Nursing Management

Process and Functions

BSN IV
 Management Process and Functions
The management process is universal. It is used in one’s personal
life as well as one’s professional life. One applies it to management of
oneself, a patient, a group of patients, or a group of workers.
Knowledge of this process assures nurses of smooth functioning of
their units in attaining their goal of quality care through the judicious
use of available human and material resources within a specified
time.

Management – is getting the right things done at the right time

Nursing Management – a relationship of inputs and outputs in which

the workers, physical resources and technology are emerged to bring
about the organizational goals for delivery of quality nursing care
 INPUT OUTPUT

HUMAN PHYSICAL AND

RESOURCES TECHNOLOGICAL Realization of
RESOURCES goals

Medical Building Delivery of

Nursing Grounds quality patient
Allied Health Supplies care
Patient / Client Equipment
Significant Others

Schematic Diagram of Nursing Management

 ORGANIZATION
ADMINISTRATION
Management Process – MANAGEMENT
consist of achieving
O D C
organizational R I O
objectives through G R N
planning, organizing, A E T
directing, and N C R
controlling human and I T O
Z I L
physical resources and I N L
technology N G I
G N
G

PLANNING
● While planning is the first function, one must recognize that it
permeates into other functions, which are dependent on it.

● Forecasting estimates the future, setting objectives, determine

the results to be achieved, developing and scheduling program,
define activities needed within a set time frame, preparing the
budget, allocates tools and resources while establishing policies
and procedure, define the course of action and standards.
 ● Organizing establishes formal authority. It sets up the organizational
structure by identifying groupings, roles and relationships within the agency.
This is depicted in an organizational chart.

● Job descriptions define the qualifications and scope of responsibilities,

relationships and authorities of personnel. Staffing would include
determining the number of staff needed thus developing and maintaining a
staffing pattern, recruiting, selecting, orienting and developing personnel to
accomplish the goals of the organization.

● The selected personnel are then distributed in the various areas of the
agency as needed and staffing schedule are made to meet the needs of
clients, personnel and agency.
 ● Directing or leading actuates efforts to accomplish goals. This
will include utilizing various modalities of nursing care through the
nursing process; updating policies and procedure, supervising
personnel to harmonize work through the nursing process,
supervising personnel to harmonize work through adequate guidance
and leadership, coordinating personnel and services to a common
goal, communicating via various routes to ensure common
understanding, developing people by providing staff development
programs and making sound decisions.

● Controlling assesses / regulates performance of workers to

ensure progress toward objectives, it utilizes standards in measuring
performance, monitoring and evaluating nursing care including
utilization of resources. Controls promptly reveal deviations from set
plans and standards necessitating immediate corrective measures,
actions and / or discipline.
 I. PLANNING
● is pre-determining a course of action in order to arrive at a desired
result
● is the process of establishing goals, defining and developing strategy
and tactic for action
● thinking ahead, determining what shall be done
● it directs one thinking of:
> WHAT is expected to do
> WHY it will be done
> WHERE it will be done
> HOW it will be done
> WHEN we expect to do it
> WHO is going to do it
● it is a continuous intellectual process of assessment, establishing goals
and objectives, implementation and evaluation subject to change as
new information is known. Knowing what should be done and
determining how to do it
Organizational planning – is a continuous process of assessing,
establishing goals and implementing and evaluating them to ensure
about the use of people, resources and environment to help achieve
agency’s goals for the present and the future
A. Importance of Planning
Nurse manager should know how to plan for the following reasons:

1. It leads to the achievement of goals and objectives

> Workers relate what they do to meaningful results since plans
are focused on objectives.
2. It gives meaning to work
> Employees or workers experience greater satisfaction if what
they are doing becomes meaningful to them.
3. It provides for effective use of available resources and facilities
> The best use of personnel and material resources avoid wastage.
4. It helps in coping with crisis
> Hospitals should provide for disaster plans. These allow the
workers to function more clearly and efficiently when actual crisis
occur such as fire, or emergencies caused by disaster, New Year or
fiestas where more people are likely to get hurt.
5. It is cost-effective
> Costs can be controlled through planning for efficient operation.
For example, projecting the number of operations in a given day
including daily dressing can forecast the needed supplies for a
week in the surgical units accurately so as to prevent undersupply
or oversupply of pilferages.
6. It discovers the need for change
> Many hospitals have found out that inpatient hospital days can
greatly be reduced by having laboratory and diagnostic work-up in
the outpatient department rather than have these examinations
on admission. Minor surgeries are also done at the outpatient
department so that more hospital beds can now be allotted to
critically ill patients or for those needing specialized services.
7. It is based on the past and future activities
> Evaluation of programs, schedules, and activities whether
successful or not, prevents and / or reduces the recurrence of
problem and provides better ideas in modifying or avoiding them.
8. It is necessary for effective control
Nurse managers evaluate the environment or setting in which they
work or where the patients are confined and make necessary
recommendations to make it more therapeutic not only for the
patients but also for the workers as well.
Performance of workers and evaluation of services to patients
based on criteria set during the planning stage would indicate
whether standards have been made and whether changes are
indicated.

B. Resistance to Planning
Planning is something that many managers avoid.
Failure of the manager to plan may be attributed to one or
more of the following factors:
1. Managers may lack knowledge of the philosophy, goals, and
objectives and workings of the organization
2. They may not understand the significance of planning process, that
the success or failure of the work activities relate directly to the
quality of the plan – how this plan is carefully and thoroughly done
or how it is poorly done
3. Time spent on planning often seems wasted in relation to the day-
to-day doings of one’s job
4. Some manager may lack confidence, fearing failure
5. Some managers prefer to act on immediate problems because they
generate immediate feedback
6. Planning may bring unwanted change

Knowing these factors will help nurse manager to overcome

them and utilize planning as basic key to the success of
their work.
C. Scope of Planning

Top Management or the Nursing Directors, Chief Nurses or

Director of Nursing and their assistants set the over-all goals and
policies of the organization. Their scope of responsibility is the over-
all management of the organization.
Middle Management of Nursing Supervisors direct the activities
that actually implement the broad operating policies such as staffing
and delivery of services to the units headed by the Senior or Head
Nurses. Formulation of policies, rules and regulations, methods and
procedures for personnel for immediate level planning for ongoing
activities and projects are done in coordination with the top
management and those in the lower level.
At the Lower or First Level Management, the Head Nurses or
Senior Nurses (including Charge Nurses or Team Leaders) do the daily
schedules, or weekly plans for the administration of direct patient
care in their respective units.
D. Major Aspects of Planning
Plans can be understood through four major aspects:
1. Plans should contribute to objectives
It should seek to achieve a consistent, coordinated structure of
operation focused on desired ends. Action without plans often
result to chaos.

2. Planning precedes all other process of management (organizing,

directing, controlling)
It supports easy accomplishment of the agency’s objectives,
which are necessary for group effort. Planning and control are as
inseparable as Siamese twin.
Example: Hospital must be built on planned budget control of
expenses and activities must be made, otherwise cost may swell
bigger than the appropriated budget and the hospital may not be
finished and its operations may not be started as targeted.
3. It pervades all levels
It pervades from higher to lower echelons and vice versa and
horizontally through peer levels and / or across services and
members of the health team.

4. It should be efficient
It should contribute to the attainment of objectives not only in
terms of pesos, man-hour, units of products but also include values
as individuals and group satisfaction. Fear, resentment and low
morale result in low production.
 E. Characteristics of a Good Plan
A well-developed plan should:
1. have clearly worded objectives, including results and methods for
evaluation,

2. be guided by policies and / or procedures affecting the planned action,

3. indicate priorities,

4. develop actions that are flexible and realistic in terms of available

personnel, equipment, facilities, and time

5. develop a logical sequence of activities, and

6. select the most practical methods for achieving each objective

F. Elements of Planning
F.1. Forecasting

Forecasting estimates the future, including the

environment in which the plan will operate. It includes who
the patients are – their customs, belief, language dialect
barriers, public attitude and behavior, the acuity of their
conditions / illness, the kind of care they will receive; the
number and kind of personnel (professional and non-
professional); and the resources, equipment, facilities, and
supplies needed.
F.2. Setting the Vision, Mission, Philosophy, Goals, and
Objectives
A vision statement outlines the organization’s future role and
function. It gives the agency something to strive for.
The mission statement outlines the purpose the agency is in
(whether hospital or health care), who the clients are (the poor,
the needy, the middle or upper class), what services are provided
(inpatient, outpatient, emergency) and why it exists.
A philosophy describes vision. It is a statement of beliefs and
values that directs one’s life or one’s practice. In an organization,
the philosophy is the sense of purpose of the organization and the
reason behind its structure and goal.
Hospitals, clinics, and health agencies thus have as their
primary reason for existence, the function of providing patient /
client care services. These may include diagnostic, therapeutic,
preventive, health promotion, personnel education and research
services. These services vary among agencies depending on the
clients served, the geographical location and the basic mission of
the agency.
 The philosophy of nursing service dovetails with the
philosophy of the agency. It is an intentionally chosen set of values
or purpose that serve as the bases for determining the means to
accomplish nursing objectives.

Nursing philosophy is broad and general in wording, yet

directs nursing behavior, giving it a sense of purpose. Generally
emphasized in the statement of the philosophy are the quality and
quantity and scope of service, decision making based on factual
information, appropriate delegation, achievement of organizational
goals, communication vertically and horizontally, flexibility to meet
changing needs of the organization, individuals, community and
society in general.

Organizations and people who set goals and objectives do

better than those who do not. When manager forms goals, they
put them on paper, and review them periodically. It forces him /
her into action to try to accomplish them. The more a person sets a
goal and specifies objectives for each of the result areas he likes to
achieve, the more likely he will reach these.
 Goals and objectives differ in that goals are more general and
cover broad area while objectives tend to be more specific.
Objectives are concrete. They are action commitments through
which its mission and purpose will be achieved and the philosophy
or belief sustained. They are stated in terms of results to be
achieved and should focus on the production of health care
services to the patient. Philosophy states beliefs and values while
objectives state specific and measurable goals to be accomplished.

F.3. Developing and Scheduling Programs

Programs are determined, developed, and targeted within a
frame to reach the goals and objectives set.

