). They often find time to regroup and focus
their thinking for a change. The following are characteristics of the thinker. They are:
• Outcome-directed or goal-oriented;
• Open to new ideas or out-of-the-box thinker; Flexible and adaptable;
• Willing to change and accepts challenges;
• Innovative in ideas which result in new direction; Creative and conduct researches for new interventions;
• Analytical and reflective thinker;
• Communicator and expressive of ideas and concerns; Assertive, can influence people of her thoughts and
ideas; Persistent with barriers and persevering;
• Caring, warm and friendly;
• Energetic and has the capacity to act consistent with norms; Risk-taker, trying all possible outcomes;
• Knowledgeable, rational and reasonable; and
• Intuitive or have clinical insights.
• These characteristics can be honed and developed over time. y can be cultivated as long as one believes it
is possible.

DECISION MAKING

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 • Nurses make decisions of varying importance every day, so the idea that decision making can be a rather
sophisticated art may at first seem strange. However, studies have shown that most people are much poorer
at decision making than they think. An understanding of what decision making involves, together with a
few effective techniques, will help produce better decisions at work.

DECISION MAKING DEFINED

• Decision-making is the process of identifying and choosing a particular course of action from among several
possible choices. This process is influenced by the values and preferences of the decision maker.
• The making of a decision reduces doubt. The decision is based on information gathered by the decision-
maker.
• Decision-making is an end-point of critical thinking which leads to problem solution using these steps:
o Define the problem;
o Assess all options;
o Weigh all options against a set of criteria or standards;
o Test possible options;
o Consider consequences of the decision; and
o Make a final decision.
• When making a clinical decision, the nursing process is used for the nurse to determine actions that will
help move the client toward achievement of the expected outcome. Nurse managers exercise cirical
judgment viewed within the context of the management process involving client care, manpower resources,
and hospital resources.

KINDS OF DECISIONS
There are several basic kinds of decisions.
1. Whether Decisions Whether decisions refer to the decision made before the selection of one of several
alternatives, where. selection is made after weighing the pros and cons. For example, before figuring out the
alternatives of what car to buy, the decision has to be made whether or not to buy a car.
2. Which Decisions - This is the process of choosing from among several alternatives, which are measured based
on a set of pre- defined criteria.
3. Contingent Decisions These are decisions that have been made but put on hold until some conditions are met
like time, energy, price, availability, opportunity and encouragement. For example, I have decided to buy that
car if I can get it for the right price; I have decided to write that article if I can work the necessary time for it to
fit into my schedule.

DECISION MAKING MODELS

• Decision making is the hardest task a manager has to face. Depending on the situation, the manager must
know when the decision will result in a win-win, win-lose, disagreement and collaboration or solution-
shaping outcome.
o Win-Win. It is characterized by a mutual willingness in the group to come up with solutions that
are acceptable to all. This is based in part on everyone's preferred solution to combine the self
interests and purposes of the people in the group, and to negotiate solutions that are acceptable to
all.
o Win-Lose. In this model, some interests are advanced at the expense of others.
o Disagreement and Collaboration. Decisions resulting in the following elements are made when
conflicts and disagreements are openly explored, using collaboration and cooperation:
▪ High quality decisions
▪ Creative decisions
▪ Decisions that are understood.
▪ Decisions that are accepted and owned
o Solution Shaping. This method is focused on how to modify or amend an unpopular proposed
solution rather than attempt to pressure people into changing their minds about the solution.

TOOLS IN DECISION MAKING

• Decisions are made based on different factors such as time, risk and performance possible. There is more
than one way to arrive at a decision. Consequently, different tools in decision-making have evolved to suit
various managerial preferences such as probability theory, decision trees, queuing theory and linear
programming.

