Nursing Leadership and Management

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LECTURE NOTES
For Nursing Students

Nursing Leadership
and Management

Amsale Cherie
Ato Berhane Gebrekidan
Addis Ababa University
In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

2005

Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.
Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

Important Guidelines for Printing and Photocopying
Limited permission is granted free of charge to print or photocopy all pages of this
publication for educational, not-for-profit use by health care workers, students or
faculty. All copies must retain all author credits and copyright notices included in the
original document. Under no circumstances is it permissible to sell or distribute on a
commercial basis, or to claim authorship of, copies of material reproduced from this
publication.
©2005 by Amsale Cherie and Ato Berhane Gebrekidan
All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.

PREFACE
The rapid change in technology, knowledge explosion
and the increased and complex health care demands
challenge the nurse's knowledge, technical competence,
interpersonal skills and commitment. Nurses work at
each level of the health care system, have varied role,
and are constantly in contact with people. Dealing with
this dynamism and responsibility requires nurses to
have knowledge and skills of management. It becomes
apparent that the leadership needed to get work done
through people is increasingly important for nurses to
dispose their professional performance. Furthermore,
proactive leaders who had a vision and could motivate
associates to work toward common goals could help
organization survive and even thrive during rapid
change.

Although, this is the case teaching materials in this
endeavor are scarce in Ethiopia. Therefore, this lecture
note is written to narrow this gap. The target audiences
for this teaching material are student nurses at BSc level
and nurses working at each level of the health care
system. This material is not intended to substitute other

i

teaching and reference materials. Its objective is to
provide useful insights and information on management
in general and nursing management in specific.

The lecture note is organized into fourteen chapters.
Chapter

one

management

to
and

five

deals

nursing

with

introduction

service

to

administration;

mission, philosophy and goals of an organization;
organization and organizational structure; functions of
management

and

decision

making

respectively.

Theories of leadership, management of resources,
evaluation of health care activity, and communication
and group dynamics are the topics dealt in chapters 6,
7, 8, 9, and 10 respectively. In addition, conflict
resolution;

management

of

change,

project

management and quality assurance are discussed in
chapter 11, 12, 13 and 14 in its order.

ii

ACKNOWLEDGMENTS
We want to express our heart-felt gratitude to the Carter
Center, EPHTI for providing us financial and technical
assistance to materialize this lecture note. We are also
indebted to Ato Aklilu Mulugeta Business Manager, for
the Carter Center, Addis Ababa for the administrative
support and encouragement.

Almaya, Dila, Gondar and Jimma University staffs
deserve special acknowledgment for reviewing and
providing invaluable comments.

Our deepest appreciation goes to Ato Befekadu Tesgera
from Salam Nurses College for reviewing this lecture
note.

We want to extend our sincere thanks and gratitude to
Centralized School of Nursing Addis Ababa University
and Defense University for their unreserved support for
the completion of this teaching material.

iii

TABLE OF CONTENTS
Preface ............................................................................... i
Acknowledgement ..............................................................ii
Table of Contents ..............................................................iv

CHAPTER ONE: Introduction to Nursing Service
Management ........................................ 1
Definition of management and nursing service
administration .................................................................... 2
Types of managers ........................................................... 6
Managerial Skills ............................................................... 7
Managerial roles ............................................................... 8
Health Service Organizational Model .............................. 10
Learning activities ........................................................... 11

CHAPTER

TWO:

Philosophy

of

Nursing

Service

Management ......................................... 12
Organizational philosophy and philosophy of nursing
service administration ........................... 13
Goals ………….. .............................................................. 15
Institutional Goals ........................................................... 16
Nursing Department Goals ............................................. 16
Nursing Unit Goals .......................................................... 17

iv

Organizational Climate .................................................... 18
Learning Activities: .......................................................... 18

CHAPTER THREE: Organization and organizational
structure ................................................ 19
Systems Theory .............................................................. 20
Organizational Structure ................................................. 25
Organizational Characteristics ........................................ 27
Organizational Principles ................................................ 29
Organizational Concepts ................................................. 29
Types of Formal Organization Structures ....................... 31
Line and Staff Pattern/Relationship/in an organization ... 34
Matrix Organizational Structure ...................................... 35
Functional Line and Staff Pattern .................................... 36
Systems of Nursing Service Delivery .............................. 38
Team Nursing

............................................................... 40

Primary Nursing .............................................................. 43
Case Management .......................................................... 45
Learning Activities ........................................................... 46

CHAPTER FOUR: Functions of Management ................ 48
Definitions

............................................................... 48

Management Functions of a Nurse Manager .................. 49
Planning

............................................................... 50

v

Types of Planning ........................................................... 51
Organizing

............................................................... 58

Establishing Objectives ................................................... 60
Delegation

............................................................... 63

Staffing

............................................................... 67

Directing

............................................................... 67

Coordinating

............................................................... 69

Controlling

............................................................... 69

Learning Activities ........................................................... 70

CHAPTER FIVE: Decision Making ................................. 71
Decision Making .............................................................. 71
Types of Decisions .......................................................... 72
Steps of logical Decision Making .................................... 74
Factors Influencing Decision Making .............................. 74
Implications for Nurse Managers .................................... 75
Decision Making Tools .................................................... 76
Barriers to Effect Decision-Making .................................. 78
Learning Activities ........................................................... 80

CHAPTER

SIX:

Theories

of

Leadership

and

Management.......................................... 81
Leadership and Management Theories .......................... 81
Early Leadership Theories .............................................. 84

vi

Behavioral Theories ........................................................ 86
Authoritarian-Democratic-and Laissez-Faire Styles ........ 86
Management Theories .................................................... 93
Contemporary Leader-Manager Theories ....................... 97
Motivating Staff ............................................................. 101
Motivation Theories ....................................................... 102
Transformational Leadership ........................................ 106
Nurses Role-as-a Leader .............................................. 108
Obtaining and Using Power .......................................... 114
Bases of Power ............................................................. 114
Application to Nursing ................................................... 116
Learning Activities ......................................................... 119

CHAPTER SEVEN: Managing Resources ................... 121
Human Resource Management .................................... 121
Retaining Employees .................................................... 127
Methods and Techniques of Training ............................ 129
Performance Appraisal ................................................. 130
Budgeting

............................................................. 134

Standard Cost ............................................................. 138
Zero-Based Budgeting .................................................. 138
Supplementary Budgets ................................................ 140
Budgeting Process ........................................................ 141
Cost Implication to Budgeting ....................................... 143

vii

Per Diem

............................................................. 146

Material Management ................................................... 149
Managing Equipment .................................................... 150
Managing Time ............................................................. 152
Preparing duty roster .................................................... 153
Learning activities ......................................................... 154

CHAPTER EIGHT: Evaluating Health Activities ........... 155
Evaluation

............................................................. 155

Roles of Evaluation ....................................................... 155
Levels of Evaluation ...................................................... 156
Steps of Evaluation ....................................................... 156
Types of Evaluation ...................................................... 157
Learning Activity ............................................................ 158

CHAPTER NINE: Communication ................................ 159
Communication ............................................................. 159
The Message

............................................................. 160

The Communication Process ........................................ 161
Blocks to Communication ............................................. 172
Communication Networks ............................................. 176

CHAPTER TEN: Group Dynamics ............................... 178
Group Dynamics ........................................................... 178

viii

Task Behaviors of a Group ........................................... 181
Phases of Small Groups ................................................ 185
Techniques for Decision Making in Small Groups ........ 188
Brainstorming

............................................................. 189

Nominal Group Technique ............................................ 190
Delphi Method ............................................................. 192
Team Work

............................................................. 194

Conflict within teams ..................................................... 198
Standards

............................................................. 199

Learning Activities ......................................................... 200

CHAPTER ELEVEN: Conflict Resolution ..................... 202
Conflict Resolution ........................................................ 202
Types of Conflict ........................................................... 204
Interpersonal Conflicts .................................................. 204
Inter-group Conflicts....................................................... 204
Personal Group Conflicts .............................................. 205
Conflict Resolution Theory ............................................ 207
Manifest behavior .......................................................... 209
Conflict Resolution or Suppression ............................... 210
Win-Win Strategies ....................................................... 212
Conflict Management/Styles of Approaching Conflict/ ... 214
Avoidance

............................................................. 215

Accommodation ............................................................ 218

ix

Collaboration

............................................................. 223

Learning Activities ......................................................... 224

CHAPTER TWELVE: Management of Change ............ 226
Management of Change ............................................... 226
Purpose of Change ....................................................... 226
Factors that cause change ............................................ 227
Lewin’s 3 Step model of the change management ....... 232
Making the change process effective ............................ 237
Managing resistances to change .................................. 241
Learning Activities ......................................................... 243

CHAPTER FORTEEN: Project Plan Management ....... 245
Project Plan Management ............................................. 245
Developing Detailed Project Activities .......................... 251
Learning Activity ............................................................ 259

CHAPTER FIFTEEN: Quality Assurance/Improvement 260
History of Quality Assurance ......................................... 260
Quality Assurance Process ........................................... 264
References

............................................................. 269

x

Nursing Leadership and Management

CHAPTER ONE
INTRODUCTION TO NURSING
SERVICE MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:
ƒ

Define administration/management and nursing
service administration

ƒ

Describe the managerial level, role and skills

ƒ

Explain the importance of good management in
a health service organization

Management is as old as human kind and existed since
man has been organized in to communities. Managers
influence all phases of our modern organizations. Our
society simply could not exist as we know it today or
improve its present status without a steady stream of
managers to guide its organizations. Peter Drucker
makes this same point in stating that effective
management is quickly becoming the main resource of
developed countries and the most needed resource of
developing ones (1).