Time Management – is a technique for allocation of one’s time

through the setting of goals, assigning priorities, identifying and
eliminating time wastes and use of managerial techniques to reach
goals efficiently.
Time Management Principles
a. Planning anticipates the problems that will arise from actions
without thought. It anticipates the crisis that may occur of the
resources needed to solve the problems

b. Task to be accomplished should be done in sequence, which are

prioritized according to importance

c. Setting deadlines in one’s work and adhering to them is an excellent

exercise in self-discipline

d. Deferring, postponing, or putting off decisions, actions or activities

can be a habit which oftentimes cause lost opportunities and
productivity, generating personal or interpersonal crisis

e. Delegation permits a manager to take authority for decision-making

and to delegate tasks to the lowest level possible consistent with his
judgment, facts and experience. Delegation frees her some time
that can be devoted to other tasks
F.4. Preparing the Budget
Budget – is the annual operating plan, financial “road map” and a
financial plan which serves as an estimate of future costs and plan
for utilization of manpower, material and other resources to cover
capital projects in the operating programs.
– is a plan for future activities expressed in operational as well
as financial or monetary terms

In health care institution, budget consist of four components:

a. Revenue Budget – summarizes the income management expect to

generate during the planning period

b. Expense Budget – describes expected activity in operational and

financial terms for a given period of time
c. Capital Budget – outlines the programmed acquisitions,
disposals, and improvements in the institution’s physical capacity
d. Cash Budget – represents the planned cash receipts and
disbursement as well as the cash balances expected during the
planning period

Nursing Budget – is a plan for allocation of

resources based on preconceived needs, for a
proposed series of programs to deliver patient
care during one fiscal year

Hospital Budget – is a financial plan to meet

the future service expectations. These
expectations are derived from the best judgment
of the need of the community. Budgeting
translates these needs of manpower, equipment
and supplies so that both services are provided
with the highest level of quality with the minimum
amount of cost
The Budgetary Process
To assure an orderly and timely development of the
budget, the budget committee must be well defined.
This committee can assist the budget officer in budget
preparation and in monitoring the budget. The Chief
Nurse or her assistant is usually a member of the Budget
Committee. Within the nursing service, the Chief Nurse
works with supervisors and Head Nurses in the
preparation for the nursing service.
The following factors should be considered:
assurance of standards according to the philosophy and
objectives of the hospital and the division of nursing,
past experiences in the unit, anticipated needs of the
unit, and percentage of the unit occupancy.
 The estimation of staff for each unit should be based
on the number of patients, the number of nursing care
hours needed, the provision of vacation, sick and other
leaves, holidays and the average number of absences per
staff member per year and other privileges as attendance
to continuing education programs. These give a visible
method of interpreting nursing care needs to the budget
committee and to the hospital administration.

The next step is to ascertain the amount and kind of

supplies needed for the operation of each nursing unit. A
review of past expenses and consumptions provide data
for planning. Capital equipment to be replaced is
requested with documented justification.
The Chief Nurse compiles and completes the final draft and
presents this to the Budget Officer or Hospital Administrator. A
carefully planned budget presentation will usually reflect favorable
action from the administration.
F.5. Establishing Nursing Standard, Policies, and
Procedures
a. Nursing Standards
The function of these established standard in an evaluation
process is to supply professionally desirable norms against which
the department’s performance can be measured. Areas for
improvement are identified, and a plan of action to correct this be
made and implemented.
b. Nursing Service Policies
Policies are broad guidelines for the managerial decision that
are necessary in organizational and departmental planning. They
govern the action of worker and supervisors at all levels and are
intended to achieve predetermined goals. They serve as basis for
future actions and decisions, help to coordinate plans, control
performance and increase consistency of action by increasing the
probability that different managers will make similar decisions
when independently facing similar situations.
 There are three general areas in nursing that require policy
formulation:
i. areas in which confusion about the focus of responsibility might
result in neglect or malperformance of an act necessary to a patient’s
welfare
ii. areas pertaining to the protection of patients’ and families’ rights
e.g. right to privacy, property rights
iii. areas involving personnel management and welfare
c. Nursing Procedures
Procedures are specific directions for implementing written
policies. Two areas where procedures are needed are:
i. those that are related to job situations such as reporting complaints
or disciplinary instances
ii. those that involves patient care – procedure that involve patient
care should consider the safety of the patient, his comfort while
undergoing it, and the proper care, use of supplies and equipment
and good workmanship on the part of the person doing it
 Nursing procedure manuals should be available in each unit to
be familiarized in the nursing unit. It should be reviewed, updated
and revised with the maximum involvement from the unit nursing
staff.
G. Planning Process
1. Analysis and assessment of system
Five basic considerations in an analysis
of the system as a whole:
1.1. objectives, performance measures
1.2. environment, fixed constraints
1.3. resources
1.4. activities, goals and performance of its subsystem
1.5. operation (process or action, strategies of work)
2. Formulation of organizational and individual goal
It helps identify the ends toward which the administrator
would like the system to move during a specific period of
time.
This stage requires that a schedule of achieving these
goals be established.
3. Assessment of present organizational potentialities and
capabilities
Realistic goals and objectives can’t be established without
knowing the current capabilities of the organization and
specifically those of his own department.
True planning takes into account all the limitation as well as
the resources of the situations and factors such as shortage of
equipment and personnel or lack of adequate funds.

4. Formulating alternative courses of action

This stage considers specifying means by which organizational
goals and objectives are to be achieved.

5. Setting of priorities on the basis of effectiveness and evaluation

In this stage the consequences of the various plans are
projected. This phase is largely concerned with the establishment
of priorities.
6. Implementation
This phase is concerned with resources allocation
commitment. This is the action and direction stage.
7. Evaluation control and surveillance
Evaluation or provision of measuring the outcome of service
against the objectives should be built into every plan.
Format of Planning
Background
Objectives
Activities
Time Frame / Target Time
Resources
Personnel
Materials
Fixed Assets
Budget
Possible Problem
Contingency Plan
II. ORGANIZING
Organizing is the second managerial function. Having
planned, the manager must now organize so that personnel can
accomplish the plans with efficiency and effectiveness. Organizing
involves establishing a formal structure that provides the
coordination of resources to accomplish objectives, establish
policies and procedures, and determine position qualifications
and descriptions.

Organization – comprises structure and process, which allows the

agency to enact its philosophy and utilize its conceptual
framework to achieve its goals
– refers to a body of people, method, policies and procedures
arranged in a systematic process through delegation of functions
and responsibilities for the accomplishment of purpose
Organizing – it is a process of establishing formal authority. It
involves setting up the organizational structure through
identification of groupings, roles and relationships, determining
the staff needed through developing and maintaining staffing
patterns and distributing them in the various areas as needed,
and developing job descriptions by defining the qualifications and
functions of personnel

Organizational Structure – refers to the process or the way a group

is formed including its channels of authority, span of control, and
lines of communication

Organizational Chart – it is a line drawing that shows how the parts

of an organization are linked. It depicts the formal organizational
relationships, areas of responsibility, people to whom one is
accountable, and channels of communication
 A pattern of nursing care is that system used for the delivery
of nursing care to patients / clients. Patterns of care vary from
hospital to hospital and this depends on the organizational
structure adopted by the agency to meet its prescribed needs.
The method selected for assignment of nursing staff to patients /
clients directly relates to staffing pattern adopted by the health
agency. Assignments can be stable only when there is a strong
support system of qualified nursing personnel to carry forth the
plan. In nursing services, nursing assignments may be called by
various terms as modalities of nursing care, systems of nursing
care, or patterns of nursing care. Historically, four basic methods
are used:
1. Case Method – means that one nurse performs all services for
the patient.
Advantages of the Case Method:
a. The nurse has close contact with the patient
b. Able to provide complete nursing care over a longer period of
time
c. Gives greater opportunity to directly assess patient’s progress,
since the plan of nursing care is complied and carried out from
day-to-day by one nurse

Disadvantages of the Case Method:

a. Not administratively or economically feasible
b. Not possible when highly skilled functions are necessary
c. The nurse may know only a few types of cases
d. Tendency to disregard patient as a person with unique identity
 Instructor Charge Nurse Charge Nurse

Student Registered Nurse

Patients / Clients Patients / Clients PL / CL PL / CL

Lines of authority in a typical hospital with case nursing

2. Functional Method of care relieves the professional
nurse of daily task to several patients but does not give all
the nursing care to any one patient. Nursing assistants may
carry out measures relating to personal hygiene,
observations of vital signs, moving patients, and
administering treatments
Advantages of the Functional Method:
a. Nurse develops expertise or very efficient in one phase of
nursing like administration of medication
b. Economy in time and equipment
c. Confusion is avoided
d. Very good method in case of shortage of personnel
e. Nurses can change from one assignment to another
without loss of efficiency
f. Necessary during mealtime, PM shift and night
g. There is a smooth division of labor
Disadvantages of the Functional Method:
a. Patient care is fragmented often incoordinated
b. Patient does not know his particular nurse
c. Creates sense of boredom for patients and nurses
d. Patient feels as belonging to no one
e. Nurse doesn’t bother about rationale of the procedure they do
f. Nurses are not concerned with patients not assigned to them
Charge Nurse

Patients /
RN RN NA
Clerical Clients
Medication Treatment Hygienic
Housekeeping Family,
Nurse Nurse Care
Visitors

Patients / Clients

Lines of authority in a typical hospital with functional nursing

3. Team Method of care is patient centered even if several people
give care. The professional nurse directs the care and may give
some of it. The directions of care make the professional nurse the
leader of the nursing team. The nurse makes decisions and must
be able to understand and communicate with others effectively
and be able to help the team work out the organized plan. The
other team members may be other professional nurses, nursing
assistants, or student nurses. Every team member should have
some knowledge of the patient’s condition, including problems
and suggestions
Advantages of the Team Method:
a. Sense of satisfaction on the part of the nurse
b. Close relationship among the members
c. Better utilization of personnel
d. Greater amount of supervision is provided
e. Care provided is comprehensive
 Disadvantages of the Team Method:
a. Conference schedule never ends
b. Inconsistencies in team work
c. Not all are qualified to become team leader
d. Large amount of time is wasted
e. Team leader overpowers the head nurse
Team Concept
a. There is interchange of ideas
b. Joint problem solving
c. Centered on continuity comprehension
Charge Nurse

Team Leader Team Leader Team Leader

Nursing Staff Nursing Staff Nursing Staff

Patients / Clients Patients / Clients Patients / Clients

Lines of authority in a typical hospital with team nursing
4. Primary Nursing is a way of delivering nursing care by a
registered nurse with the concept of one patient relationship. The
24-hour responsibility of evaluating patient care is placed on the
registered nurse. Its emphasis is on the professional clinical
practice in that nurse performs the essential role of practitioner,
teacher, and manager of the patient’s care and services in the
hospital and other health care setting. It includes the following
characteristics:
a. Professional nurses are identified as primary nurses who assess
the patient’s need for care, sets care goals, writes a nursing care
plan, administers care according to that plan, evaluates the
outcomes of care and makes the necessary changes or
adjustments as necessary. He / she provides pre-discharge
planning and teaching
b. Assigned with a relatively small case load (4-8 patients)
c. Nursing process is used
d. Focus is on the one-to-one relationship of “my patient my
nurse from admission to discharge
e. Care is based on patient’s needs and patient’s problems
f. Primary nurse is accountable for assigned patients 24 hours a
day, 7 days a week
g. Emphasis is on professional clinical practice rather than
performance of routine and tasks
Since the primary nurse assumes a 24-hour responsibility for
nursing care, secondary or associate nurses executes the nursing
care plan during the afternoon and night shifts and during the
days when the primary nurse is off-duty.