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 1. Probability Theory - This theory was devised to address the presence of risk or uncertainty in a decision-making
situation by looking for predictable patterns based on historical data, thereby reducing the uncertainty. When
there is limited historical precedent, it becomes hard to apply the theory and the risk remains unchecked.
2. Decision Trees - A Decision Tree model, which is more graphic in sature, enables the planner to visualize
alternative courses of action taking into account all factors involved like risks, information needs and outcomes
for a problem over time. The graphic is essentially a tree-shaped diagram which starts with a primary decision
that branches out into increasing numbers of alternatives, each of which further branches out until all possible
alternative outcomes are laid out on the diagram. The Decision Tree gives the manager a forecast of the possible
results of his choices and enables him to make a cost-benefit analysis of each alternative. While most risks are
independent of other risks and easier to manage, certain risks are interconnected, and some risks only appear as
a result of actions taken from managing an existing risk, and this is why the Decision Tree model is useful. It is
actually a technique for determining overall risk associated with a series of related risks. Example: A project
requires a large equipment order for the hospital. There may be a 20% risk that the primary hardware supplier
may not be able to provide all the equipment needed for a large order in a timely manner. This could be Risk A.
As part of the risk response plan, the decision maker may choose to talk to a second vendor to see if they can
help fulfill the equipment order on short notice. They normally have the equipment in stock. However, the
decision maker learns there is a 25% possibility that there may be a disruption in their plant because of a potential
strike. This is Risk B. Clearly the two risks are related. Risk A is the primary project risk. Successfully managing
Risk A means there will be no reason to work with the second vendor and therefore Risk B will never enter into
the project. However, if Risk A comes true, then the risk plan will need to deal with a second risk, Risk B. The
worst case scenario is calculated by multiplying the individual risks. Since there is a 20% chance of Risk A, and
a 25%
3. Quening Theory - the Queuing Theory, problems are addressed one after her and after having determined the
best balance of factors ted to service. It is the mathematical study of waiting lines . Queuing Theory is a powerful
tool that helps hospitals and clinics to uncork chronic bottlenecks in the flow of patients in the emergency
department ER the out-patient department (OPD), Through queuing, nurses or clinic secretaries determine how
handle patients seeking health care by defining the way they will be served, the order in which they are served,
and the way in vitich resources are divided.
a. The three queuing disciplines are:
i. First in First Out (FIFO) - patients are served according to their order of arrival.
ii. Last in First Out (LIFO) - the last patient to arrive on the queue is the one who is actually
serviced first.
iii. Processor Bharing (PB) patients are serviced equally, Le. they experience the same amount of
delay.
4. Linear Programming - Finally, the Linear Programming method uses matrix algebra or linear mathematical
equations to determine the best way to use limited resources to achieve maximum results.

TEAM BUILDING
• A team is a group of people brought together for the purpose of sharing and applying their individual skills
towards the achievement of goals.
• Team Building is where the members of this team work together toward achieving goals faster and more
productively. It focuses on both the task and relationship aspect of group performance to maximize
efficiency and productivity.

CHARACTERISTICS OF AN EFFECTIVE TEAM

An effective team:
• Has defined goals, as basis to work with.
• Work cooperatively and collaboratively with other team members towards achieving these goals,
• Has agreed goals that reflect members' needs and values and
• Has a good definition of its members roles.

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 However, although the ARA of each team member is clearly defined, the team should be adaptable. Therefore, when
a team encounters difficulty in meeting expected responsibilities, there should be role flexibility and willingness of
the other members to help share. There are several task roles of the group members:
• Initiator-contributor. One who redefines problems and offers solutions, clarifies objectives, suggests agenda
items and maintains time limits.
• Information seeker. The one who collects the data for the group.
• Information giver. Provides information given by sharing experiences and making inferences.
• Opinion seeker. Clarify issues, viewpoints that defines or reflect the values of other members' suggestions.
• Opinion giver. Conveys to group members what their pertinent values should be.
• Elaborator. Predicts outcomes and provides illustrations or expands suggestions, clarifying how they could
work.
• Coordinator. Links ideas or suggestions offered by others.
• Orienteer. Summarizes the group's discussions and
• actions.
• Evaluator Critic. Appraises the quantity and quality of the group's accomplishments against set standards.
• Energizer. Motivates group to accomplish, qualitatively and quantitatively, the group's goals.
• Procedural technician. Supports group activity by arranging the environment and providing necessary tools.
• Recorder. Documents the group's actions and achievements.