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Nursing Leadership and Management

Essentially,

the

organizations

role

of

toward

managers

goal

is

to

accomplishment.

guide
All

organizations exist for some purpose or objective, and
mangers have the responsibility for combining and using
organizational

resources

to

ensure

that

the

organizations achieve their purposes. Management
moves organizations toward these purposes or goals by
assigning activities that organization member perform. If
these activities are designed effectively, the production
of each individual worker represents a contribution to
the attainment of organizational goals. Managers strive
to encourage individual activity that will lead to reaching
organizational goals and to discourage individual activity
that

hinders

organizational

goal

accomplishment.

Management has no meaning apart from its goals (2).
Management must keep organizational goals clearly in
mind at all times

1.2. Definition of management and nursing
service administration
1.2.1. Definition of management
Different authorities define management differently but
have strong unifying similarities in all the definitions. The
term management can be used in several ways. For
2

Nursing Leadership and Management

instance, it can simply refer to the process that
managers follow to accomplish organizational goals.
The term can be used, however, to refer to a body of
knowledge. In this context, management is a cumulative
body of information that furnishes insight on how to
manage.

Management is the art of getting things done through
people. It is the process of reaching organizational goals
by working with and through people and other
organizational resources. It is the process of planning,
organizing,

leading

and

controlling

the

work

of

organization members and of using all available
organizational resources to reach stated organizational
goals. It is the process of directing, coordinating and
influencing the operation of an organization to obtain
desired result and enhance total performance.

1.2.2. Nursing service administration
Nursing service administration is a coordinated activity,
which provides all of the facilities necessary for the
rendering of nursing service to clients.
Nursing service administration is the system of activities
directed toward the nursing care of clients, and includes
3

Nursing Leadership and Management

the establishment of over-all goals and policies within
the aims of the health agency and provision of
organization, personnel, and facilities to accomplish this
goals in the most effective and economical manner
through cooperative efforts of all members of the staff,
coordinating the service with other departments of the
institution

Nursing service administration is the marshaling of
resources to accomplish a purpose.
It is both an art and a science. It is a science in the
sense that one may systematically study and analyze
the behavior of people as a collective endeavor and,
even their individual behavior in relationship to their
individual purposes and to draw generalizations from
them that are valid guides to foresight and action. It is
an art because it requires qualities of dynamic character
to make them effective in application.
Nursing service administration is the process of
planning, organizing, leading
encompasses

human,

informational

resources

and

material,
in

an

controlling

that

financial

and

organizational

environment to achieve the predetermined objectives.

4

Nursing Leadership and Management

Nursing service is the process composed of the set of
interrelated social and technical functional activities
occurring within a formal organizational setting to
accomplish predetermined objectives through utilization
of human and other resources.

The primary objective of the role of nursing service
administration is the provision for continuous individual,
group and community service, including whatever is
necessary. In addressing the factors, which determine
health, and to bring them back to self-directive activity
towards their own health. The subsidiary objectives of
this role are the professional activities of administration,
including human relations, communications, teaching,
research, and personal development, designed to
further the primary objective-the optimum nursing care
of patients. In this lecture note management and
administration are used interchangeably.

1.2.3. Types of managers, managerial skill and roles
Nursing service managers are people who appointed to
positions of authority, which enable others to perform
their work effectively, who have responsibility for
resource utilization and who are accountable for work
5

Nursing Leadership and Management

results and can be proud of their organizations and what
they do.

Types of managers
Traditionally classifications of managers are by level in
the organizational hierarchy; common nomenclature is:
Ö Top level–such as board of directors, Presidents and
vice presidents
Ö Middle

level–such

as

directors

of

nursing,

supervisory staffs and department heads
Ö First line/front line/ or supervisory management–
such as head nurses and staffs.
Regardless of level, managers have several common
attributes; they are:
Ö Formally appointed to positions of authority
Ö Charged with directing and enabling others to do
their work effectively
Ö Responsible for utilizing resources
Ö Accountable to superiors for results
The primary differences between levels of managers are
the degree of authority and the scope of responsibility
and organizational activity at each level. For example,
top-level managers such as nursing administrators have
authority

over

and

responsibility
6

for

the

entire

Nursing Leadership and Management

organization.

Middle

level

managers

such

as

department heads and heads of services have authority
over and responsibility for a specific segment, in
contrast to the organization as a whole and act as a
liaison between top-level managers and first level
managers. First line managers, who generally report to
middle level managers have authority over and are
responsible for overseeing specific work for a particular
group of works.

Managerial Skills
Managers can also be differentiated by the extent to
which they use certain skills: conceptual, human
relations and technical skills. All managers use human
relation skills because they accomplish work through
people. Human relations skills include motivation,
leadership and communication skills. The degree to
which each is used varies with the nature of the position,
scope of responsibility, work activity, and number, types
and skills of subordinates. Senior managers use
disproportionately more conceptual skills in their jobs
than do middle level or first line managers. These
include recognizing and evaluating multiple complex
issues and understanding their relationships, engaging
7

Nursing Leadership and Management

in planning and problem solving that profoundly affect
the health service organization, and thinking globally
about the organization and its environment. In contrast
first line managers tend to use job related technical
skills, or skills that involve specialized knowledge.

Managerial roles
All health service managers engage in planning,
organizing, staffing, directing, controlling, and decision
making to some degree. In addition, they perform other
activities

related

to

accomplishing

work

and

organizational objectives that do not readily fall within
the functional classification. These roles are defined as
the behavior or activities associated with a management
position because of its authority and status. Mintzberg's
classification identifies:
Ö Interpersonal
Ö Informational and
Ö Decisional roles

Interpersonal role
The three interpersonal roles are
™ Figurehead: all managers, but especially senior
managers, are figureheads because they engage
8

Nursing Leadership and Management

in ceremonial and symbolic activities such as
greeting

visitors

and

making

speeches

at

organizational events.
™ Liaison: involves formal and informal internal and
external contacts.
™ Influencer: includes activities inherent in the
directing function, the purpose of which is to
motivate and lead.

Informational role
The three informational roles of a manager are
™ Monitor
™ Disseminator and
™ Spokesperson

Decisional Roles
The four decisional roles of a manager are
™ Entrepreneur
™ Disturbance handler
™ Resource allocator and
™ Negotiator

9

Nursing Leadership and Management

1.3 Health care, health services and health
service organizational models
Health care: is the total societal effort, organized or not,
whether private or public, that attempts to guarantee,
provide, and finance the promotion of health, prevention
of diseases, and restoration of health and rehabilitation.
Health service: is the delivery of health care
Health service organizations: Deliveries of health
services to clients occur in a variety of organizational
settings. Health service organizations can be classified
by ownership, profit motive, whether the client is
admitted. Historically, hospitals and nursing facilities
have been the most common and dominant health
service organizations engaged in delivery of health
services.

Health Service Organizational Model
Model
™ Organizations are open systems
™ Composed of inputs, throughput and output

1.4 The Benefit of good Management in Health
Service organizations
™ High lights priority areas
10

Nursing Leadership and Management

™ Adopts the service to the needs of a changing
situation
™ Makes use of the most limited resources
™ Improves the standard and quality of services
™ Maintain high staff morale

Learning activities
1. Briefly discuss management and nursing service
administration
2. List the three levels of management
3. Discus the four common attributes of managers
regardless of their level
4. Describe the three management skills
5. Explain the role of managers in an organization
6. What is health care, health service and health
service organization?
7. Discuss the components of the health service
model
8. What is the benefit of good management for an
organization?

11

Nursing Leadership and Management

CHAPTER TWO
PHILOSOPHY OF NURSING
SERVICE MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:
ƒ

Define mission, philosophy and goals

ƒ

Explain the relationship of mission, philosophy
and goals

ƒ

Discuss the importance of mission, philosophy
and goals of an organization for nursing service
administration

Mission
A mission statement is a broad general goal of an
organization
community.

that
The

describes
mission

its

purpose

statement

of

in
a

the
small

community hospital may indicate that its purpose is to
serve

the

health

care

needs

of

the

immediate

community and provide care for commonly occurring
illnesses. A large university hospital may have a mission
statement that encompasses research, teaching and
care for complex problems. These two organizations will
12

Nursing Leadership and Management

establish

different

priorities

for spending, choose

different technologies as essential to their missions, and
structure their staff in different ways. These mission
statements provide the overall umbrella under which all
functions of the organization take place.
In addition to or even in place of a mission statement a
general statement of philosophy
may be used. When both are present, they should
agree. The philosophy is typically longer and more
detailed.