The primary and secondary nurses are freed from

administrative and housekeeping responsibilities to maximize
their time for patient care. Authority, accountability, and
autonomy rest with primary nurse. Therefore, he / she
communicates directly to any member of the health team within
the hospital and the community.
 The head nurse’s role in this kind of assignment shifts from
taskmaster, decision maker and coordinator of patient care to role
model, consultant and quality control expert for the primary
nurse in the unit. He / she encourages clinical decision making
and ensures needed support in fulfilling patient care
management coordination function.
Advantages of the Primary Nursing:
a. Provision or increased autonomy on the part of the nurse
thereby increasing motivation, responsibility, and accountability
b. It assures continuity of care
c. Makes available increased knowledge of patient’s psychological
and physical needs
d. Leads to increased rapport and trust between the nurse and
the patient, thereby establishing therapeutic relationship
e. It improves communication with members of the health team
and eliminates the use of nursing aides in the provision of direct
nursing care
 Hospital
Physician Charge Nurse
Resources

Primary Nurse

Patient / Client

Associate Nurse Associate Nurse Associate Nurse(s)

Evenings Nights as needed
Days

Lines of authority in a typical hospital with primary care

nursing
Elements of Organizing
The elements of organizing are: setting-up the organizational
structure, staffing, scheduling, and developing job description.

A. Setting-up the Organizational Structure

The creation of an organizational system compatible with the
philosophy, conceptual framework, and goals of the organization
provides the means for accomplishment of purpose.
Understanding of the organizational structure as a whole
facilitates the development of roles and relationships enabling
goal achievement. Departmentalization and division of work
provide orderliness in administration. Through a breakdown of
activities, each individual is responsible for and performs a
specified set of activities.
Purposes of Organizational Structure
1. It enables members what their responsibilities are so that they
may carry them out
2. It frees the manager and the individual workers to concentrate on
their respective roles and responsibility
3. It coordinates all organizational activities so there is minimal
duplication of effort or conflict
4. It reduces the chances of doubt and confusion concerning
assignment

Two Types of Organizational Structure

1. Informal Organizational Structure
▪ comprises personal and social relationship that do not appear
on the organizational chart
▪ informal structure provides social control of behavior which
can either be internal or external
  Internal Control – if pressure is intended to make a
member conform to group expectation (ex. dirty shoes)
 External Control – an attempt to control the behavior of
someone outside the social group
 it has its own channel of communication, which may
disseminate information mere broadly and rapidly than the
formal communication system. The best way to correct an
invalid rumor is for the manager to provide accurate
information
 informal organization structure is important to management,
thus the manager must be aware of its existence, study its
operating techniques, prevent antagonism, and use it to meet
the agency’s objectives
2. Formal Organizational Structure
 it is the official arrangement of positions or working
relationship that will coordinate efforts of workers of diverse
interests and abilities
 it describes positions, tasks, responsibilities, and relationships
 it provides orderliness in administrations thru establishment
of formal organizational pattern by departmentalization and
division of work
 bases of formal organization structure: philosophy and
objectives of the nursing department and goal of the
institution
Activities to Promote a Positive Organizational Climate
1. Develop the organization’s mission, goals, and objectives with
input from the nurses, including their personal goals
2. Establish trust and openness through communication that include
prompt and frequent feedback and stimulates motivation
3. Provide opportunities for growth and development, including
career development and CEP
4. Analyze the compensation system for the entire nursing
organization and structure to reward competence, longevity, and
productivity
5. Promote self-esteem, autonomy, and self-fulfillment, including
feelings that help work experience high quality
6. Assess unneeded threats and punishments and eliminate them
7. Provide job security with an environment that enables free
expression of ideas and exchange of opinion without threat of
recrimination, which may occur as negative performance reports,
negative counseling, confrontation, conflict, or job loss
8. Encourage and support loyalty, friendliness, and civic
consciousness
9. Help nurses to overcome their shortcomings and develop their
strengths
10. Be a role model of performance desired of practicing nurses
Organizational Change
▪ change means substituting one thing for another,
experiencing a shift in circumstances that cause
differences or becoming different then before
Forces That Influence Change
a. External Forces – are those happenings (outside the
organization) that influence the organization as a whole
or the top administrators
Ex 1. population explosion – additional maternity ward
Ex 2. legislation that restricts patient from admission –
primary nursing’s use of observation room
Ex 3. economic forces – training and education
contribute to the cost containment and improvement of
quality care
Ex 4. a breakthrough in research – this can alter care
given to certain patient
b. Internal Forces – are those that originate primarily from inside
operations or are the result of external forces
Ex 1. composition of staffing pattern
decrease number of RN and increase number of NA
Ex 2. productivity need
1:4 ~ 1:6 N ~ P ratio
Ex 3. quality of working life may need to be improved, such as:
▪ sufficient number of qualified nurses
▪ staff development program
▪ time spent by nursing personnel with non-nursing duties
▪ instability and inflexibility of staff
▪ absenteeism among staff
Resistance to Change Factors:
1. If the person to be influenced by a proposed change are not given
adequate information regarding the nature of the change
2. When one feels pressured to make a change and will be
decreased when one has a “say” in the nature and direction of
the change
3. If change is made on personal grounds rather than on impersonal
requirements
4. If the change ignores existing alliances within the group
5. If there is relative satisfaction with the existing system
Change Process: A Planned Procedure
The process of change is change with a purpose devised to
solve problem affecting nurses and their work. It deals with
making alterations by choice and deliberation, rather than by
indoctrination, coercion, natural growth or accident.
1. Perceive a need for change – sensing an unrest among staff that
there is a need for change
2. Initiate group interaction – technique employed is through an
informal discussion group, committee or task force group and
general meeting to explore a situation
2.1. Identify external and internal forces from change
2.2. State the problem – this is the critical step in the change
process. External and internal forces are examined. Statement of
the problem is formulated
2.3. Identify constraints – constraints are something that restrict
limits or regulate a person and activities
2.4. List change strategies or possible approaches to solve the
problem. Allow sufficient time for dialogue to occur. Promote a
free, open receptive climate. Make no comments about
responses. Continue the discussion until all possible solutions are
exhausted
 2.5. Select the best change strategy or strategies – the leader
should be someone other than the HN. In this situation, because
he / she is the focal point of the problem. Care must be taken not
to invite people who are not skilled in the art of facilitating.
Approaches to solving the problem are the priority and analysis is
made with regards to the course of action taken
2.6. Formulate plan for implementation – if priority number is
selected, plan on the strategy. Select representative of the group
who are to meet with the HN
2.7. Develop or select tools for evaluation
3. Implement the change one step at a time, if possible. The HN
must meet with her staff periodically to hear their reaction
4. Evaluate the overall results of the change and make adjustments
as necessary; retain, alter, or delete parts or discontinue the
process
Strategies for Affecting Change
Whether working with the individual, group, or the system,
the HN is sure to be involved with management of change. The
following are strategies in managing change:
1. Empirical – Rational Change
▪ based on the assumption that people are rational and behave
according to rational self interest
▪ it follows then that people are willing to adopt a change if it is
justified and if the person is shown how he / she can benefit
from the change
Ex. system analysis
operation research
implementation of research findings
2. Normative – Re-educative Change
▪ are based on the assumption that people act accordingly to
their commitment to socio-cultural norms. Intelligence and
rational are not denied but also attitude and values are
considered
▪ the manager pay attention to changes in values, attitudes,
skills, and relationships in addition to providing information
Ex. personnel counseling
training groups or small groups
3. Power – Coercive Change
▪ involves compliance of the less powerful to the leadership,
plans, and directions of the more powerful
▪ Intelligence, rationality nor values and attitudes are not denied
but they acknowledge the need to use sources of power to
bring about change
Ex. strikes, sit-in, administration decisions and rulings
negotiations
conflict confrontation
Organizing Principle
In designing the organizational structure of the nursing
department / service / division, organizational principles must
be observed:
1. Unity of Command – although employees may interact with
many different employees in the performance of their duties,
they should be responsible to only one superior. This is to avoid
confusion, overlapping of duties, and misunderstanding
2. Scalar Principle – authority and responsibility should flow in clear
unbroken lines from the highest executive to the lowest. Proper
definition and delegation of authority and responsibility facilitates
the accomplishment of work. In this connection, the following
must be observed:
a. When responsibility for a particular job is delegated to a
subordinate, the latter should have authority over resources
needed to accomplish the task
b. When a particular function is delegated to a subordinate, the
superior’s own responsibility is in no way diminished
c. When a person is bestowed the authority for action, he is
accountable for his actions to the person that bestowed him such.
The conscientious nurse exhibits accountability toward her
employing hospital, the patient, the government, her profession,
and to God
3. Homogenous Assessment or Departmentation – workers
performing similar assignments are grouped together for a
common purpose. Departmentation specializes activities,
simplifies the administrator’s work and maintains effective
control.
4. Span of Control – the number of workers that a supervisor can
effectively manage should be limited, depending upon the pace
and pattern of the working area. If the workers are highly skilled,
are working near each other, the number of workers may be
increased. At the top level of the structure, a 1:6 ratio of the
supervisor-workers is common, while at the base of the
organization a 1:10 ratio is common
5. Exception Principle – recurring decisions should be handled in a
routine manner by lower-level managers whereas problems
involving unusual matters should be referred to higher levels. This
will enable subordinates to learn how to make decisions at their
own level
Organizational Culture
☻is the sum total of an organization’s beliefs, norms,
values, philosophies, traditions, and sacred cows. It
is a social system that is a subsystem of the total
organization. It has artifacts, perspectives, values,
assumptions, symbols, language, and behaviors
that have been effective.
☻ it includes communication networks, both formal
and informal. They include a status / role structure
that relates to characteristics of employees and
customers or clients. Such structures also relates to
management style, whether authoritarian or
participatory. In a health care setting, these
structures promote either individually or
teamwork. They relate to classes of people and
could be identified through demographic surveys of
both employees and patients
 The basic mission of the organization is part of its culture:
employment, service, learning, and research. There is a technical
or operational system for getting the work done. Also, there is an
administrative system of wages and salaries of hiring, firing, and
promoting of report making and quality control of fringe benefits
and of budgeting.