Groups tend to become more cohesive when the team members:

• Are motivated by the same goals and tasks;
• Must interact to achieve their goals and tasks;
• Work in proximity to each other (or the same unit and on the same shift, for example); and
• Have specific needs that can be satisfied by involvement in the group.

CHAPTER 10: CONTROLLING

INTENDED LEARNING OUTCOMES: "Positive Attitude says

At the end of this chapter, the student should be able to - You can achieve success"
• Explain the value of controlling and its functions in the nursing service.
• Differentiate the kinds of control as it is applied in the nursing service.
• Discuss the control process and its implication to leadership and management.
• Explain the elements of controlling in various areas of leadership and management.
• Identify factors that influence change and change process.
• Apply the strategies for managing change.
• Utilize the principles of total quality management in any nursing care activity.
• Explain the meaning of standards of care as it affects performance of nurses.

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 The head or president of any organization is responsible for its overall direction. Since she cannot perform all these
functions, she has to delegate to her subordinates the responsibility and authority to perform certain tasks for which she
is still responsible. Thus, she has to use some systems of control to enable her to appraise the performance of each and
every one of her subordinates. Unsatisfactory performance may be corrected before it causes serious damage.
A good control system encourages each employee to exercise self-control or discipline. Self-control would be
possible when standards or criteria for performance exist to the point where an employee knows the specific level of
performance expected of her.

DEFINITIONS
Controlling is the use of formal authority to assure the achievement of goals and objectives. Here, performance
is measured and corrective action is taken to ensure the accomplishment of organizational goals. It also involves
assisting, regulating, monitoring. and evaluating individual and group performance.
Some people react strongly against the phrase "management control". The word itself can have a negative
connotation, e.g., it can sound dominating, coercive and heavy-handed. It is now preferred to intents and purposes,
coordinating is controlling. use the term "coordinating" rather than "controlling". But, for all
The control or coordinating function of management can be a critical determinant of organizational success.

FUNCTIONS OF CONTROL
Control serves both as a means and an end. It promotes effective use of resources, provides professional
reinforcements, and maintains activity and expectations.

PRINCIPLES OF CONTROLLING
There must be
1. A Critical Few, meaning that fewer people involved in control brings about the best results. The principles unity
of direction or unity of command is at play.
2. A defined Point of Control or a centralization or decentralization of authority. The level of ARA designated to
a nurse leader or manager in terms of problem solving and decision making.
3. Self-control or Discipline, which translates to personal acceptance of responsibility and accountability.

KINDS OF FORMAL CONTROL

The types of formal control that a manager can use may be grouped into:
1. Pre-action Control - This is controlling by means of personal supervision and utilizing control checks consisting
of policies and procedures for any given task or function.
2. Post-action Control - This is controlling as the task or function is being performed or may have been performed
and correcting deviations from standards or plans.

TYPES OF CONTROL
Controls are most effective when they are applied at key places. Supervisors can implement controls before the
process begins (feedforward), during the process (concurrent) or after it ceases (feedback).

1. Feedforward Controls - Feedforward controls focus on operations before they begin. Their goal is to prevent
anticipated problems. An example of feedforward control is preparing all supplies and equipment for a
scheduled wound dressing, or bedside lumbar tap; intravenous insertion, among others in order to determine
what is lacking and other things to be done Regular maintenance feeds forward to prevent problems. Othe
examples include safety systems, training programs, and budgets.
2. Concurrent Controls - Concurrent controls apply to processes as they are happening. Concurrent controls
enacted while work is being performed. This requires direct supervision or the use of automated systems such
as include any type of material or supplies for therapeutic care which computers programmed to inform the user
when they have issued the wrong command, and organizational quality programs and resources.
3. Feedback Controls - Feedback controls focus on the results of operations. They guide future planning, inputs,
and process designs. Examples of feedback controls include timely (weekly, monthly, quarterly, annual) reports
so that almost instantaneous adjustments can be made.

CHARACTERISTICS OF EFFECTIVE CONTROLS

1. Control systems must be designed appropriately to be effective.
2. When control standards are not flexible or unrealistic, employees cannot focus on the organization's goals.
3. Control systems must prevent, not cause, the problems they were designed to detect.