Organizational

Philosophy

and

philosophy

of

Nursing Service Administration
Organizational Philosophy is its explicit and implied view
of itself and what it is. Generally it is expressed in
mission statements. The philosophy is directly linked to
and rooted in the organizations cultural beliefs and
values. Philosophy depicts the desired nature of the
relationships between health service organizations and
its customers, employees and external constituents. It is
a set of beliefs that determines how organizational
purposes are achieved and that serves as the
foundation

for

agency

procedures.
13

objectives,

policies

and

Nursing Leadership and Management

Nurses have the right to know the beliefs about nursing
care, nursing practice and nursing management held by
the collective group, which they are a part of the nursing
department. A statement of philosophy is a valuable
management tool. Nurses should be given a copy
before they join the staff so that they can judge whether
their personal philosophy is sufficiently in agreement
with the organizational philosophy to enable them to
become a contributing member of the department.
Philosophy

statements

documents

because

are

stated

relatively
beliefs

are

enduring
usually

expressions of firm commitment to the best that can be
achieved and are derived from the broad goals of the
agency.
A useful philosophy has a timeless quality because
basic premises change only under unusual conditions.
Nevertheless,

philosophy

statements

need

to

be

reviewed periodically. If a review by all members of the
department reveals that the statement still reflects the
guiding beliefs of the collective group, there is no need
to revise the document. If scrutiny indicates that the
statement is not consistent with current agency goals or
philosophy or is not effective in directing the actions of
the department, then the statement should be rewritten
14

Nursing Leadership and Management

to assure that it meets the criteria of compatibility,
attainability, intelligibility, acceptability, measurability and
accountability. When developing or reevaluating a
philosophy, the manager should consider theory,
education, practice, research, and nursing's role in the
total organization.

Goals
Goals are the broad statements of overall intent of an
organization or individual. They are usually stated in
general terms. The purpose of writing goals is to identify
where you are going and to enable you to evaluate
when you have arrived there. A meaningful stated goal
is one that succeeds in communicating the intent of
those generating the goal. It should be stated in such a
way that it will be understood clearly by others. As a
nurse in a health care institution, you need to be aware
of the existence of several levels of goals: the
institutional level, the nursing department level and the
nursing unit level. The goal levels all need to relate to
the health needs of the community, because these are
the focus of health care.

15

Nursing Leadership and Management

Institutional Goals
Based on the community’s health needs, the institution
forms goals and objectives. An institution that focuses
thinking on goals for the future and activities that will
move the organization toward these goals is referred to
as a proactive institution. The managers of such
institutions spend a great deal of time, money and
energy on identifying possible future events and on
preparing the institution to deal with them. Institutions
that do not have specific or future oriented goals are
reactive institutions. They spend their time reacting to
events, that is, “putting out fires” rather than “preventing
them.” A

reactive facility would wait until such

emergencies occurred and then would handle them as a
crisis rather than as an anticipated event.

Nursing Department Goals
The goals of the institution definitely affect those of
nursing service, which must support and complement
institutional goals. In an institution with an overall goal of
developing

a

mental

health

program,

a

nursing

department goal may include developing nurses in
psychiatry.

16

Nursing Leadership and Management

The astute manager of a nursing department must also
be proactive about the national issues facing nursing,
community needs for nursing, and the needs within the
institution itself. This manager would formulate goals to
help the nursing department meet the challenges of care
in the future, because the ultimate nursing department
goal is quality client care.

Nursing Unit Goals
It is important that each employee understand the
institutional and nursing department goals, because the
group or unit goals develop from them. Each nurse
should be able to contribute to the formation of unit
goals in terms of philosophy of care, quality of care, and
development of nursing expertise.
Helping to formulate the goals for your unit is important,
because these goals can also represent your individual
goals. Unit goals develop from the group as a whole and
often include individual goals in the process.
Development and implementation of goals must be
meaningful to the group if they are to be successful. The
member of the group must feel that they are the
originators of the unit goals and objectives.

17

Nursing Leadership and Management

Organizational Climate
The climate of an organization refers to the prevailing
feelings and values experienced by individuals. The
feeling of thrust, belonging, esteem and loyalty are part
of

the

climate.

Values

for

competence

and

accomplishment are also part of the climate. The climate
is bases on the official policies and procedures of the
organization, and the feedback provided within the
organization

Learning Activities:
1. What is the mission of a health service
organization?
2.

What is the importance of having a philosophy
for an organization?

3.

What is the relationship between organizational
philosophy and the philosophy of nursing?

4. Describe the three types of goal
5. Discuss the similarities and difference of mission,
philosophy and goals of an organization

18

Nursing Leadership and Management

CHAPTER THREE
ORGANIZATION AND
ORGANIZATIONAL STRUCTURE
Objectives:
At the end of this chapter, the student should be able to:


Discuss systems theory and its components



Describe

formal

and

informal

organizational

structures


Identify the four types of formal organizational
structures



Describe the differences between centralized and
decentralized structures



Discuss advantages and disadvantages of each of
the following organizational structure: Pure line, line
and staff, functionalized line and staff; and matrix



Explain the relationship between responsibility and
authority under ideal circumstances.



Identify the major components required to deliver
effective nursing care



Discuss and compare each type of client care
delivery system

19

Nursing Leadership and Management

Systems Theory
Ludwig Von Bertalanffy introduced general system
theory several decades age in an attempt to present
concepts that would be applicable across disciplines
and would be applicable to all systems. The theory was
one of wholeness, proposing that the whole is more than
the sum of parts; the system itself can be explained only
as a totality. Holism is the opposite of elementarism,
which views the total as the sum of its individual parts.
A system may be defined as "sets of elements standing
in interrelation". All systems have elements in common.
Societies, automobiles, human bodies and hospitals are
system The theory of open system is part of a general
system theory; An open system is defined as a "system
in exchange of matter with its environment, presenting
import and export, building up and breaking down of its
material components. Open systems theory emphasizes
the relationship between a system and its environment
and the interrelationships of different levels of system
(Katz & Kahn, 1996, p.3).
Systems are either closed or open. Closed systems are
self-contained and usually can only be found in the
physical sciences. This perspective has little relevance
for the study of organizations. The open system
20

Nursing Leadership and Management

perspective recognizes the interaction of the system with
its

environment.

Katz

and

Kahn

outline

10

characteristics that are common to all open systems.
Understanding these characteristics helps one to
conceptually understand how organizations function.
The first characteristic is input, or importation of energy.
Open systems import forms of energy from the external
environment. As, the human cell receives oxygen and
nourishment from the blood stream, and organization
receives capital, human resources, material, or energy
(e.g. electricity) from its environment.

The second characteristic is through put, in which open
systems transform the energy and materials. Just as the
human cell transforms nourishment into structure, an
origination can create a new product, process materials,
train

people,

or

provide

a

service.

The

third

characteristic is output. Open systems export some
product a manufactured substance, an inquiring mind, or
a

well

body

into

the

environment.

Fourth,

an

organizations throughput works as a system of cyclic
events. Organizational activities occur over and over
again in a self-closing cycle, as the material that is input
is transformed by throughput and results in output.
21

Nursing Leadership and Management

System-boundaries-it

follows

boundaries,

separate

which

that

systems

them

from

have
their

environments. The concept of boundaries helps us
understand the distinction between open and closed
systems. The relatively closed system has rigid,
impenetrable boundaries; where as the open system
has permeable boundaries between itself and a broader
supra system. Boundaries are relatively easily defined in
physical and biological systems, but are very difficult to
delineate in social systems such as organizations.
The fifth open system characteristic is negative entropy.
To survive, open systems must reverse the entropic
process, they must acquire entropy. The entropic
process is the universal law of nature in which all forms
of organization move toward disorganization or death"
(Katz & Kahn, 1966). In order to arrest entropy and be
transformed into negative entropy, a process of
transformation with continuous up dates or changes in
the organization is necessary. The outside forces and
governmental agencies (importing resources from its
environment) supply major financial support to fuel the
system's ongoing functions and continue operational
processes.

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Nursing Leadership and Management

The six characteristic of an open system is information
input:

the

feedback

and

coding

process.

Every

organization must take in information and feedback from
the environment, code that information, and then store it
so it can be used to predict the environment. Negative
feedback is the type of input that allows the system to
identify

deviations

in

its

functioning

processes.

Feedback enables the organization to maintain a steady
state, the seventh characteristic of an open system.
Sometimes called homeostasis, a steady state refers to
the ability and desire of an organization to maintain
some constancy in energy exchange. Just as the human
body stays in a steady state, with no significant variation
in its size and mass over time, so an organization
attempts to stay in a steady state. This is acquired
through avoidance of entropy.
The eighth characteristic is differentiation, which occurs
with growth of the organization.
This requires multiplication and changes in established
roles with new knowledge and expansion of expertise.
This activity must create a constant flow of energy
exchange as each member also continuously adapts to
new functional changes. As a result, integration and
coordination are achieved. This process leads to the
23

Nursing Leadership and Management

establishment of a new organizational structure. The last
characteristic of an open system is equi-finality: The
principle that any final goal or end can be reached by a
variety of means. As open systems move and develop
within their environment, they may set different goals at
different times and choose different methods to attain
them, but the ultimate goal of any open system is
survival. The adaptability of humans for survival
represents equi-finality.