The artifacts of an organizational culture may be physical,

behavioral (rituals), or verbal (language, stories, myths). Verbal
artifacts result from shared values and beliefs. They include
traditions, heroes, and the party line, and result in ceremonies
that embody rituals. They include ceremonies to reward years of
service, annual picnic, the Christmas Party, and the wearing of
badges and insignia.
 Perspectives are shared ideas and actions. They relate to
decision-making methods. For example, social, technical, and
managerial systems or subsystems will either support innovation
or demand conformity.

Dress, personal appearance, social decorum, and the physical

environment are all part of the organizational culture. They will
require strict compliance through written or implied rules.

Values are the general principles, ideals, standards, and sins

of the organization. Basic assumptions are the core of the culture.
They include the beliefs groups have about themselves, others,
and the world.
Culture and the Manager
When output or productivity decreases in amount or kind,
managers look at the social, technical, and managerial systems
that are part of the organization culture. They know that the
people behave in accordance with their understanding of the
organization’s norms and values. If they want to be successful,
they identify these norms and values and apply their efforts in
conformity with them.
The successful managers identify and accept the prevailing
culture before making changes. It is more difficult to change a
culture at the level of basic beliefs, values, and perspectives. It is
easier to change technical and administrative systems.
Organizational Climate
☻ is the emotional state shared by members of the system. It can
be formal, relaxed, defensive, cautious, accepting, trusting, and so
on. It is employees’ subjective impression or perception of their
organization. The employees of the major concern to the nurse
managers are the practicing nurses. Practicing nurses create, or at
the very least contribute to the creation of, the climate perceived
by patients. The work climate set by the nurse managers
determines the behavior of the practicing nurses in setting the
work climate.

Practicing nurses want a climate that will give them job

satisfaction. They achieve job satisfaction when they are
challenged and their achievements recognized and appreciated
by managers and patients. They achieve satisfaction from climate
of collegiality with the managers and other health care providers
in which they participate in decision-making.
Types of Formal Organizational Structure Classified by Nature of
Authority
1. Line Organization
☻ oldest, simplest, and most direct type in which each position
has general authority over lower positions in the hierarchy in
the accomplishment of the main goals of the agency
☻ connects positions and tasks of each level with those above
or below it
☻ it is the backbone of the hierarchy, staff, and functional
organization merely supplement the line
☻ the line positions are related to direct achievement of
organizational objectives. The manager has the right to give
the order, demand, accountability, and discipline violators
2. Staff Organization
☻ is purely advisory to the line structure with no authority to
place recommendations into action
☻ provides advisory functions to line supervisors and executives,
offers suggestion to aid and not to criticize
☻ they handle details, locate required data and other counsel on
managerial problems
☻ they function through influence for they do not have authority
to accept, use, modify, or reject plans
☻ they make the line more effective, but organization can
function without staff authority, staff assistant, and
administrative assistant
3. Functional Organization
☻ permits a specialist to aid line positions within a limited and
clearly defined scope of authority
☻ it decreases the line manager’s problem because it permits
orders to flow directly to lower levels without attention to
routine technical problems by the line positions
Major Forms of Organizational Structure:
1. Centralized
♥ control emanates from top down
♥ most common in hospital
♥ emphasis is concentrated on traditional nursing
Functional arrangement is by such activities as:
> transportation
> food
> budget control
> personnel
> various specialties in Nursing Service MSP
Advantages:
a. It can be highly cost-effective
> The special services are grouped together which
eliminates duplication of effort
b. It makes management easier
> Managers have to be experts in only a
concentrated range of skills
 Disadvantages:
a. As the organization becomes large and more complex, the
hierarchal arrangement can prove cumbersome

b. The arrangement does not readily adapt to change

> Because such decisions have to be made by the higher
managers

2. Decentralized or Participatory Structure

> this is a system whereby the large structure is broken down
into smaller units, and authority is delegated to those closer
to the majority of workers
> the top management still retains ultimate responsibility for the
operations of the various hospital departments but planning
and implementation for each department is carried out by the
department head who functions autonomously with authority
to administer that department 24 hours a day
Advantages:
As middle managers, the department head can:
a. Reflect their interest and have a voice in decision making
b. Improve quality of care through 24 hours continuity
c. Increase communication departmentally and interdepartmentally
d. Problem solved with greater imagination and creativity
Disadvantages:
a. The initial cost in developing managers and staff training (turn over
rate under decentralization has been found to be low)
b. Communication breakdown – the most serious problem that can
occur. Effective communication cannot occur with the face exchange
of information among all the concerned parties
c. Problems with the role clarification can also occur. Question of who
has the authority of the authority of the system is not yet well
established
3. Matrix System
> the benefits of centralized and decentralized control are used.
It provides for both hierarchal coordination in a separate
department as well as lateral coordination across department
> it contains three unique sets of relationships
a. Unit or department manager who heads and balance the
dual line of authority
b. The matrix manager who shares workers e.g. project
manager in charge of cost control
c. The staff who reports to these 2 different managers
Advantages:
a. The management can apply specialized skills to solve a
problem
b. Interdisciplinary cooperation is encouraged
Disadvantage:
a. All members must possess good interpersonal skills to receive
orders from two different bosses
Organizational Chart
Most nursing organizations have made graphic
representative of the organizing process in the form of
organization chart. These charts usually show reporting
relationships and communication channels. Line charts show
supervisor and supervisee relationships from top to bottom of
the nursing organization. These are hierarchical relationship on
which communication channels follow the line of authority to
and through the chief nurse executive. Organizational charts
are sometimes referred to as schemas.

Two Forms of Schemas or Organizational Charts

1. Flat
2. Pyramidal
Differentiation Flat Pyramidal
1. Number of levels Fewer More

2. Span of control Broad Narrower

3. Delegation Greater Lesser

4. Authority Decentralized Centralized

5. Accountability Greater Lesser

6. Control Less control of More control of

subordinates subordinates
7. Communication Easier Harder
Five Major Characteristics of Organizational Charts
1. Division of Work – each box represents an individual or sub-unit
responsible for a given task of the organization’s workload
2. Chain of Command – lines indicate who reports to whom and by
what authority
3. Type of Work to Be Performed – this is indicated by labels or
description for the boxes
4. Grouping of Work Segment – this is shown by the clusters of work
groups (department or single units)
5. Levels of Management – these indicate individual and entire
management hierarchy. Hierarchy refers to a body of people or
thing organized or classified in pyramidal fashion according to
rank, capacity or authority assigned to vertical levels with offices
ranked in grades or classes, one above the other
B. Staffing
It is the process of determining and providing the acceptable
number and mix of nursing personnel to produce a desired level
of care to meet the patients’ demand of care.
The purpose of all staffing activities is to provide each
nursing unit with appropriate and acceptable number of each
category of workers to perform the nursing tasks required. Too
few or an improper mixture of nursing personnel will adversely
affect the quality and quantity of work performed.

Factors Affecting Staffing

1. Type, philosophy, and objectives of the hospital and nursing
service
2. Population served – kind of patients served whether charity or
pay
3. Number of patients and acuity of their illness – knowledge and
ability of the nursing personnel are matched to the actual care
needs of patients
4. Availability and characteristics of the nursing staff – education,
level of preparation, mix of personnel, number, and position
5. Administrative policies such as rotation, weekend, and holiday off-
duties
6. Standard of care desired – should be available and clearly spelled
out. Institutions may utilize the ANSAP’s Standard of Nursing
Practice
7. Lay-out of the various nursing units and resources available
within the department – adequate equipment, supplies, and
materials should be provided
8. Budget – amount allotted for salaries, fringe benefits, supplies,
materials, and equipment
9. Professional activities and priorities in non-patient activities –
involvement in professional organizations, formal educational
development, participation in research and staff development
10. Teaching program – extent of staff involvement to teaching
activities
11. Expected hours of work per annum of each employee – this is
influenced by the 40 hours a week law
12. Pattern of work schedule – traditional 5 days a week, 8 hours
per day; 4 days a week, 10 hours per day and three days off; or 3
½ days of 12 hours per day and 3 ½ days off per week
Patient Care Classification System
The patient care classification system is a method of grouping
patients according to amount and complexity of their nursing care
requirement, of nursing time and skill they require. This
assessment can serve in determining the amount of nursing care
required, generally within 24 hours, as well as the category of the
nursing personnel who should provide the care.
To develop a workable patient classification system, the
nurse manager must determine the following:
1. The number of categories into which the patients should be
divided
2. The characteristic of patients in each category
3. The type and number of care procedures that will be needed by a
typical patient in each category
4. The time needed to perform procedures that will be needed by
the typical patient in each category
Classification Categories
The various units may develop their own way of classifying
patient care according to the acuity of their patient’s illness.
Categories or level of care of patient, nursing care hours needed
per patient per day, and ratio of professional to non-
professional

Level of Care NCH needed Ratio of prof.