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 Performance variance can also be the result of an unrealistic standard. The natural response of employees whose
performance falls short is to blame the standard or the supervisor.
If the standard is appropriate, then it is up to the supervisor to stand his or her ground and take the necessary corrective
action.

DESIGNING EFFECTIVE CONTROL SYSTEMS

Anything that can be planned can be controlled. Controls should primarily serve the need for which they are
intended. Here are the guidelines for designing effective control systems.
1. Control at all levels in the health care delivery system. All nursing units must have a standard control system.
2. Acceptability of those who will enforce the decisions. The nurse manager's manner of influence on her staff to
comply with the policies or procedures.
3. Flexibility of the enforcers and the implementors to enforce decisions based on practical situations.
4. Accuracy. Steps or mechanisms of control must be clear and vivid with significant implications.
5. Timeliness. Activities are planned with time target set.
6. Cost effectiveness. Resources used are well maintained and enough or adequate to meet the needs of the unit.
7. Understandability. Policies and procedures are simple, easy to understand and can be implemented with less
difficulty.
8. Balance between Theory of Objectivity and Subjectivity, and practice-based system.
9. Coordinated with planning, organizing and leading.

THE CONTROL PROCESS

STEPS IN THE CONTROL PROCESS

Assuming that both plans or standards and organization structure are clearly known and that the personnel to
perform the task, work, or job know the extent of their authority and responsibility, the control technique and system
that may be used to evaluate performance would be essentially organization.
The control process is a continuous flow between measuring, comparing and action. There are four steps in the
control process; establishing performance objectives and standards, measuring actual performance, comparing measured
performance against established objectives and standards, and taking necessary corrective action.
1. Establish and Specify Criteria and Performance Standards - Control process serve as the criteria against
which performance is measured, and give an idea of the level of performance that managers can expect of a
person. This consists of the following.
a. Standards - Standards are created when objectives are set during the planning process. A standard is any
guideline established as basis for measurement. It is a precise, explicit statement of expected results for
a product, service, machine, individual, or organizational unit. It is usually expressed numerically and
is set for quality, quantity, and time. Tolerance is a permissible deviation from the standard.
b. Time Controls - Time controls relate to deadlines and time constraints. Material controls relate to
inventory and materials needed. Equipment controls are built into the machinery, imposed on the
operator to protect the equipment against failure or damage. Cost controls help ensure that cost
standards are met. Employee performance controls focus on actions and behaviors of individuals and
groups of employees. Examples include absences, tardiness, accidents, quality and quantity of work.
Budget control refer to cost or expense related standards. They identify the quantity of materials used
and production output.
c. Financial Controls - Financial controls facilitate achieving the organization's profit motive. One method
of financial control is budgeting. Budgets allocate resources to important activities and provide
supervisors with quantitative standards against which to compare resource consumption. They become
control tools by pointing out deviations between the standard and actual consumption.
d. Operations Control - Operations control methods assess how efficiently and effectively an
organization's transformation processes create goods and services. Methods of transformation controls
include Total Quality Management (TQM), statistical process control and the inventory management
control.
e. Statistical Process Control - Statistical process control is the use of statistical or mathematical methods
and procedures to determine whether production operations are being performed correctly, to detect any
deviations, and to find and eliminate their causes. A control chart displays the results of measurements
over time and provides a visual means of determining whether a specific process is staying within
predefined limits.

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 f. The Just-in-Time (JIT) System - The Just-in-Time System is the timely application of materials for use
in case nurses need it for patient care such as giving of medication for the illness of a patient.
Communication, coordination and cooperation are required from supervisors and employees to deliver
the smallest possible quantities at the latest possible date at all stages of the transformation process in
order to minimize inventory.

2. Monitor and Measure Performance of Nursing Care Services and Evaluate it against the Standards
through Records, Reports and Observations- There are different techniques for monitoring and measuring
service.
a. Nursing Rounds Nurses pay particular attention to issues of patient care and nursing practice. This will
also find out if the needs and problems of patients are met or unmet.
b. Quality Assurance monitors compliance of nursing personnel with established standards in terms of
nursing care given to patients.
c. Nursing Audit consists of documentation of the quality of nursing care in relation to the standards
established by the nursing department.