The total nursing management process and each
management functions can be preserved as a system
consisting of several inputs, one or more throughput
processes, numerous outputs, and multiple feedback
processes between outputs and throughput, output and
inputs, and throughput and inputs. When management
malfunctions, in the major system or a subsystem,
analysis

of

the

interrelationships

among

system

elements will usually reveal imbalances, obstruction of
some point in the system. Usually, when the cause for
system

malfunction

is

accurately

diagnosed,

the

problem can be eliminated or relieved by appropriate
managerial interventions.

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Nursing Leadership and Management

Organizational Structure
An organization is a group of people working together,
under formal and informal rules of behavior, to achieve a
common purpose. Organization also refers to the
procedures, policies, and methods involved in achieving
this common purpose. Thus, organization is both a
structure and a process. Organizational structure refers
to the lines of authority, communication, and delegation;
can be formal or informal. Organizational process refers
to the methods used to achieve organizational goals. An
organization's

formal structure

is

depicted in

its

organizational chart that provides a "blueprint," depicting
formal relations, functions and activities.

The principal purpose for defining the organization
diagram is to clarify chain of command, span of control,
official communication channels, and linkage for all
department personnel. It is customary to show formal
organization structure in a diagrammatic form with a
three dimensional model having depth, height and width.
Boxes containing various position titles are positioned
vertically

to

highlight

differences

in

status

and

responsibility. Position boxes are connected with lines to
demonstrate the flow of communication and authority
25

Nursing Leadership and Management

throughout the entire network. Different types of
interconnecting lines signify different types of relation
ships.

For example, a solid line between two positions, indicate
direct authority or command giving relationship. A
dashed line or broken or dotted line indicates a
consulting relationship with no prescribed frequency of
the structure to collaborate for planning or control
purpose. Commands do not flow.

The primary significance of formal organization structure
is the frequency of communication between particular
staff members. Particular worker is expected to relate
directly with certain individuals and not others. For
instance, the Nursing director must give direction to and
receive reports from vice-director or supervisors and not
others. In this sense, the formal organization structure
restrains worker behavior.

The organization chart does not show the degree of
authority that a manager has over subordinates. A
manager with authority of head nurse may lack authority
to hire or fire the worker.
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Nursing Leadership and Management

Every organization also has an informal structure,
characterized by unspoken, often covert, lines of
communication and authority relationships not depicted
in the organizational chart. The informal structure
develops to meet individuals' needs for friendship, a
sense

of

belonging,

and

power.

The

lines

of

communication in the informal structure (commonly
termed "the grapevine") are concerned mainly with
social issues. Persons with access to vital information
can become powerful in the informal structure. Some
administrators try to hinder the effects of informal
organization because they facilitate the passing of
information. The information may be rumor, but the best
way to combat rumor is by free flow of truthful
information. The informal organization can help to serve
the goals of the formal organization if it is not made the
servant of administration. It should not be controlled. A
major shortcoming in its use is that not all employees
are part of the informal organization.

Organizational characteristics
1. Span of control - refers to the number of employees
a manager can effectively oversee. Mostly top executive
cannot manage as many employees’ managers at lower
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Nursing Leadership and Management

levels. Theoretically, A 1:3 supervisory ratio is common
at the top of an organization; a 1:6 ratio is common at
the middle; and a 1:20 or larger ratio is common at the
base.

The effective span of control for each manager depends
on work pace and pattern of workers skill and
knowledge, the amount of work in interdependence. The
top executive must supervise managers of different
specialties; although mid level and first level managers
supervise workers in the same specialty that performs
similar tasks often in a common work area.
When span of control is too broad, the manager has
insufficient time to observe and cannot evaluate
performance or give feed back. On the other hand, too
narrow span of control has time to supervise each one
closely,

and

too

close

supervision

discourages

subordinates problem solving independent judgment
and creative thinking. Research shows that worker
productivity

is

higher

when

impossible.

28

close

supervision

is

Nursing Leadership and Management

Organizational Principles


The principle of unity of Command: An employee
may interact with many individuals in the course of
the work but should be responsible to only one
supervisor.



The

principle

of

Requisite

Authority:

when

responsibility for a particular task is delegated to a
subordinate,
authority

subordinate

over

must

resources

also

be

given

needed

for

task

accomplishment.


The Principle of Continuing Responsibility: When a
manager delegates a function to a subordinate, the
manager's responsibility for that function is in no way
diminished.



The Principle of Organizational Centrality: Workers
who interact with the greatest number of other
workers receive greatest amount of work related
information

and

become

most

powerful

in

organizational structure.

Organizational Concepts
1. Responsibility- is the obligation to do, to the best
of one’s ability, the task that has been assigned,
or delegated. In any organization, responsibility
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Nursing Leadership and Management

begins

with

the

overall

objective

of

the

organization. For example, for nurses in a
hospital,

service

or

patient

care

is

the

responsibility.
2. Authority- the right of decision and commands.
An individual with authority has the right to make
decisions about his or her own responsibilities.
Responsibility and authority are delegated down
the scalar chain.
3. Delegation- is the process of assigning duties or
responsibilities

along

with

corresponding

authority to another person. Authority must be
delegated with the responsibility.
4. Accountability- is answering to someone for what
has been done. It is related with responsibility.

Centralization versus Decentralization
In a highly centralized organization, the chief executive
makes most decisions. Decentralization is the allocation
of responsibility and authority for management decisions
downward

through

the

chain

of

command.

In

centralized, decisions made at the apex of the
organization takes longer period of time than decisions
made at the lower levels. Therefore, highly centralized
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Nursing Leadership and Management

organizations are slow in adapting to major changes.
Lower level workers become passive, unenthusiastic
and mechanical.
The executive who will not permit supervisors to select
staff,

determine

improvements,

staff

schedule,

evaluate

goal

institute

working

achievement,

and

recommend policy change deprive middle managers of
opportunities for professional growth.
Decentralization of responsibility leads to improved
employee morale. When middle managers are given
responsibility for decision-making, they in-turn make still
further, empowering staffs to formulate unit level work
plans, policies and procedures.
As job responsibility and autonomy increase, so does
job satisfaction. It improves staff nurse moral and
retention. The head nurse's tasks in a decentralized
organization are similar to a nursing director task in a
highly centralized organization. Therefore, expert staff
specialist should support the head nurses.

Types of Formal Organization Structures
Line Pattern/Relationship:

This is the oldest and

simplest type of formal organization chart. It is a
straightforward, direct chain of command with superior
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Nursing Leadership and Management

subordinate relationships. The line pattern is more
efficient than other structures, because it provides clear
authority-responsibility relationships between workers
and requires less information transmission between
managers and workers.
The typical line pattern is divided laterally into segments
representing

different

nursing

specialties.

The

perspective of workers differs from the bottom to the top
of the structure. Workers at the base of pyramidsNursing assistants, Orderlies, staff nurses perform the
basic work of nursing mission, i.e. direct patient care.
Employees in the middle of the structure- head nurses,
patient care coordinators, supervisors are responsible
for professional decision-making and direction of day to
day operations. Personnel at the top of the structureVice president or director and assistant directors are
responsible for non-programmed decision making, such
as goal setting, program planning, and performance
evaluation.

Advantages of Line Pattern
™ It is easy to orient new employees, because of
clearly defined interpersonal relations as well as
responsibility and accountability;
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Nursing Leadership and Management

™ Easy to manage, because orders can be
transmitted quickly;
™ Well established division of labor;
™ There is a clear-cut work specialization and role
separation.

Disadvantage
™ As a result of specialization, it makes employee's
task narrow, repetitive performance and causes
communication difficulties among specialists;
™ Since it is rigid, workers tend to resist innovative
changes

and

resist recommendations

from

outsiders;
™ Line pattern causes passivity and dependence in
staff

members

and

autocratic

behavior

in

managers. The strong chain of command and
concentration of authority at the top of hierarchy
cause lower level employees to refer difficult
problems to their immediate superior. Managers
talk more than to listen;
™ It is characterized by weak integration of different
divisions or departments. Interaction is only on
the same division and there is no lateral
communication. Head nurses will never seek
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Nursing Leadership and Management

advice from a more experienced head nurse in a
different clinical division to resolve a patient care.

Line and Staff Pattern/Relationship/in an Organization
Line functions are those that direct responsibility for
accomplishing the objectives of a nursing department.
For the most, part they are filled with registered nurses
licensed assistant nurses or other types of nurses. Staff
functions are those that assist the line in accomplishing
the primary objectives of nursing. They include clerical,
personnel, budgeting, and finance, staff development,
and research. The relationship between line and staff
are a matter of authority. Line has authority for direct
supervision of employees, while staff provides advice
and counsel.
To make staff effective, top management ensures that
line and staff authority relationships are clearly defined.
Personnel

of

both

should

work

to

make

their

relationships effective; they attempt to minimize friction
by increasing mutual trust and respect.
The advantage of a line and staff pattern is that key
management functions that the chief executive has
neither skill nor time to execute well are delegated to
functional experts who can devote full time to the
34

Nursing Leadership and Management

assigned

function

without

being

distracted

by

responsibilities of day today management of personnel
and material.
The disadvantage of line and staff pattern is that staff
officers have less power than line officers, because the
latter direct the basic operations. Furthermore, staff
officers must stand quietly in the background, while line
managers receive recognition for improvements. Staff
positions are also located at the periphery of formal
structure, which casts incumbents in the role of social
isolates.