/ pt / day to non-prof.
Level I: self care or minimal 1.5 55:45
care
Level II: moderate or 3 60:40
intermediate
Level III: total or intensive care 4.5 65:35
Level IV. highly specialized 6 70:30
or critical care 7 or higher 80:20
Percentage of Nursing Care Hours
The percentage of nursing care hours at each level of care
also depends on the setting in which the care is being given.
Percentage of Patients at Various Levels of Care Per Type of
Hospital

Type of Hospital Minimal Moderate Intensive Highly Sp.

Care Care Care Care
Primary Hospital 70 25 5 -

Secondary 65 30 5 -
Hospital
Tertiary Hospital 30 45 15 10

Special Tertiary 10 25 45 20
Hospital
Computing for the Number of Nursing Personnel

When computing for the number of nursing personnel in the

various nursing units of the hospitals, one should ensure that there
should be sufficient staff to cover all shifts, off-duties, holidays,
leave, absences, and time for staff development programs.

The Forty-Hour Week law, Republic Act 5901, provides that

employees working in hospitals with 100-bed capacity and up will
work only 40 hours a week. This also applies to employees working
in agencies with at least one million population. These employees
working in agencies located in communities with less than one
million will work forty-eight hours a week and therefore will get
only one off-duty a week.
 Total Number of Working and Non-working Days and Hours of
Nursing Personnel Per Year
Rights and Privileges Given Each Working Hrs / Week
Personnel / Year 40 Hrs 48 Hrs

1. Vacation Leave 15 15
2. Sick Leave 15 15
3. Legal Holidays 10 10
4. Special Holidays 2 2
5. Special Privileges 3 3
6. Continuing Education Program for 3 3
Professionals
7. Off-duties as per RA 5901 104 52
Total Non-working Days / Year 152 100
Total Working Days / Year 213 265
Relievers Needed
To compute for relievers needed, the following should be
considered:
a. Average number of leaves taken each year……………15
a.1. Vacation Leave……………………………..10
a.2. Sick leave…………………………………….5
b. Holidays…………………………………………………….12
c. Continuing Education……………………………………....3
d. Special Privileges as per CSC MC #6 series 1996……..3
Total Average Leave 33 days

It will be noted therefore that although an employee is

entitled to 15 days sick leave and 15 days vacation leave, 12
holidays, 3 days for continuing education, plus 3 days of special
privileges or 48 days total, he / she gets only an average of 33
days leave per year.
 To determine the relievers needed, divide 33 (the average
number of days an employee is absent per year) by the number
of working days per year each employee serves (whether 213 or
265). This will be 0.15 per person who works 40 hours per week
and 0.12 per person for those working 48 hours per week.
Multiply the computed reliever per person by the computed
number of nursing personnel. This will give the total number of
relievers needed.

Distribution by Shifts
Studies have shown that the morning or day shift needs the
most number of nursing personnel (45% ~ 51%), for the afternoon
shifts (34% ~ 37%), and for the night shifts (15% ~ 18%). In the
Philippines, the distribution usually followed is 45% for the
morning shift, 37% for the afternoon shift, and 18% for the night
shift.
Staffing Formula
To compute for the staff needed in the inpatient units of the
hospital, the following steps are considered:
1. Categorize the number of patients according to the level of care
needed
a. Multiply the total number of patients by the percent of patients
at each level of care (whether minimal, intermediate, intensive,
or highly specialized)
2. Find the total number of nursing care hours needed by the
patients at each categorized level
a. Number of patients at each level by the average number of
nursing care hours needed per day
b. Get the sum of the nursing care hours needed at the various
level
3. Find the actual number of nursing care hours needed by these
given number of patients
a. Multiply the total number of nursing care hours needed per
day by the total number of days in a year
4. Find the actual number of working hours rendered by each
nursing personnel per year
a. Multiply the number of hours on duty per day by the actual
working days per year
5. Find the total number of nursing personnel needed
a. Divide the total number of nursing care needed per year by the
actual number of working hours rendered by an employee per
year
b. Find the number of relievers – multiply the number of nursing
personnel needed by 0.15 (for those working 40 hours per week)
or by 0.12 (for those working 48 hours per week)
c. Add the number of relievers to the number of nursing
personnel needed
6. Categorize into professionals and non-professionals
a. Multiply the number of nursing personnel according to the
number of professionals to non-professionals
7. Distribute by shifts
 To illustrate: Find the number of nursing personnel needed for a
100-bed capacity tertiary hospital

1. Categorize the patients according to level of care needed

100 patients x 0.30 = 30 patients needing minimal care

100 patients x 0.45 = 45 patients needing moderate /
intermediate
care
100 patients x 0.15 = 15 patients needing intensive care
100 patients x 0.10 = 10 patients needing highly
specialized
care
2. Find the number of nursing care hours needed (NCH) by the
patient at each level of care

30 patients x 1.5 (minimal care) = 45 NCH needed / day

45 patients x 3.0 (moderate care) = 135 NCH needed / day
15 patients x 4.5 (intensive care) = 68 NCH needed / day
10 patients x 6.0 (highly sp. care) = 60 NCH needed / day
5. Find the total number of nursing personnel needed
a. 112,420 NCH / year = 66 nursing personnel
1,704 working hrs / yr
b. 66 x 0.15 = 10 relievers
c. 66 + 10 = 76 total nursing personnel needed

6. Categorize to professional and non-professional personnel. Since

this is a tertiary hospital, the ratio of professional to non-
professional is 65:35

76 x 0.65 = 49 professional nurses

76 x 0.35 = 27 nursing attendants (non-professional
nurses)
7. Distribute by shifts

49 nurses x 0.45 = 22 professional nurses on morning

shift
49 nurses x 0.37 = 18 professional nurses on PM shift
49 nurses x 0.18 = 9 professional nurses on night shift

27 nursing attendants x 0.45 = 12 nursing attendants on

morning shift
27 nursing attendants x 0.37 = 10 nursing attendants on
PM shift
27 nursing attendants x 0.18 = 5 nursing attendants on
night shift
 It should be noted that the above personnel are only for
Inpatient. Therefore, additional personnel shall be hired for those
supervisory and administrative positions and those in special
units such as Operating Rooms, the Delivery Rooms, Emergency
Rooms, and Outpatient Departments. Although roomed-in babies
in the mother’s unit are not included in the patient census, they
are given service such as bathing, changing of diaper, and the like.
Additional staff should be provided for the babies.
Hospitals now are also centers of wellness. Therefore,
additional personnel shall be needed for health education classes
both the inpatient and outpatient units.
C. Scheduling
♥ is a timetable showing planned work days and shifts
for nursing personnel
The objective in scheduling is to assign working
days and days-off to the nursing personnel so that
adequate patient care is assured, a desirable
distribution of off-duties is achieved, the individual
members of the nursing are treated fairly and that
they know in advance what their schedules are.
Factors Considered in Making Schedules
1. Different levels of the nursing staff – an adequate
mix of nurses and nursing attendant should be
observed so that they only assume duties they are
legally responsible for, according to their position,
education, training, and experience
2. Adequate coverage for 24 hours, seven days a week – afternoon
and night shift’s requirements for staff are usually lower than in
the morning shift. Also, Saturdays and Sundays tend to have lower
requirements since there are lesser medical rounds, fewer
medical orders, and lower patient census
3. Staggered vacations and holidays – since everybody can enjoy
the holiday off on exactly the same day that they occur, schedules
for holidays are staggered at least once a month. Vacation is
likewise staggered to ensure adequate coverage at all times.
Weekends are scheduled in such a way that everyone gets a fair
share of at least one weekend off a month
4. Long stretches of consecutive working days – this should be
avoided as much as possible because it might affect the health of
the nursing personnel. Afternoon and night shifts are more
difficult than the day shifts. The nursing personnel should get
their fair share of these shifts including the “relief” duty for the
three shift periods
5. Evening and night shifts and floating – there are some problems
that occur in the schedules. Busy units may require additional
help. Unscheduled absences may occur and suddenly a staff may
be pulled out from her regular area of assignment to cover for
another unit. The nurse may feel insecure in the area where she is
asked to help or relieve. Disruption in the unity of work groups
may occur and this may cause job dissatisfaction and high
turnover rates. This is especially true if the nurse does not have
the necessary skill and knowledge that the unit may require

In order to minimize problems as a result of emergency

assignment, cross-training and / or orientation to complementary
units is advised. During orientation to the Nursing Service, new
nurses are told of the possibility that they may be asked to relieve
in areas of the hospital other than their regular assignments.
Emphasis however is given to the fact that cross-training enhance
their skills and capabilities aside from meeting the needs of the
service.
Assessing Scheduling System
While scheduling may vary from agency to agency, the
scheduling system must function smoothly in terms of:
1. Ability to cover the needs of the unit. A minimum required
number of staff to meet the nursing needs of the patients on the
units at all shifts
2. Quality to enhance the nursing personnel’s knowledge, training,
and experience. While being permanently assigned to one unit
enhances skills in caring for a particular kind of patient (whether
obstetrical, medical, surgical, or pediatrics) many nurses who
have future plans of going into teaching or specialization or even
working abroad, would prefer to experience being assigned to
various units first before settling down to a particular unit of their
choice
3. Fairness to the staff. All nursing personnel should get a fair share
of weekends, holiday offs, rotation patterns for the whole year
including assignment to “difficult” or “light” or “undesirable”
units or shifts
4. Stability. The nursing personnel should like to know in advance
their schedule of assignment so that their personal schedules
(whether home, social, and civic responsibilities) are in harmony
with each other
5. Flexibility. Flexibility means the ability to handle changes brought
about by emergency leaves, scheduled or unscheduled leaves of
absence
Types of Scheduling
There are several types of scheduling which are:
1. Centralized Schedules – one person, usually the Chief Nurse or
her designate, assigns the nursing personnel to the various units
of the hospital. This includes the shifts of duty and off-duties
2. Decentralized Schedules – one person, usually the Chief Nurse or
her designate, assigns the nursing personnel to the various
nursing units. The shift and off-duties are arranged by the
Supervising Nurse or Head or Senior Nurse of the particular units
3. Cyclical Schedules – the cyclical schedule covers designated
number of weeks called the cycle length and is repeated thereon.
It assigns the required number of nursing personnel to each
nursing unit consistent with the unit’s patient care requirements,
the staff preference, their education, training, and experience
The following scheduling variables should be considered:
a. Length of scheduling period whether 2 to 4 weeks
b. Shift rotation
c. Weekends off
d. Holidays off
e. Vacation leaves
f. Special days (birthdays, wedding anniversary, etc.)
g. Scheduled events in the hospital (training programs, meetings,
etc.)
h. Job categories
i. Continuing Professional Education (CPE) programs
Advantages of Cyclical Schedule:
1. It is fair to all. Favoritism is minimized as all nursing personnel gets
their fair share of rotation to the various shifts
2. It saves time as the schedule does not have to be redone every
week or two
3. It enables the employees to plan ahead of their personal needs
preventing frequent changes in schedule
4. Schedule leave coverage such as vacation, holidays, and sick
leaves are more stable
5. Productivity is improved
D. Developing Job Description
A job description is a statement that sets the duties and
responsibilities of a specific job. It includes the needed
characteristics or qualifications of the individual to perform such
duties successfully. It is an important management tool to make
certain that responsibilities are wisely delegated, work efficiently
distributed, talents fully used, and morale maintained.
Contents of Job Description:
1. Identifying Data:
Position Title: Staff Nurse
Department: Nursing
Supervisor’s Title: Head / Senior Nurse
2. Job Summary: This will include the essential feature of the job that
distinguishes it from the others
3. Qualification Requirements: Education preparation, training, and
experience necessary to fill the position
4. Job Relationships – source of workers
5. Specific and Actual Functions and Activities