A Nursing Audit, in particular, serves many purposes.

• It prioritizes nursing care by promoting optimum nursing care.
• It can identify deficiencies in the organization and administration of nursing care, and may be used to correct
such deficiencies through continuing education and administrative change.
• It may also be used to increase performance to assure that improvements have been maintained.

Supervisors collect data to measure actual performance of the staff to determine variation from standard.
• Written data might include time cards, production tallies, inspection reports and sales tickets.
• Personal observation, statistical reports, oral reports and written reports can be used to measure performance.
• Management by walking around or observation of employees working, provides unfiltered information,
extensive coverage and the ability to read between the lines.
• While providing insight, this method might be misinterpreted by employees as mistrust. Oral reports allow for
fast and extensive feedback.

Computers give supervisors direct access real time, unaltered data and information. Online systems enable
supervisors to identify problems as they occur. Database programs allow supervisors to query, spend less time gathering
facts and be less dependent on other people. Supervisors have access to information at their fingertips. Employees can
supply progress reports through the use of office networks and electronic mail.
Statistical reports are easy to visualize and effective at demonstrating relationships. Written reports provide
comprehensive feedback that can be easily filed and referenced. Computers are important tools for measuring
performance. In fact, many operating processes depend on automatic or computer-driven control systems. Impersonal
measurements can count, time, and record employee performance.

3. Compare Performance with Standards, Models or Criteria to Determine Deviations or Differences in

Performance
Evaluation of the performance is necessary to ensure that tasks are being carried out as planned. Here the actual
accomplishment is matched with the acceptance standard to check if there are delays or deviations from the standard.
Comparing performance with standards. determines variation. Some variation can be expected in all activities
and the range of variation which is the acceptable variance, has to be established.
Management by exception let operations continue as long as that exceed this range would alert the supervisor
to a problem. they fall within the prescribed control limits. Deviations or differences
There are ways or techniques for such corrections and improvements of performance based on feedback.
a. The Program Evaluation and Review Technique (PERT) employs a matrix that uses network of activities
represented in a chart, including the goals or product desired, time management, budget and estimation
of critical paths.
b. Benchmarking seeks out the best so as to improve its performance. It provides a standard or point of
reference in measuring or judging such factors as quality, values and cost.

4. Enact Remedial Measures or Steps to Correct Deviations or Errors

a. Correction of deviations or errors. In the performance of any given' function or task, corrections may
be made by modifying the plan either by changing the number of personnel, or by better selection and

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 training of subordinates, or by changing the other factors of production or by adding more materials or
resources to minimize or eliminate errors or any deviations.
b. A Master Control Plan may be used by Managers depicting its functions, goals and objectives to be
accomplished and its specific activities to ensure quality of performance and products.
c. Take necessary action. The supervisor must find the cause of performance deviation from standard.
Then, he or she takes action to remove or minimize the cause. If the source of variation in work
performance is from a deficit in activity, then a supervisor can take immediate corrective action and get
performance back on track.

Also, the supervisors can opt to take basic corrective action, which would determine how and why performance
has deviated. and correct the source of the deviation. Immediate corrective action is more efficient, however basic
corrective action is more effective.
An example of the control process is a thermostat,
Standard: The room thermostat is set at 20 degrees Celsius.
Measurement: The temperature is measured.
Corrective Action: If the room is too cold, the heat comes on. If the room is too hot, the heat goes off.

Effective control Involves keeping the process continuous for all areas. This includes management of the nursing
division and each sub-unit, performance of personnel and the final Product: the Nursing Process.
The process that guarantees plans are being implemented properly is the controlling process. Controlling is the
final link in the functional chain of management activities and brings the functions of management cycle into full circle.
This allows for the performance standard within the group to be set and communicated.
Control allows for ease of delegating tasks to team members and as managers may be held accountable for the
performance of subordinates, they may be wise to extend timely feedback of employee accomplishments.