Matrix Organizational Structure
This Pattern is a complex construct in which and
employee may be responsible to two or more bosses for
different aspects of work. In this pattern, a staff nurse
stationed on a given patient unit is responsible to the
head nurse of that unit but also to a case manager who
oversees the clinical progress of her patients. It could
also be through vertical and horizontal coordination.
Potential problems with a matrix type organization can
easily be discerned. If, for example, the head nurse and
the case manager give conflicting orders to the staff
nurse, the job may be indefensible, or a manipulative
35

Nursing Leadership and Management

staff nurse may play his/her two bosses off against each
other. When a matrix organization is used, there must
be clear decision rules and, it is hoped, good
interpersonal relationships. The employee must know
which boss has the final word when they receive
conflicting orders or conflicting demands concerning
work priorities.

Functional Line and Staff Pattern
A third type of formal organization structure is the
functionalized line and staff organization. In this
structure, staff officers are no longer purely advisory but
have some command authority over line employees.
The director of in-service may have the authority to
decide how much indoctrination training and what type
of orientation each new nurse must receive and when
orientation classes will be held. The director of quality
improvement may have the authority to assign selected
staff nurses to gather data on critical indicators of care
quality, regularly submit quality monitoring reports, and
remedy identified problems.
As a nursing organization increases in size, it may
evolve from a pure line, to a line and staff, and finally, to
a functional line and staff structure. The advantage of
36

Nursing Leadership and Management

functionalized line and staff organization is that the
expert responsible for a specified management function,
such as staffing, policies, quality improvement, or staff
development, has authority to command line managers
to implement needed actions that relate to the expert’s
specified function.

Standards for evaluating the effectiveness of line
and staff relationships in a hierarchical organization
Standards
1. Line authority relationships are clearly delineated
and

defined

by

the

organizational

and/or

functional charts and policies;
2. Staff

authority

relationships

are

clearly

delineated and defined by the organizational and
/or functional charts and policies;
3. Functional

authority

relations

are

clearly

delineated and defined by the organizational and
/or functional charts and policies;
4. Staff personnel consult with, advise and provide
counsel to line personnel;
5. Service

personnel

functions

are

understood by line and staff personnel;

37

clearly

Nursing Leadership and Management

6. Line personnel seek and effectively use staff
services;
7. Appropriate staff services are being provided by
line nursing personnel and other organizational
departments or services;
8. Services are not being duplicated because line
and staff authority relationships.

Systems of Nursing Service Delivery
Effective management makes the organization function,
and the nursing manager has a responsibility of nursing
care delivery systems that demonstrate ways of
organizing nursing’s work. Within these systems there
are advantages and disadvantages for quality of care,
use of resources, and staff growth.

Case Method
The new method, traced back to Florence Nightingale,
began in the early days of the nursing profession and
was the convenient and appropriate way to manage
care. Individuals are assigned to give total care to each
patient,

including

the

necessary

medicine

and

treatments. The nurses report to their immediate
superior, who is the head nurse. The disadvantages of
38

Nursing Leadership and Management

this system are that all personnel might not have been
qualified to deliver all aspects of care, and depending on
the structure, too many people were reporting to the
head nurse (overextended span of control).

Functional Method
The functional method is the next step to deal with
different levels of caregivers. Assignments of patient
care are made by the level of task; in other words, each
person performs one task or functions in keeping with
the employees’ educational experience. For example
Nurse Aides /Health Assistants/ give baths, feed
patients, and take vital signs to all patients. Professional
nurses are responsible for medications, treatments, and
procedures for all patients. The head nurse is
responsible for overall direction, supervision, and
education of the nursing staff.

Advantages
ƒ

Reduce personnel costs

ƒ

Supports cost control

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Nursing Leadership and Management

Disadvantages
ƒ

Fragments nursing care

ƒ

May decrease staff job satisfaction

ƒ

Decreases personal contacts with client

ƒ

Limits continuity of care

Team Nursing
A dramatic change occurred after World War II in the
years between 1943 and 1945. The level and number of
auxiliary

personnel

began

increasing,

and

the

professional nurse was assuming more and more of the
management functions. Because of the changing
configuration of the work group and the dramatic social
upheaval, a study was commissioned to device a better
way to provide nursing care. Dr. Eleanor Lambertson of
Columbia University in New York and Francis Perkins of
Massachusetts General Hospital were the authors of the
system known as team nursing. Team nursing was
developed to deal with the influx of post war workers
and the head nurse’s overextended span of control. This
was accomplished by arranging the workers in teams.
The team consists of the senior professional nurse
becoming the team leader; the members of the team are
other registered nurses (RNs), licensed practical nurses
40

Nursing Leadership and Management

(LPNs) or vocational nurses, and nurses’ aides. Each is
being given a patient assignment in keeping with the
employee’s education and experience. The team leader
make the assignments, delegated the work through the
morning report, make rounds throughout the shift to
make sure patients are being cared for properly, and
conducts a team conference at the end of the shift to
evaluate the patient care and plan an update nursing
care plans.
Since 1950, team nursing is becoming a popular way to
structure nursing care.
Team nursing is a pattern of patient care that involves
changing the structural and organizational framework of
the nursing unit. This method introduces the team
concept for the stated aim of using all levels of
personnel to their fullest capacity in giving

the best

possible nursing care to patients. The structural and
organizational changes necessary for this method
includes the introduction of the nursing team with the
team leader assuming responsible for the management
of the patient care. The head nurse decentralizes
authority to the team leader to direct the activities of the
team members. The head nurse is no longer the center
of all communication on the division because the
41

Nursing Leadership and Management

members communicate directly with the team leader.
The team leader had the responsibility for synchronizing
the abilities of her/his team members so that they are
able to function effectively in a team relationship.
Emphasis is placed on the ability of all participants of
patient care to plan, administer, and evaluate patient
care.
The team approach to patient care represents more
than reorganization or restructuring of nursing service.
Instead, it is a philosophy of nursing and a method of
organizing patient care. The difficulty with this method
concerns the nurse’s absence at the bedside; the nurse
is directing the care of others and thus not using
nursing’s specialized knowledge as the best provider of
patient care. Problems with this system have become
the stimulus for a new system.

Advantages
ƒ

Supports comprehensive care

ƒ

May increases job satisfaction

ƒ

Increases cost effectiveness

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Nursing Leadership and Management

Disadvantages
ƒ

Decreases personal contact with client

ƒ

Limits continuity of care

Primary Nursing
Primary nursing as a system of care provided for a way
to provide quality comprehensive patient care and a
framework for the development of professional practice
among the nursing staff. Primary nursing was a logical
next step in nursing’s historic evolution. By definition,
primary nursing is a philosophy and structure that places
responsibility and accountability for the planning, giving,
communicating and evaluating of care for a group of
patients in the hands of the primary nurse. Primary
nursing was intended to return the nurse to the bedside,
thus improving the quality of care and increasing the job
satisfaction of the nursing staff.
The primary nurse is expected to give total care, to
establish therapeutic relationship, to plan for 24 hours
continuity in nursing are through a written nursing care
plan, to communicate directly with other members of the
health team, land to plan for discharge. The patient’s
participation is expected in the planning, implementing,
land evaluating of his or her own care. Perhaps the best
43

Nursing Leadership and Management

aspect

of

primary

nursing

is

the

improved

communication provided by the one-to-one relationship
between nurse and patient.
Associate nurses are involved with this method by
caring for the patients in the absence of primary nurse.
Their responsibilities include continuing the care initiated
by

the

primary

nurse

and

making

necessary

modifications in the absence of primary nurse.
Primary nursing was adapted in organizations to fit the
staffing patterns and general nursing philosophy.
Because of the need for high percentage of professional
nurses, other modifications of the system developed,
such as modular nursing.

Advantages
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ

May increase job satisfaction
Improves continuity of care
Allows independent decision making
Supports direct nurse-client communication
Encourages discharge planning
Improves quality of care

Disadvantages
ƒ

Increases personnel costs initially

44

Nursing Leadership and Management

ƒ

Requires properly trained nurses to carry out
systems principles

ƒ

Restricts opportunity for evening and night shift
nurses to participate

Case Management
More recently, a new method of nursing care delivery
has

evolved

known

as

case

management.

The

American Nurses Association (ANA) has defined case
management to be a system of health assessment,
planning,

service

procurement

and

delivery,

coordination, and monitoring to meet the multiple
service needs of clients. This is an all-inclusive and
comprehensive model and is not restricted to the
hospital setting.
When a patient deviated from the usual expected course
of recovery or health, consultation ensures to quickly
correct the problem. This requires a great deal of
systematic knowledge about a patient's problems and
putting that knowledge into a type of nursing care plan
(case management plans) with time lines to demonstrate
progress or deviations from the critical paths. In addition
to the nursing and medical services that are required for

45

Nursing Leadership and Management

patients, other services are included, such as physical
therapy and respiratory therapy.