Uses of Job Description:

1. For recruitment and selection of qualified personnel
2. To orient new employees to their job
3. For job placement, transfer, or dismissal
4. As an aid in evaluating the performance of an employee.
Objective evaluation benefits both the employer and employee
5. For budgetary purposes. Salaries are equated with the level of
responsibilities and skills defined in the job description and thus
become the basis for improvement and / or further action
6. For determining department functions and relationships to help
define the organizational structure. One of the organizing
principles is grouping employees performing similar function to
avoid duplication or overlapping of functions and improves
workflow
7. For classifying levels of nursing functions according to skill levels
required. This enables nursing administrators to determine
whether a realignment of responsibilities is indicated
8. To identify training needs
9. As basis for staffing
10. To serve as channel of communication
III. DIRECTING
After the manager has planned, organized, and staffed, he /
she must direct personnel and activities to accomplish the goals
of the organization. Knowledge of one’s leadership style,
managerial philosophy, sources of power and authority, and
political strategies are important. To get the work done by others,
the manager must deal with conflict and motivate and discipline
staff: all of these tasks require good communication skill and
assertive behavior.

Direction – it is the issuing of assignments, orders, and instructions,

that permits the worker to know what is expected of him / her,
and the guidance and overseeing of the worker so that he / she
can contribute effectively to the attainment of organizational
objectives
– it actuates efforts to accomplish goals
Purposes of Directing:
1. To achieve objectives in the manner it was planned and organized
2. To accomplish assignment given by the management
3. To regulate the activities
4. To contribute effectively and efficiently to the attainment of the
organization
Elements of Directing:
A. Delegation
● is the process by which a manager assigns specific tasks / duties to
workers with commensurate authority to perform
the job
● is a means of allocating and decentralizing authority, imposing
responsibility and accountability and assigning tasks down
to the lowestpossible level at which there is sufficient competence
and information for effective decision making on task performance
A.1. Basic Concept of Delegation
Responsibility – obligation to do what is asked
Authority – the right to decide and command
Accountability – responsible / answerable for one’s actions
A.2. Steps to Better Delegation:
1. Think before you delegate
Part of planning to delegate is determining what to accomplish
and how well you expect each person to do. You must decide
specifically what you can and cannot delegate.
Matters that cannot be delegated:
a. Overall responsibility, authority, and accountability for
satisfactory completion of all activities in the unit. Nurse
management cannot be absolved with poor performance of
subordinates by blaming them
b. Authority to sign one’s name is never delegated – the worker
that performed the task should be the one to sign it
c. Evaluating the staff and / or taking necessary corrective or
disciplinary action
d. Responsibility of maintaining morale or the opportunity to say
a few words of encouragement of the staff especially the new
ones. Showing confidence in the workers boost their morale and
build up their self confidence
e. Too technical jobs and those that involved trust and confidence
2. Plan and organize until activities are in logical order
Decide what is most important and therefore what must be done
first. Then arrange the rest of the work in order of importance
and available time.
3. Determine why you are delegating certain action activities to
a particular person
Perhaps the individual needs to acquire knowledge and skills or
has asked for certain assignments.
Reasons why managers fail or refuse to delegate:
a. Lack of confidence in their staff
b. They feel that they can do the task better and faster
c. They are too busy and enough time is needed to teach
d. They resent necessary interruption to explain
e. They fear of losing control if some of their duties are delegated
4. Be specific when you delegate
Let people know exactly what they are responsible for very often,
information should be out in writing, use feedback to ensure each
person understand what is to be done.
> Direction must be complete, understandable
> Speak distinctly and slowly
> Avoid giving too many direction at one time
> The wordings of direction indicates its importance
 5. Be willing to accept the risks and accountability for the
actions of others
Individuals are obligated to carry out the delegated tasks and are
accountable for their own performance, she is accountable to her
supervisors not only for her own actions but also the final result
of all the services rendered by individual staff members.
6. Keep informed after you delegate
Get periodic reports, but also examine results of the work, both in
the progress and upon completion. When something is wrong,
discuss it with the person and if the work is done well, you must
give recommendation.

B. Supervision
> is a process of getting the work done through others which is
done properly, on time, and within the budget
Supervision is…
What When Who How Why
Planning Skillfully
Directing Safety
Guiding Correctly
Teaching Patiently so that every Competently
Observing Continuously Every Tactfully worker can According to
Encouraging worker Fairly do his / her his / her
Correcting work and capability
Commenting give any care & limitation
Evaluating of work

The purposes of supervision are to inspect, to guide, evaluate,

and improve work performance of employees through a criteria
against which the quality of work production and utilization of time
and resources are made.
Nurse manager provides guidance and direction to workers to
achieve the goals and objectives of the institution and that of the
nursing unit.
 The atmosphere created by the supervision as he / she
makes his / her rounds or talks to the staff will determine to a
large extent the acceptability of the comments, criticism and / or
corrections he / she makes.
Given a soft, courteous manner, these will be taken willingly
and be accepted as a challenge to improve performance. Given a
harshly, especially in public, builds up resentment, ill-will, and
poor quality of work.
Emphasis of supervision is getting the work done according
to definite policies and procedures.
Types of Supervision:
1. Autocratic Supervision
> supervisor plans all the work
> makes all the decision
> issues commands to workers who are to obey without question
> regards individual as machine and not as human being
> more on direction and inspection
2. Democratic Supervision
> emphasis is instead of getting the work done, is now placed on
helping the individual to do the work better
> there is a greater degree of freedom wherein workers are given
a voice in setting up work goals and planning method for
reaching them
> teaching and helping people develop new skills and greater
understanding of their job
Supervisor’s challenge – is to create a climate in which
spontaneous teamwork is possible and harmonize the goals of
the individual with those of the group
Importance of Supervision:
1. It is concerned with people as well as the work area,
working condition, and work itself
> supervision must try to provide as much as possible
suitable working condition not only physical surroundings
but also good atmosphere in which the staff works
(environment where people work should give them a feeling
of freedom and the desire to do the best they can)
2. It is also concerned with the planning, execution, and evaluation
of work
> the staff should also have the part in this planning and help to
perform and evaluate their own work

3. Orientation, training, and guidance of individual according to their

needs are directed toward utilization of their capabilities and the
development of new skills

Supervisor should be acquainted with every individual and

must be able to stimulate each individual the desire for self
improvement. If the person recognizes his / her needs for
improvement, the leader must supply the necessary help and
instruction at the same time guide the worker in acquisition of
acceptable attitude and interests and good working habits.
C. Coordination
Coordination unites personal and services to a
common objective. Synchronization of activities
with the various services and departments
enhances collaborative efforts resulting in
efficient, smooth, and harmonious work
flow. Coordination also prevents overlapping
of functions, enhances good working relationships and work
schedules are finished on time.
At the unit level, supervising nurse coordinate their work
with other departments, services or units utilizing clearly defined
policies, standard operating procedures, and guidelines through
proper channel of communication.
Types of Coordination:
1. Intradepartmental – coordination is usually within the
department
2. Interdepartmental – coordination between one department to
another
2.1. Coordination with Medical Services
All nurses should know the medical staff in their respective
units, their services, and scheduled time of medical rounds. On
the other hand, nurse should know the patients in
the unit, their diagnosis, actual conditions, medical plan or care,
and treatments so that they can participate
intelligently in planning the care of each individual patient.
Too often, nurses just become “implementers of care”. They
do not actively involve themselves in planning the care of
patients. They must remember that in carrying out written
prescriptions of medications and treatments, they must exercise
reasonable judgment and care to avoid errors or
misinterpretations.
2.2. Coordination with Administrative Service
> pertains to resources both human and material. At the unit
level, nurses participate in budgeting planning for
staffing, adequate facilities, and material resources
> repairs and maintenance of equipments are made in
appropriate forms
Use of logbook – date and equipment should pass thru
the administration services
> overstocking of supplies should be avoided to prevent
wastage

2.3. Coordination with the Laboratory Service

Request for laboratory examinations should be
given specific instruction relevant to the
examination to be done such as fasting blood sugar.
Laboratory results are properly filled with
latest exam on top for easy references.
2.4. Coordination with the Radiology
Service
Request for x-ray examination are
likewise forwarded to x-ray services for
proper scheduling and specific instruction
if needed.

2.5. Coordination with Pharmacy

Service
Policies regarding procurement
of drugs are formulated jointly by the
administrative, medical and nursing
services with the pharmacy.
There are some hospitals that clinical pharmacist in
their units are manned by clinical pharmacist. They prepare
medicines prescribed by the physician and these are
administered by the nurse in the unit.
2.6. Coordination with the Dietary Services
The head nurse is responsible for forwarding the diet list of
the patients in the unit, taking into consideration
prescribed, special diets, patients’ idiosyncrasies for food
allergies, food preferences, and religious
restrictions.