CHARACTERISTICS OF THE CONTROL PROCESS

1. The control process is cyclical which means it is never finished. Controlling leads to identification of new
problems that in turn need to be addressed through establishment of performance standards and measuring
performance among others.
2. Controlling often leads to management expecting employee behavior to change. Employees often view
controlling negatively, no matter how positive the changes may be for the organization.
3. Control is both anticipatory and retrospective. The process anticipates problems and takes preventive action.
With corrective action, the process also follows up on problems.
4. Ideally, each person in the health care delivery views control as his or her responsibility. The organizational
culture should prevent a person walking away from a small, easily solvable problem because "that isn't my
responsibility." In a service driven profession, each staff cares about each client.
5. Controlling builds on planning, organizing and leading. Controlling is related to each of the other functions of
management.

MANAGEMENT CONTROL STRATEGIES

Managers can use one or a combination of four (4) control strategies or styles, such as primarily on budgets and
rules. Bureaucratic control, Clan control and Self-control.
Each serves a different purpose. Market control is made up of external forces. Without external forces to bring
about needed control, managers can turn to internal bureaucratic or clan control. One relies on employees wanting to
satisfy their social needs through feeling a valued part of the business.
Self-control, sometimes called adhocracy control is complementary to market, bureaucratic and clan control.
By encouraging individuals to take initiative in addressing problems on their own, there can be a resulting sense of
individual empowerment, which plays out as self-control. Self-control then benefits the organization and increases the
sense of worth of the business, industry and the individual.

ELEMENTS OF CONTROLLING
I. PERFORMANCE APPRAISAL
• A performance appraisal is a method of acquiring and processing information needed to improve the individual's
performance and accomplishments.
• It consists of setting standards and objectives against determined standards, and objectives; reviewing progress;
having on-going feedback between the appraiser and the one who is being appraised planning for reinforcement,
deletion or correction of identified behavior as necessary.

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 • The purpose of the evaluation is to assess the appropriateness, adequacy, effectiveness and efficiency of services.
The methods used "may be anecdotal records, checklist, rating scale, ranking among others.

PERFORMANCE APPRAISAL TOOLS

Some of the tools used to-evaluate performance are trait rating scale, job dimension scales, Behaviorally
Anchored Rating Scale (BARS), checklist, peer review, and self-appraisal.
1. Trait Rating Scale - This is a method of rating a person against a set standard which may be the job description,
desired behavior and personal trait.
2. Job Dimension Scale - It focuses on job requirements and the quality work performance.
3. Behaviorally Anchored Rating Scale (BARS) - This focuses on desired behaviors to improve performance.
4. Checklist - It is composed of behavioral statements that represent desirable behavior.
5. Peer Review - It is a collegial evaluation of the performance done to promote excellence in practice and offer
information, support, guidance, criticism and direction to one another.
6. Self-Appraisal - This tool allows the employee to evaluate his own performance.

COMMON ERRORS IN APPRAISAL

It is not unusual to encounter errors during the appraisal. Some of these common errors are halo effect, logical
errors, central tendency errors, leniency errors, Hawthorne effect and Horn's effect."
1. Halo Effect - This has a tendency to overrate staff based on the rater's first impression of the ratee. The evaluation
is based on the good traits or good things one sees in a person.
2. Logical Error - It is often based on first impressions of the rater to the ratee. The first encounter may provide
the rater the qualities or specific traits which serves as bars to the quality of performance of the ratee.
3. Central Tendency Error - feedback tools are inadequate and when there's no sufficient. This rates the staff as
average.
4. Leniency Error - There is the propensity to overlook or observe the weaknesses and mistakes of the person being
evaluated leading to an inaccurate picture of the job performance.
5. Hawthorne Effect - The behavior of the ratee changes simply because he is above the rater. The ability of the
rater to closely observe the challenged by the knowledge he/she has of the ratee.
6. Horn's Effect - This occurs when rating an employee very low because error committed.