Advantage
ƒ

Improves

nurse

responsiveness

to

clients

changing needs
ƒ

Improves continuity of care

ƒ

May increase nurse’s job satisfaction

Disadvantage
ƒ

Increases personnel costs

Learning Activities
1. Describe the form of organizational structure
of the nursing division on which you work as
an employee. Discuss the changes that could
be made to make it more functional.
2. Obtain the organizational chart of nursing
from any department. Is it centralized or
decentralized? Where does the nursing fit?
3. Discuss the functioning of the nursing
delivery system (s) in your health care
organization and does it make the nursing

46

Nursing Leadership and Management

delivery system more efficient or effective?
How do you improve it?
4. Using

"standards

for

evaluating

the

effectiveness of line and staff relationships in
an hierarchical organization," evaluate the
nursing division or service in which you work
as a student or as an employee.

47

Nursing Leadership and Management

CHAPTER FOUR
FUNCTIONS OF MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:


Define the common terms used in the management
process



List down the expected functions of a nurse
manager



Discuss the concepts of each function using some
examples



Describe the effect of delegation on the manager’s
responsibility for the delegated functions.

Definitions


Planning – determining the long-and short-term
objectives (ends) of the institution or unit and the
actions (means) that must be taken to achieve
these objectives.



Staffing- Selecting the personnel to carry out
these actions and placing them in positions
appropriate to their knowledge and skills

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Nursing Leadership and Management



Organizing- Mobilizing human and material
resources so institutional objectives can be
achieved.



Directing- Motivating and leading personnel to
carry out the actions needed to achieve the
institution’s objectives.



Controlling-

Comparing

results

with

predetermined standards of performance and
taking

corrective

action

when

performance

deviates from these standards.


Decision

Making-

searching

for

Identifying

solutions,

and

a

problem,

selecting

the

alternative that best achieves the decision
maker’s objectives.

Management Functions of a Nurse Manager
Success of management depends on learning and using
the management functions. These functions include
planning, organizing, staffing, directing, coordinating and
controlling. These functions represent these activities
expected of managers in all fields. Managers develop
skill in the implementation of these functions as they
gain experience in th role of managers. Nurse Managers

49

Nursing Leadership and Management

also use the same functions as they fulfill their
responsibilities in the organization.

Planning
Planning is a technical managerial function that enables
organizations to deal with the present and anticipate the
future. It is the first and fundamental function of
management because all other management functions
are dependent on it. Planning is deciding what is to be
done, when it is to be done, how it is to be done and
who is to do it. It is an orderly process that gives
organizational direction. Planning is the process of
determining how the organization can get where it wants
to go. Planning is the process of determining exactly
what the organization will do to accomplish its
objectives. In more formal terms, planning has been
defined as ‘the systematic development of action
programmes aimed at reaching agreed objectives by the
process of analyzing, evaluating and selecting among
the opportunities which are foreseen.

Purpose of planning
™ It gives direction to the organization.
™ It improves efficiency.
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Nursing Leadership and Management

™ It eliminates duplication of efforts.
™ It concentrates resources on important services.
™ It reduces guess work.
It improves communication and coordination of
activities

The planning hierarchy
Planning responsibilities are different for managers at
each organizational level.

Strategic planning
Top-level managers, formulate long-term strategic
planning to reinforce the firm’s mission (the mission
clarifies organizational purpose)
Strategic plans are specified for five years period or
more; but

circumstances dictate the planning

horizon.
Tactical planning
Middle management is responsible for translating
strategies into shorter-term tactics. Tactical plans
are often specified in one-year increments. Eg.
annual budget.

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Nursing Leadership and Management

Translating strategic plans into measurable tactical
objectives is important because most strategic
objective is rather vague.

Operational planning
Operational planning is accomplished by fist-line
managers. Operational planning is most concerned
with budgets, quotas and schedules. These are
refinements of tactical objectives in which work is
defined

and

results

are

measured

in

small

increments. Time horizon for operational planning is
very short. Most plans at this level reflect operational
cycles.
Operational objective are:
™ Narrow in scope
™ Short-lived
™ Subject to sadden change.
In order to fulfill her/his own job responsibilities and to
guide subordinates towards agency goals, the nurse
manager must spend scarce materials and human
resources wisely. Since the nursing service operation in
even a small agency is immensely complicated, careful
planning is needed to avoid waste, confusion and error.

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Nursing Leadership and Management

The formal planning process
Formal planning is a systematic process. It consists of
five guidelines. These guidelines provide a general
pattern of rational planning.

Situation audit or environmental assessment
It analyzes the Past, current and future forces that affect
the organization. Expectation of outside interests such
as government officials, insurance companies and
consumers are sought. Expectations of inside interests
such as nurse, doctors, administrators and other staffs
are collected. Environment, demographic, resources,
legal, technological factors should also be considered.

Establish Objectives
Every plan has the primary purpose of helping the
organization succeed through effective management.
Success

is

defined

as

achieving

organizational

objectives. These are performance targets, he end
results that managers seek to achieve.

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Nursing Leadership and Management

Characteristics of objectives
Well-defined objectives have several Characteristics.
They are:


Specific



Measurable



Realistic and challenging



Defined time period

Involve management and staff
Involving a greater number of managers will result in
better plans and more wide spread acceptance of
objectives.

Develop alternatives
A successful planning process will generate several
options for manages to consider. These options are
alternative courses of action that can achieve the same
result. The task of management is to decide among
them. Managers usually consider many alternatives for a
given situation, but a viable alternative suggests a
proposed course of action that is:


Feasible



Realistic



Sufficient
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Nursing Leadership and Management

Communicate plans
Planning requires clear and effective communication at
all

levels

before

performance

begins

to

mirror

expectations. Objectives are written and plans are
documented to give employees direction. Managers
communicate plans into two categories:

A. Standing use plans- are those that are used on
a continuous basis to achieve consistently repeated
objectives. Standing plans take the form of:


Policies



Procedures



Rules

Policies: A standing plan that furnishes broad
guidelines for channeling management thinking
toward taking action consistent with reaching
organizational objectives. It provides guidelines for
behavior. Policies are also instruments of delegation
that alert subordinates to their obligations. Effective
policy statements are clear, understandable, stable
overtime, and communicated to everyone involved.
Procedures: a standing plan that outlines a series of
related actions that must be taken to accomplish a
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Nursing Leadership and Management

particular task. It is an explicit set of actions, often
sequential in nature, required to achieve a well
defined result. Formal procedures provide specific
and detailed instructions for the execution of plans.
Good procedures provide a sequence of actions that
once completed fulfill specific objectives, reinforce
policies

and

help

employees

achieve

results

efficiently and safely.
Rule: is a standing plan that designates specific
requires action. It indicates what an organization
member should or should not do and allows as no
room for interpretation. It is a statement that tends to
restrict actions or prescribe specific activities with no
discretion. Rules usually have a single purpose and
are written to guarantee a particular way of behaving
in a particular way.

B. Single use plans-are those that are used once
to achieve unique objectives or objectives that
are seldom repeated. They are communicated
through:


Programs



Budget



Schedule
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Nursing Leadership and Management

Programs: is a single use plan designed to carry out
a special project within an organization. It comprises
multiple activities orchestrated to achieve one
important objective.
Budget: is a single use financial plan that covers a
specified length of time. It describes in numerical
terms

resources

allocated

to

organizational

activities. By budgeting, managers identify resources
such as money, material and human resource. It
also communicates performance expectations.
Schedule: is a commitment of resources and labor
to tasks with specific time frames.

Approaches to planning
There are three distinct approaches that describe
who has the responsibility for formulating plans:


Centralized

top

down

planning-

is

the

traditional approach to planning in which a
centralized group of executives or staff
assumes the primary planning responsibility.


Bottom-up planning- is an approach that
delegates planning authority to division and
department managers, who are expected to

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Nursing Leadership and Management

formulate plans under the general strategic
umbrella of organizational objectives.


Team planning- is a participative approach to
planning

where

by

planning

teams

comprising managers and staff specialties
initiate plans and formulate organizational
objectives.

Organizing
Organizing may be defined as the arranging of
component parts into functioning wholes. The purpose
of organizing is to coordinate activities so that a goal
can be achieved. The terms “planning” and “organizing”
are often used synonymously. For example, organizing
is considered step in the nursing process; however,
planning is the second. In the managerial process (i.e.,
managerial theory of leadership, planning is considered
the first step and organizing, the second.

In the managerial, planning is the determination of what
is

to

be

accomplished,

and

organizing

is

the

determination of how it will be accomplished. However,
most authors still describe the two processes with
considerable overlap.
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Nursing Leadership and Management

In the nursing process, planning includes writing
objectives, setting priorities, and determining activities to
meet

the

objectives.

Thus,

organizing

may

be

considered part of the planning, even though it is not
specifically identified. Planning, and thus organizing,
may be viewed as being part of all processes, including
the leadership process. Thus, planning and organizing
may be said to answer the what, why, how, when, and
where questions about specific activities.