2.7. Coordination with the Medical Social Service

>Nurse’s coordination with the medical social services
through referral of patient with psycho-
social-economic problems
 h. Coordination with Medical Records Services
Nurses are responsible for accurate documentation and
completeness of patient’s chart including their safety and
confidentiality.
3. Extra-installation
Coordination is from hospital to another agency. Patients are
often referred to the health center nearest their residence upon
discharge from the hospital for follow up.
D. Communication
Is the process whereby a message is passed from sender to
receiver with the hope that the information exchange will be
understood as the sender intended.
Elements of Communication
1. Sender
2. Message
3. Receiver

 If one of these three elements is missing, no communication can

take place
Channels of Communication
Communication channels used by the manager may be:
 Upward – the manager is a subordinate to a higher management .
Needs and wants are communicated upward to the next level in
the hierarchy
 Downward – the manager relays information to subordinates.
This is a traditional form of communication in organizations and
helps coordinate activities in various levels of the hierarchy
 Horizontal – managers interact with others on the same
hierarchical level as themselves who are managing different
segments of the organization
 Diagonal – the manager interacts with personnel and managers of
other departments and groups, such as physicians, who are not
on the same level of the organizational hierarchy. Although these
people have no formal authority over the manager, this
communication is vital to the organization’s functioning. Diagonal
communication tends to be less formal than other types of
communication.
 Grapevine – the most informal communication network.
Communication flows haphazardly between people at all
hierarchical levels and usually involves three or four people at a
time. Grapevine communication is subject to error and distortion
because of the speed at which it passes and because the sender
has little formal accountability for the message

Interpersonal Communication in a Multicultural Workplace

Because it is impossible for the individual manager to

communicate face to face with each member in a large
organization, managers must develop other interpersonal
communication skills. These skills include nonverbal
communication, verbal communication, and listening skills.
 The following is a partial list of nonverbal clues that can
occur with or without verbal communication:
 Space
 Environment
 Appearance
 Eye Contact
 Posture
 Gestures
 Facial Expression
 Timing
 Vocal Clues such as tone, volume, and inflection

Verbal Communication Skills

Highly developed verbal communication skills are
critical for the leader / manager. One of the most important
verbal communication skills is the art of assertive
communication. Assertive behavior is a way of
communicating that allows people to express themselves in
direct, honest, and appropriate ways that do not infringe on
another person’s rights.
Rights and Responsibilities of the Assertive Person
Rights Responsibilities
To speak up To listen
To take To give
To have problems To find solutions
To be comforted To comfort others
To work To do your best
To make mistakes To correct your mistakes
To laugh To make others happy
To have friends To be a friend
To criticize To praise
To have your efforts rewarded To reward others’ efforts
To be independent To be dependable
To cry To dry tears
To be loved To love others
IV. CONTROLLING
> is an ongoing function of management occurring during planning,
organizing, and directing activities
> it is assessing / regulating performance in accordance with the
plans that have been adopted, the instructions issued, and the
principles established
> is the process by which managers assures that the actual
expenditures and activities conform to plan

The controlling process plays an important role in identifying

opportunities for improvement, comparing performance against
set standard, providing information about how well processes and
people are doing so that they can be motivated to perform better
in the future.
Reasons for Conducting Evaluation
There are some reasons why evaluation is needed and why it
plays an important role in quality and productivity improvement

1. Ensure quality nursing care is provided

2. Set sensible objectives and comply with them
3. Provides standards for establishing comparisons
4. Provides visibility and a means for employees to monitor their
own performance
5. Highlights quality problems and determine the areas that require
priority attention
6. Gives an indication of the costs of poor quality
7. Justifies the use of resources
8. Provides feedback for improvements
Evaluation Principles
In order the employees are evaluated accurately and fairly,
certain principles must be observed.
1. The evaluation must be based on the behaviorally oriented
performance standard of the position occupied
> the employee is presented as objectives to strive for and
achieve, therefore performance must be based on these
2. In evaluating performance, adequate samples and representative
samples of the employee’s behavior should be observed
> usual and consisted behavior should be evaluated instead of an
isolated or a typical behavior
3. A copy of the job description, performance standards and
evaluation form are given to the employee before the scheduled
evaluation conference for review so that discussion by the rater
and the rate will be from the same frame of reference
4. Documentation of an employee’s performance appraisal should
include both satisfactory and those needing improvement with
specific behavioral instances to clarify these evaluative comments
5. Prioritize areas needing improvement as the worker attempts to
upgrade his / her performance
6. Schedule and conduct the evaluation conference at a time
convenient for both the rater and the ratee, in pleasant
surrounding with ample time for discussion of the evaluation
7. The evaluation report and conference should be structured that it
can be perceived and accepted as a means of improving job
performance