DYSFUNCTIONAL CONSEQUENCES OF CONTE

Managers expect people in an organization to char behavior in response to control. However, staff resistance can easily
make control dysfunctional. The following behaviors I demonstrate means by which the manager's control efforts can
be frustrating:
1. Game Playing -Control is something to be beaten, a game between the "boss and me and I want to win."
2. Resisting Control - A passive aggression or negative reaction to too much control will lose track on what is
supposed to be done. Resisting control may occur when there is poor relationship or lack of communication
between the manager and staff. Inability of the manager to lead wisely will also result to staff aggression.
3. Providing Inaccurate Information - A lack of understanding of why the information is needed and important
leading to "you want numbers, we will give you numbers."
4. Following Rules to the Letter - People following dumb and unprofitable rules in reaction to "de as I say. This
blatant command from the manager may instill negative reaction which may lead to lack of staff motivation to
act accordingly. This may even lead the staff to do things contrary to what is expected.
5. Sabotaging - Stealing, discrediting other workers, chasing customers away. gossiping about the firm to people
in the community.
6. Playing One Manager Off Against Another - Exploiting lack of communication among managers, asking a
second manager the staff does not like the answer from the first manager.

CHANGE PROCESS
Change means substituting one thing for another, experiencing a shift in circumstances that causes differences
or becoming different from before. Organizations can properly be viewed from this angle, as being in a continuous
process of change eg, changing methods and systems to improve the accomplishment of objectives, changing objectives
and retrenchment to adjust depleted resources to meet competitions and the fluctuations of environmental factors in the
health care delivery.

CHANGE PROCESS
Emotional Stages of Change

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 1. Equi- There is sense of balance and inner peace before change occur.
2. Denial change.
1. Energy is drained by the denial of the reality of
2. Anger-Energy is used to ward off the change.
3. Bargaining-Energy is used to eliminate the change. 5. Chaos-Energy is diffused with loss of identity and
direction. 6. Depression-No energy is left to produce results.
7. Resignation - Energy is expended to accept change passively.
8. Openness - Renewed energy is available.
9. Readiness - There is willingness to use energy to explore new events.
10. Reemergence - Energy is rechanneled producing empowerment.

FACTORS THAT INFLUENCE CHANGE

There are several forces, both external and internal, that influence change. External forces are events or 10
happenings that influence the organization as a whole or FINGE its top administration. Examples of this are population
staff. Below are steps in the change process that should be followed in changing the organization.

STEPS IN THE CHANGE PROCESS

1. The change process begins or is initiated when one perceives a need for change.
2. This person then initiates group interaction, which is to identify external and internal forces for change.
3. During this interaction, the beneficial activities are:
a. To state the problem;
b. Identify constraints;
c. List change strategies or possible approaches to problem-solving;
d. To select the best change strategy; and finally
e. Formulate as a group a plan for implementation and or develop or select tools for evaluation.
Wholesale change of a system is never a good idea. It is important to implement any radical change one step at
a time. After the implementation of the change it is important to evaluate the overall results of the change and make
such adjustments as may be necessary.

STRATEGIES FOR MANAGING CHANGE

1. Empirical-Rational - Empirical-rational strategies for change management are based on the assumption that
people are rational and behave according to rational self-interest. They assume that people are willing to adopt
to change if justified, and determined how he can benefit from the change process. The 'power ingredient' of the
strategy is knowledge.
2. Normative-Reductive - Normative-reductive strategies are based on the assumption that people are consistent
to their commitment to socio-cultural norms and values. For example: a group may foster development of staff
through personnel counseling, training groups, small groups and experiential learning because a person needs
to participate in her own reeducation process.
3. Power-Coercive - Power-coercive strategies involve the compliance of the less powerful with the leadership,
plans and direction of the more powerful. These strategies use sources of power to bring change, such as strikes,
sit-ins, negotiations, conflict, confrontation, administration decisions and rulings. The application of power is
done either by legitimate authority, economic sanction or political clout.

RESISTANCE TO CHANGE
Resistance to change is expected for a number of reasons, such as lack of trust, vested interest in the status quo,
fear of failure, loss of status or income, misunderstanding and belief that the change is not necessary. The manager may
then take steps to handle this resistance, such as the following:
1. Communicate with those who oppose the change and understand the reasons for the opposition
2. Clarify information and provide accurate feedback
3. Be open to revisions but form and dear about what mas remain
4. Present negative consequences of resistance.
5. Emphasize positive consequences of change and how the individual will benefit but avoid trying too hard to
convince the people with rational arguments as resistance is one based on feelings that are not rational
6. Keep those resisting change in face-to-face contact with supporters, encourage proponents to empathize with
their opponents, recognize valid objections and relieve unnecessary
7. Maintain a climate of trust, support and confidence.
8. Create a different disturbance to distract the attention of those involved.