There are six steps in the organizing process:
1. Establish overall objectives
2. Formulate supporting objectives, policies and
plans
3. Identify and classify activities necessary to
accomplish the objectives
4. Group the activities in light of the human and
material resources available and the best way of
using them under the circumstances
5. Delegate to the head of each group and the
authorities necessary to perform the activities
6. Tie

the

groups

together

horizontally

and

vertically, through authority relationships, and
information systems.
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Nursing Leadership and Management

Establishing Objectives
The first step in the process of organizing is to establish
overall objectives. Objectives are explicit, concise
statements of what is to be accomplished. They provide
directions for selecting materials and methods to
achieve the desired goal. Behavioral objectives can be
measured through observable performance. Overall
objectives are usually broad and give a general idea of
what is to be accomplished.
Five criteria for sound objectives in a management area
have been established. First, the objective must be
acceptable to both the leader and the group who will be
involved in achieving it. They must agree that it is worthy
of their efforts. All members of the group should see the
objectives as related to the purpose of the group.
Second, the objective must be attainable within a
reasonable period of time, that is, it must be realistic.
Third, the objective must be motivational, that is, it
should be stated in such a way that it causes the group
to want to strive toward reaching it. When the nurseleader collaborates with group members in establishing
objectives, members’ ideas should be included, so that
they will feel a part of the objective. When members

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Nursing Leadership and Management

have input into the objective, it becomes their own, and
they are motivated to achieve it.
Fourth, the objective must be simple. It should be
clearly describe only one behavior. A good objective is
as brief as possible, yet it’s meaning is clear.
Finally, the objective must be communicated to all
persons who are concerned with its achievement. The
leader, the group, and their superiors should all know,
initially and throughout the process, the goals toward
which they are working.

Formulate Supporting Objectives
Another part of the second step in the organizing
process

is

the

recognition

of

existing

policies,

procedures, and rules that affect the task and
objectives. A policy is a guide to action that provides a
standard decision for recurring problems and is made by
top-level administrators. Policies aid in keeping activities
in line with the overall objectives of the organization. For
example, all critical patients on being discharge must go
to the door in a wheelchair” is a policy to aid in meeting
the overall goal, “patients will not fall in the hospital.” If a
policy states that a registered nurse must discharge all

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Nursing Leadership and Management

patients,

an

objective

cannot

provide

for

health

assistants or volunteers to discharge patients.

Identify and Classify Activities
If the written objectives are very specific, the required
activities will be obvious. The activities that a nurse will
have to perform to provide care include giving
medications, bathing patients, making beds…. The
nurse leader must know when, what, how and why
activities are done. Then prioritize activities based on
biological and behavioral sciences.

Group Activities
The fourth step in the process of organizing is to group
activities according to the human and material resources
available. Once all the activities have been identified
and given a priority, the nurse leader must analyze her
resources, so that they can be used to best advantage
in terms of time, talents, and economy. The nurse leader
must assess both her group members and the material
resources that she has at hand.

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Delegation
Delegation is the process of assigning part or all of one
person’s responsibility to another person or persons.
Delegating is an effective management competency by
which nurse managers get the work done through the
employees.
The purpose of delegation is efficiency; no one person
can do all the work that must be done; therefore, some
work must be passed on, or delegated to others.
However, it must be remembered that, even when an
activity is delegated to someone else, the ultimate
responsibility for that activity still belongs to the nurseleader (i.e. the person who delegated the activity.
Nurse managers need to be able to delegate some of
their own duties, tasks, and responsibilities as a solution
to

overwork,

which

lead

to

stress,

anger,

and

aggression. As nurse managers learn to accept the
principle of delegation, they become more productive
and come to enjoy relationships with the staff. The
following list suggests ways for nurse managers to
successfully delegate.


Train and develop subordinates. It is an
investment. Give them reasons for the task,

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authority, details, opportunity for growth, and
written instructions if needed.


Control and coordinate the work of subordinates,
but do not go over their shoulders. To prevent
errors,

develop

ways

accomplishment

of

of

communication,

measuring

objectives

standards,

the
with

measurements,

feedback and credit.


Follow up by visiting subordinates frequently.
Expect employees to make suggestions to
improve work and use the feasible ones.



Encourage

employees

to

solve

their

own

problems, and then give them the autonomy and
freedom to do.


Assess results. The nurse manager should
accept the fact that employees will perform
delegated tasks in their own style.



Give appropriate rewards



Do not take back delegated tasks.

Barriers to Delegating
Barriers in the Delegator
ƒ

Preference for operating by oneself

ƒ

Demand that everyone “know all the details”
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Nursing Leadership and Management

ƒ

“I can do it better myself” fallacy

ƒ

Lack of experience in the job or in delegating

ƒ

Insecurity

ƒ

Fear of being disliked

ƒ

Refusal to allow mistakes

ƒ

Lack of confidence in subordinates

ƒ

Perfectionism, leading to excessive control

ƒ

Lack of organizational skill in balancing workloads

ƒ

Failure to delegate authority commensurate with
responsibility

ƒ

Uncertainty over tasks and inability to explain

ƒ

Disinclination to develop subordinates

ƒ

Failure to establish effective controls and to
follow up

Barriers in the Delegatee
ƒ

Lack of experience

ƒ

Lack of competence

ƒ

Avoidance of responsibility

ƒ

Over dependence on the boss

ƒ

Overload of work

ƒ

Immersion in trivia

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Nursing Leadership and Management

Tie together
The final step in the process of organizing is that of
coordination. Group of group members must be placed
horizontally and vertically into a framework of authority
relationships

and

information

systems

in

the

organizational structure. The goal of organizing is the
coordination of activities, and it is with this last step that
the framework is fully established. It brings the whole
process together. Even though all the five previous
steps are satisfactorily completed, if the members’
activities are not tied in, the process can still fail.
Members need to know to whom they can go for help
and relief.


Open communication lines are and essential part
of coordination



Group members must also know to whom they
can turn for assistance



Group members, as well as the nurse leader,
must be aware of who is fulfilling which tasks, so
that they will be able to find one another when
necessary.

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Staffing
Staffing is the management activity that provides for
appropriate and adequate personnel to fulfill the
organization’s objectives. The nurse manager decides
how many and what type of personnel are required to
provide care for patients. Usually the overall plan for
staffing is determined by nursing administration and the
nurse manager is in a position to monitor how
successful the staffing pattern is as to provide input into
needed change.

Staffing is a complex activity that involves ensuring that
the ratio of nurse to patient provides quality care. The
situation of a nursing shortage and the high activity
levels of admitted patients to acute care areas
complicate this process. Staffing depends directly on the
workload or patient care needs. An ideal staffing plan
would provide the appropriate ratio of caregivers for
patients’ individual needs based on data that predict the
census.

Directing
Directing is a function of the manager that gets work
done through others. Directing includes five specific
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Nursing Leadership and Management

concepts;

giving

directions,

supervising,

leading,

motivating, and communicating, as described below:


Giving directions is the first activity and suggests
that directions should be clear, concise and
consistent

and

should

confirm

to

the

requirements of the situation. The manager
should be aware of the tone of the directives.
Different types of situations require different
emphasis.

For

example,

and

emergency

situation calls for different variation of voice than
does a routine request.


Supervising is concerned with the training and
discipline of the work force. It also includes follow
up to ensure the prompt execution of orders.



Leading is the ability to inspire and to influence
others t the attainment of objectives



Motivating is the set of skills the manager uses to
help the employee to identify his/her needs and
finds ways within the organization to help satisfy
them.



Communicating: involves the what, how, by
whom, and why of directives or effectively using
the communication process.

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Coordinating
Coordinating is by definition the act of assembling and
synchronizing people and activities so that they function
harmoniously

in

the

attainment

of

organizational

objectives. Think about the situations in your own life
when you have had to coordinate the multiple activities
for an important event. An example in everyday life that
demands coordination is a wedding. The music, flowers,
ceremony and numerous other considerations must be
coordinated so that each can contribute to make the
wedding beautiful and joyful. The more assurance that
all

parties

are

cooperating

and

fulfilling

their

agreements, the more likely that the wedding will be a
success with minimal complications.

Controlling
Is the regulation of activities in accordance with the plan.
Controlling is a function of all managers at all levels. Its
basic objective is to ensure that the task to be
accomplished
involves

is

appropriately

establishing

standards

executed.
of

Control

performance,

determining the means to be used in measuring
performance, evaluating performance, and providing
feedback of performance data to the individual so
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Nursing Leadership and Management

behavior

can

be

changed.

Controlling

is

not

manipulation, rigid, tight, and autocratic or oppression.
Management by objectives (MBO) can be considered as
a control mechanism. Based on MBO principledetermining

objectives

(standards)

against

which

performance can be measured can be stated. Second,
specific measures have to be established to determine
whether these objectives are met. Third, the actual
accomplishment of the objectives would be measured in
relation to the standard and this information would be
fed back to the individual. Then corrective action could
be taken.