Characteristics of an Evaluative Tool

1. It should be objective
> Objectivity means that the evaluation tool is free from bias
2. It should be reliable
> reliability refers to the accuracy or precision of the tool that if
administered twice, it will produce the same results
3. It should be valid
> validity refers to the relevancy of the measurement to the
performance of the employee
4. It should be sensitive
> sensitivity means the ability of the measured fine line
differences among the criteria being measured
Basic Components of Control Process
The control process may be divided into the following basic
components:
1st. Establishing Standards for Measuring Performance
> standards are desirable sets of conditions and performance
essential in ensuring the quality of nursing care services which are
acceptable to those instrumental responsibilities in setting /
maintaining them
3 Types of Standards
1. Structure – refers to the basic support components of nursing
– are those that focus on the structure or management system
used by the agency to deliver care which includes the number
and categories of nursing personnel, their education, personal
and professional qualities and proficiencies, their functions and
physical facilities and equipment
2. Process Standards – refers to the desired effects as specified
clinical manifestations, mobility levels, patient knowledge or self
care skills
– refers to decisions and actions of the nurse relative to the
nursing process which are necessary to provide good nursing
care. These include assessment, plan of care, and nursing
intervention
 3. Outcome Standards
– are designed to measure the results of care provided in terms
of changes in the health status of clients served; changes in the
level of their knowledge, skills and attitudes; and satisfaction of
those served including the members of the nursing / health team
2nd. Establishing Objectives and Methods for Measuring Performance
> measurable criteria and objectives specific to giving nursing care
must be developed to evaluate process and outcome
> establishment of objectives provides clear direction and
communication of expected level of achievement
> there should be full commitment in the form of a performance
contract
> the greater the participation of the employee, the greater the
motivation achieved agreed upon performance objectives;
therefore should be participatively developed, be challenging but
attainable, be clear of statements or performance expectation
and lie within the individual’s scope of control
Most Commonly Used Methods for Measuring Nursing Care
1. Task Analysis
> actions and procedures such as written guides, schedules,
rules, records, and budgets are inspected
> are used to determined issues: how long it takes a nurse to
perform a procedure and how many members are needed
for a specific number of patient
Tools Used:
1.1. Time Studies
1.2. Checklists
2. Quality Control
> is essentially the activities and techniques employed to
achieve and maintain the quality of a product service or
processes
> conceived and assessment of the level of nursing care
provided and its effects on the patient through process and
outcome
> it includes monitoring activity but it is also concerned with
finding and eliminating causes of quality problems so that
the requirements of the customer are continuously met
> level of nursing care provided is assessed in quality control
> effects of the nursing care on the patient
Focus:
2.1. patient / client / family satisfaction of nursing care
2.2. facilities and climate
2.3. methods used to deliver nursing care
2.4. outcome of nursing care
3rd. Measuring Actual Performance
> measurement of performance is an on-going repetitive process with
the actual frequency dependent on the type of activity being
measured
Example: nursing care of patient is monitored continuously
formal performance appraisal – done only twice a year
> measurements may be scheduled in advance or may be done at
periodic but unannounced intervals or may occur at random
> The purpose of measurement should be clarified and the staff
should be informed on the tasks and levels that need attention
4th. Comparing Results of Performance with Standards and
Objectives
> is one of the easiest steps in the control process
> if performance matches the standards and objectives, managers are
assured that the needs of patients are being met
> if performance is contrary to standards and objectives set, then
necessary actions are needed
5th. Reinforcing Strengths or Successes and Taking Corrective
Actions as Necessary
> positive feedback stimulates motivation, consistently high
performance, and growth of the employee. Corrective actions are
applied to improve performance
Responsibility of Head / Senior Nurse
Being the first line supervisor, he’s / she’s in best position to
know whether their staff nurses are performing satisfactorily in
their work. Their influence can be dramatically in promoting
quality care to patients.
1. They have the responsibility to instruct subordinates in the
appropriate methods and procedures in providing nursing care
2. Inform them of the likely causes of errors or defects and the
preventive measures necessary
3. Initiate and facilitate any steps necessary to improve methods,
equipments, materials, and conditions in the work area for which
they are responsible
4. Draw attention to existing or potential quality problems and
report all errors and defects waste
5. Suggest ways in which risks or error or quality problems may be
reduced
6. Assist in training new staff particularly by setting as good
examples
Performance Appraisal
> is a control process in which employees’ performance are
evaluated against standards. It is the most valuable tool in
controlling human resources and productivity. It evaluates how
well the nursing personnel have performed during a specific
period of time
Purposes of Performance Appraisal
are used to:
1. Determine salary standards and to merit increases
2. Select qualified individuals for promotion or transfer
3. Identify unsatisfactory employees for demotion or termination
4. Make inventories of within the institution
5. Determine training and developmental needs of the employees
6. Improve the performance of work groups by examining,
improving, and correcting interrelationship between members
7. Improve communication between supervisor and employee and
to reach an understanding on the objectives of the job
8. Establish standards of supervisory performance
9. Discover the aspirations of employees and to reconcile this with
the goals of the institution
10. Provide “employee recognition” for accomplishments
11. Inform employees “where they stand”
Methods of Measuring Performance
These may be done through:
1. Informal Appraisal which consists of:
1.1. incidental observation of work performance while engaged in
performing nursing care
1.2. responses made by workers during conferences
1.3. noting the interaction of workers with clients, their families,
visitors, and co-workers
2. Formal Appraisal
● is accomplished regularly and methodically by collecting objective
facts that can demonstrate the difference between what was
expected and what was done
2.1. Essay
● the appraiser writes a paragraph or more covering the
worker’s strengths, weaknesses, and potentials
● in most situations, particularly the managerial positions,
essay appraisals carry significant weight on the presumption
that an honest statement from someone who knows the
person well is fully valid
 ● its drawback is in its variability in length and content and is
more difficult to compare because it touches on different
aspects of a worker’s performance
● It may also concentrate on those areas of performance
which the supervision entertains strong feelings
2.2. Checklists
● contains compilation of all nursing performance expected
of a worker
The appraiser’s task is to place a checkmark in the
appropriate column whether the worker does or does
not show the desired behavior
● a quick glance at the completed forms would reveal the
overall quality of the nurses’ performance
2.3. Ranking
● in simple ranking, the evaluator ranks the employees
according to how he / she talked with co-workers with
respect to certain aspects of performance or qualifications
 Example: Nurse A may rank lowest in educational
requirements for the next higher position among the
five candidates for promotion but may rank first in
clinical proficiency while Nurse B may rank first in
educational qualifications but rank third in clinical
proficiency.
2.4. Rating Scales
 it includes a series of items representing the different tasks
or activities in the nurse’s job description or the absence or
presence of desired behavior and the extent to which these
are possessed
Examples:
2.4.1. On a scale of 0-5, indicate the degree of the
nurse’s skill in assessing the patient’s condition
where each of the corresponding number means:
5 – Excellent
4 – Very Satisfactory
3 – Moderately Satisfactory or Average
2 – Minimally Satisfactory
1 – Unsatisfactory
 2.4.2. A descriptive graphic rating scale may be used to
describe punctuality in reporting for duty, such as:
1 – Often times late
2 – Sometimes late
3 – Always reports on time
2.5. Forced Choice Comparison
● the evaluator is asked to choose from the statements that
best describe the nurse being evaluated. The items are so
grouped that the evaluator is forced to choose from favorable
as well as unfavorable statements and to counterpart the
tendency towards leniency of some evaluators
Example: Select from the following statements which
will best describe the nurse being evaluated and the
least that describes him / her
1. respects the ideas of others
2. communication ability limited
3. even-tempered
4. capable of enduring long hours of hard work
5. tends to be loner
2.6. Anecdotal Recording
● describes the nurse’s experience with a group or a person or in
validating technical skills and interpersonal relationship
● it should include:
2.6.1. description of the particular occasion
2.6.2. delineation of the behavior noted including who,
what, why, when, where, and how
2.6.3. evaluator’s opinion or estimate of the incident or
behavior
The descriptive notes are organized to get impressions of the
overall behavior in a given period of time. Caution should therefore
be taken against tendency not to give the negative behavior more
often than the positive behavior.
Example: Miss A was on her way to lunch. She passed by a client who
was reaching for his food tray but was having a hard time as this was
placed on his left side. His right hand has an IV line. Miss A stopped,
positioned the food tray comfortably and assisted the patient to eat
although she herself was late for lunch. Miss A acted in a
commendable manner.
Quality Assurance
 problem solving process that systematically assesses the quality
of care and corrects any defect that is observed
 is the estimation of the degree of excellence patient health
outcomes and in activity and other resource outcomes
 (William Some) is the measurement of the actual level with
service provided plus the efforts to modify when necessary the
provision
Purpose of Quality Assurance
 to assure the consumer of a specified degree of excellence
through continuous measurement and evaluation
Purpose of Quality Assurance Program in Nursing
 is to measure and improve the quality of nursing delivered in the
agency
Quality – is the degree of excellence
Assurance – formal guarantee of a degree of excellence
Quality Assurance – assures patients of an acceptable standard of
care that will be provided to them
To provide quality service – the workers must accept responsibility
that they have to do the right job, right the first time and everytime.
They have to accept that quality is everyone’s responsibility
Quality Assurance describes all attitudes related to establishing,
maintaining, and assuring high quality care for patients which
includes assessment of patient care and correction of identified
problems.
Efficiency is concerned with the percentage resources actually
used over the resources planned to be used.
Performance Evaluation – focuses on the worker
– it asks question how well the worker is satisfying the requirements
of their job within the organization
Quality Assurance – focuses on the care and the service the patient
received, rather than how well the professional is performing the
duties that the position requires
Patient is the best, sometimes the only judge of interpersonal aspects
of care. (Example: empathy and communication)
Patient Satisfaction – is an essential goal of health care and therefore
a part of quality of care
Methods of Quality Assurance
1. Patient Care Audits
1.1. Concurrent, Open Chart or Benedicter
● is one in which patient care is observed and evaluated
● a review of the patients’ charts while the patients are still
confined in the hospital
● observation of the staff as patient care is given
● inspection of patient and / or observation of the effects of
patient care where the focus is on the patient (done during
rounds or patient interview)
1.2. Retrospective Audits, Phaneuf or Closed Chart
● is one in which patient care is evaluated through:
1.2.1. a review of discharged patient’s charts
1.2.2. questionnaire sent to or interviews conducted
on discharged patients
2. Peer Review
Peers (employees of the same profession, ranks, and setting) may
do patient care audits evaluating another’s job performance against
accepted standards.
3. Quality Circles
● is one of the most publicized approaches to quality introduced by
Japanese
● a group of workers doing similar work meets regularly, voluntarily, in
normal working time, under the leadership of their supervisor; to
identify, analyze and solve work-related problems and so
recommended solutions to management where possible quality,
circle members should implement the solutions themselves
Nursing Audit Committee
● is created composed of a representative from all levels of the
nursing staff
1. Member of the training staff
2. Supervising nurse
3. Head / Senior nurse
4. Staff Nurse
In smaller hospitals:
Chief Nurse may be a member of the committee
Assistant
The audit team usually designates a day within the week to
be the audit day. However, the nurses do not know which unit
will be audited. This way, the activities in the units are not
deliberately changed because they know they are being
observed. The audit team utilizes the developed process or
outcome criteria that evaluate nursing care. The staff nurse or the
senior nurse participate during the audit and are shown the
findings both the strong and weak points. They sign the audit
form to confirm the authenticity of the findings of the audit team.
Utilization of Results
● the nursing staff in the unit is given a feedback on the results
of the quality assurance study. This may be oral or written and
is directed to the staff who administer the care or their
immediate supervisors
 Positive feedback reinforces desirable performance. Consistent
positive findings deserve a commendation from the nursing service.
Negative feedback should tactfully be conveyed into a face to
face situation so that clarifications can be made on the assessment
made. Negative findings have implications for review of existing
standards in the unit for closer supervision for designing system to
remedy identified problems and staff development.
Control of Resources
Part of the control process is the periodic review of the
utilization of materials and supplies in the various nursing units.
Consumption of supplies and materials should be proportionate
to the number of patient to be served be these in the form of
dressing, treatment done, injection given, etc.
Requisition of / or stocking a large number of supplies and
materials should be avoided to prevent pilferage (steal), misuse or
spoilage. A large order is merited (deserve) when there is a large
demand.
 The head / senior nurse must know the average daily usage
and the time required to receive supplies from the time these
were requisitioned.
Ordering the correct materials and checking inventory levels
prevent stocking items that are not frequently used.
All equipment’s utilization report is made including
frequency of breakdown.
This will help evaluate the quality of equipment purchased,
the way it is handled, used, and operated.
Preventive maintenance requires regular inspection of
equipment to prevent breakdown and / or to detect needed
repairs.
Monthly linen inventory is done to determine the adequacy
of linen issued and utilized in the various units. Measures should
be instituted to prevent losses.
Absences due to leaves whether scheduled or not, should be
analyzed as these may have implications for staffing. Provisions
for relievers should be included in the staffing pattern to maintain
quality service.
Discipline
Part of the controlling process in management is discipline.
In the past, discipline connotes rigid obedience to rules and
regulations, the violation will result to positive actions.
Today, discipline is regarded as a constructive and effective
means by which employees take personal responsibility for their
own performance and behavior. This is termed as self-discipline.
Factors That Influence Self-Discipline Are:
1. A strong commitment to the vision, philosophy, goals, and
objective
● a strong commitment results in obsession and teamwork which in
turn encourages greater conformity to expected norms of
conduct within the organization
2. Laws that governs the practice of all professionals and their
respective Codes of Conduct
● among government employees, the CS Rules and Regulations as
per P.D. 807 and the Code of Conduct for Public Officials R.A. 6713
are also to be complied with
3. Understanding the rules and regulations of the agency
● all employees are oriented to the rules, regulations, and policies of
the agency. Some organizations give their employees a handbook
containing these and the possible sanctions for their infractions
4. An atmosphere of mutual trust and confidence
● self-discipline thrives best in an atmosphere of trust and
confidence between superiors and subordinates
● the subordinates will consult their superiors with their problems
without fears
● the superiors trust their subordinates will do their best performing
their job without being “snoopervised”
Disciplinary Action
● any employee charged for break of the rules and regulations, policies,
norms of conduct shall be given the corresponding due process
● there must be existing rules of conduct governing his / her behavior
and an actual violation of such rule. The employee charged must be
notified in writing about the violation. He is given the right to be
counseled
Disciplinary action should be progressive in nature, such as:
1. Counseling and Oral Warning
● counseling and oral warning is best given in private and in an
informal atmosphere
● employee is given a fair chance to air his side. The relevant
facts are analyzed and evaluated against his past performance.
He is then counseled regarding expectations of improved
behavior / performance, ways of correcting the problem and a
warning that a repetition of the same offense may warrant
further disciplinary action. The employee commits to correct
the behavior
● he is informed of any follow-up action that may be taken
2. Written Warning
● is the second step in disciplinary action
● it is preceded by an interview similar to oral warning
● he is told after the interview that he will be given a written
warning, this includes:
a. statement of the problem
b. identification of the rule which was violated
c. consequences of continued deviant behavior
the employee’s commitment to take corrective
action and any follow-up action to be taken
3. Suspension
Suspension over minor violation is given after an
evidence of oral and written warnings.
Although a violation is a major infarction, suspension,
rather than dismissal is applied when management tools
that the employee can still be rehabilitated. Accurate
documentation of oral and written warnings including
suspension if done is necessary evidence of due process.
4. Dismissal
This penalty is invoked only when all other disciplinary
efforts have failed. The Disciplinary Committee should be very
sure that the cause for dismissal conforms with the criteria of a
major discipline violation as contained in the policy manual and
for the government employees those contained in the Civil
Service Rules and Regulations and the Code of Conduct.
● a review is actually done by higher management
In the case of government employees, this is further
reviewed by then respective department and final affirmation is
done by the Civil Service Commission.