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 Making change is not easy but it is a necessary skill for managers to create change in her subordinates and in her
place of work. Successful change agents demonstrate certain characteristics that can be cultivated and mastered,
including
1. The ability to combine ideas from unconnected sources.
2. The ability to energize others by keeping the interest of the staff to the highest level and demonstrating a high
personal energy level.
3. Skill human relations can be attained with:
a. Well-developed interpersonal communication.
b. Group management and problem-solving skill
c. Skills in integrative thinking.
d. The ability to retain a picture focus, while dealing with each part of the system considering all factors
in problem- solving and decision making.
4. Sufficient flexibility to modify ideas to improve the change process, but firm enough to resolve or resist
nonproductive tampering with the planned change.
5. Enhance confidence level and the tendency not to be easily discouraged.
6. Realistic or pragmatic thinking in order to learn how to cope and adapt to change.
7. Trustworthiness, a track record of Integrity and success with other changes.
8. The ability to articulate a vision through insights and versatile thinking.
9. The ability to handle resistance through influence and support of the concerned individuals and the factors
affecting change.

II TOTAL QUALITY MANAGEMENT

Total Quality Management (TQM) is a management approach for an organization, focused on quality, based on
the participation of all its members and aimed at long-term success through customer satisfaction and benefits to all
members of the organization and to society. TQM is aimed at embedding awareness of quality in all organizational
processes.
For the Japanese, the secret to success was the implementation of systematic quality efforts to meet or exceed
customer requirements and expectations the first time and every time.

The three basic principles of TQM are to:

1. Focus on achieving customer satisfaction;
2. Seek continuous and long-term improvement in all the organization's processes and outputs; and
3. Take steps to ensure the full involvement of the entire work force in improving quality.
TOM is composed of three paradigms:
1. Total: Involving the entire organization, the entire chain, and/or product or outcome life cycle.
2. Quality: With its usual characteristics, with all its complexities to meet total client satisfaction.
3. Management: The system of managing the organization with steps like Planning, Organizing, Controlling,
Leading, Staffing, Provisioning and the like.

In Japan, TQM comprises four process namely:

1. Kalsen - Focuses on "Continuous Process Improvement", to make processes visible, repeatable and measurable.
2. Atarimae Hinshitsu The idea that "things will work as they are supposed to" for example, a pen will write.
3. Kansel - Examining the way the user applies the product leads to improvement in the product itself,
4. Miryokuteki Hinshitsu The idea that "things should have an aesthetic quality" for example, a pen will write in
a way that in pleasing to the writer"."

In sum, under TQM, the term total quality is defined in terms of planning, organizing, directing and controlling and
all aspects of the management process.

III DEVELOPMENT OF STANDARDS

A standard is not an arbitrary measure of performance. It is a pre-determined level of excellence that serves as
a guide to practice. It is established by an authority communicated and accepted by the standard. In developing a
performance standard, it is mandatory that a criterion is established and specified.
Organizational standards outline the level of acceptable practice within the institution while nursing audit is a
measurement tool used to provide the yard stick for measuring quality care.

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TYPES OF STANDARDS
Standards are used to monitor and measure performance of nursing care services and evaluate it against the
standards through records, reports and observations.
The different types of standards are the following:
1. Structure Standards - Standards that focus on the structure or management system used by an agency to organize
and deliver nursing care, including the number and categories of nursing personnel who provide that care (e.g.
a team leader is responsible for no more than 20 patients, with no fewer than 3 team members to provide care).
2. Process Standards - Standards that refer to actual nursing care procedures or those activities engaged in by
nurses to administer care.
3. Outcomes Standards – These are standards that are designed for measuring the results of nursing care. Other
means of monitoring and measuring include Conflict Management, Budgeting and Disciplines.

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