Learning Activities
1. Observe a manager using the functions of a
management. Think about what it is the manager
does while performing each of the following:
1.1 Directing
1.2 Coordinating
1.3 Controlling
2. Divide the class into three groups. Have each group
represent a different level of management. Give
each group time to devise a plan that would reflect
the type of planning expected at each level.
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CHAPTER FIVE
DECISION MAKING
Objectives:
At the end of this chapter, the student should be able to:
1. Describe the types of decisions
2. Explain the mechanisms of decision-making
3. Discuss the steps of logical decision-making
4. Identify the factors responsible for decision-making
5. Discuss the importance of decision making for nurse
managers?
6. Recognize the decision-making tools
7. Explain

the

barriers

for

decision-making

and

mechanisms of overcoming it

Decision Making
Decision making-is a choice made between two or
more alternatives. It is choosing the best alternative to
reach the predetermined objective. Thus decisionmaking is a process of identifying and selecting a course
of action to solve specific problem.

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Types of decisions
Decisions made in the nursing service can be
categorized depending upon the following criteria


How much time the manager spends in making
decision



What proportion of the organization must be
involved in making decision



The organization function/ the nursing/midwifery
functions on which they focus

On the basis of these there are three classifications:
1. Ends -Means
2. Administrative-Operational
3. Programmed-Non-programmed
1. Ends-Means
Ends: deals with the determination of desired
individual

or

organizational

results

to

be

strategic

or

achieved
Means:

decisions

operational

deal

programmes,

with

activities

that

will

accomplish desired results. These usually occur
during managerial planning processes, strategy
and objective formulation processes

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2. Administrative-Operational
Administrative: made by senior management,
which have significant impact throughout the
organization. Usually this type of decision is
concerned with policy, resource allocation and
utilization.
Operational: are generally made by mid level and
first line managers and address day to day
operational

activities

of

a

particular

organizational
3. Programmed-Non -programmed
Programmed-these are repetitive and routine in
nature.

Since

procedures,

they

rules

can

and

be

often

programmed,
manuals

formulated to cover those situations
None programmed: unique and non- routine

Conditions that initiate decision making
1. Opportunity/threat
2. Crisis
3. Deviation
4. Improvement

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Ways of Decision Making
1. Relying

on

tradition:

taking

the

same

decisions that had been undertaken when
similar problem arouse in the past
2. May appeal to authority and make decisions
based on suggestions from an expert/a
higher level management
3. Priori reasoning: based on assumption
4. Logical

decision making:

intelligent

and

systematic

is

a rational,

approach

to

decision making

Steps of logical Decision Making
1. Investigating the situation


Define the problem



Identify the problem objective



Diagnose the cause

2. Develop alternatives
3. Evaluate alternatives
4. Implement and follow up
Factors Influencing Decision Making
1. Decision makers attribute


Knowledge, experience, and judgment



Perception and personality
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Nursing Leadership and Management



Values and philosophy

2. The Situation


Urgency of solution and time pressures



Magnitude and importance



Structure and uncertainty and risk



Cost benefit

3. Environmental Constraints


External



Internal

Implications for Nurse Managers
The activities of the problem solver, the nature of the
situation and the environmental constraints influence
how decision is done; resource spent in performing it,
and the quality of the ultimate decision. However, these
influences are not mutually exclusive. Managers should
recognize these attributes and be sensitive to the factors
that affect decision-making, change their method as
appropriate, modify and mitigate detrimental influences
when possible, and cope with those that cannot be
changed. In this way, they will improve the quality of
decision-making.

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Encouraging creativity


Convergent

thinking-the

problem

is

divided into smaller and smaller pieces to
find a more manageable perspective.


Divergent thinking: One's view of the
problem is expanded. The problem is
considered in different ways



Brain

storming:

under

favorable

circumstances a group working together
can identify more ideas than an individual
or the group of individuals working
separately. It is a technique managers
can use to create a free flow of ideas

Decision Making Tools
There are many tools. The most common are:
1. Probability theory: is the likelihood that
an event or outcome will actually occur
and allow decision makers to calculate an
expected value for each alternative.
Expected Value (EV) = Income it would
produce (I) x its probability of making that
income (P).

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2. Decision tree= are graphic decision
making tools used to evaluate decisions
containing a series of steps

Deciding to decide
1. Is the problem easy to deal with
Tip: avoid being bogged down in trivial
details. Effective managers reserve decisionmaking techniques for problems that require
them.
2. Might the problem resolve itself
Tip: prioritize and rank problems in order of
importance
3. Is it my decision
Tip: the closer to the origin of the problem the
decision is the better. Before deciding ask
the following questions:


Does

the

issue

affect

other

departments?


Will it have a major impact on the
superior's area of responsibility?



Does it need further information
from higher level?

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Nursing Leadership and Management



Does it involve serious breach of
my department’s budget?



Is this problem outside my area of
responsibility or authority?

If the answer to any of these questions is 'YES' pass it
to your superior.

Barriers to Effect Decision-Making
1. Easy recall: the more easily can recall the
event, the more frequently they believe it
occur
2. Easy search: not to put effort to seek
information from the appropriate sources
3. Misconception of chance: Most people do
not understand the nature of random
events
4. Confirmation gap
5. Relaxed avoidance: the manager decides
not to decide or act after noting that the
consequences of inaction will not be
serious
6. Defensive

avoidance:

Faced

with

a

problem and unable to find a good
solution based on past experience, this
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Nursing Leadership and Management

manager seeks a way out. He/she may
let someone else make decisions. This
resigned

posture

may

prevent

consideration of more viable alternatives.
7. Panic: the manager feels pressurized not
only by the problem but also time

Overcoming barriers to individual problem solving
1. Setting priority
2. Acquiring relevant information
3. Proceeding methodically and carefully

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Learning activities
1. Define decision-making
2. Define some of the common concepts in decisionmaking
3. What is a decision environment?
4. Explain

the

impact

of

gathering

too

much

information
5. Explain the three types of decisions
6. How do nurse managers make decision?
7. What are the steps to be followed in logical
decision-making?
8. What are the factors necessitating decisionmaking?
9. Why do you think the importance of decision
making for nurse managers?
10. List the decision-making tools
11. What the barriers for decision-making? How can
we overcome these problems?

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CHAPTER SIX
THEORIES OF LEADERSHIP AND
MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:


Trace

the

evolution

of

early

leadership

and

management theories into the contemporary leader
manger theories


Compare and contrast the democratic style to the
authoritarian and laissez faire styles; Theory X to
Theories Y and Z



Discuss the three elements of situational leadership
theory

(contingency

model)

and

discuss

it

associated it with Path-Goal theory

Leadership and Management Theories
What is the Difference between Management and
Leadership?
Mangers come from the “headship” (power from
position) category. They hold appointive or directive
posts in formal organizations. They can be appointed for
both technical and leadership competencies, usually
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needing both to be accepted. Managers are delegated
authority, including the power to reward or punish. A
manager is expected to perform functions such as
planning, organizing, directing (leading) and controlling
(evaluating).
Informal leaders, by contrast, are not always managers
performing those functions required by the organization.
Leaders often are not even part of the organization.
Florence Nightingale, after leaving the Crimea, was not
connected with an organization but was still a leader.
Managers focus on results, analysis of failure, and
tasks, management characteristics that are desirable for
nurse managers. Effective managers also need to be
good leaders. Manager-leaders ask for information,
provide positive feedback, and understand the power of
groups. Mistakes are tolerated by manager-leaders who
challenge constituents to realize their potential.

Similarities between Leadership and management
Gardner asserts that first class managers are usually
first class leaders. Leaders and leader-managers
distinguish themselves beyond general run-of-the-mill
managers in six respects:

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Nursing Leadership and Management

ƒ

They think longer term-beyond the day’s crises,
beyond the quarterly report, beyond the horizon.

ƒ

They look beyond the unit they are heading and
grasp its relationship to larger realities-the larger
organization, of which they are a part, conditions
external to the organization, global trends.

ƒ

They reach and influence constituents beyond
their jurisdiction, beyond boundaries. Thomas
Jefferson influenced people all over Europe.
Gandhi Influenced people all over the world.

ƒ

They put heavy emphasis on the intangibles of
vision, values, and motivation and understand
intuitively the non-rational and unconscious
elements in the leader constituent interaction.

ƒ

They have the political skill to cope with the
conflicting

requirements

of

multiple

constituencies.
ƒ

They think in terms of renewal. The routine
manager tends to accept the structure and
processes,

as

they

exist.

The

leader

or

leader/manager seeks the revisions of process
and structure required by ever changing reality.
Good leaders, like good managers, provide visionary
inspiration, motivation, and direction. Good managers,
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Nursing Leadership and Management

like good leaders, attract and inspire. They want to
pursue goals and values they consider worthwhile.
Therefore, they want leaders who respect the dignity,
autonomy, and self-esteem of constituents.

Early Leadership Theories
A. Trait Theories – If you have ever heard the
statement that “leaders are born, not made”, then
you

have

heard

someone

expressing

the

fundamental belief underlying a trait theory of
leadership. Trait theories assume that a person
must have a certain innate abilities, personality
traits, or other characteristics in order to be a
leader. If true, it would mean that some people
are naturally better than others.
B. Great Man Theory – According to the “Great
man” theory of leadership tremendous influence
of some well known people has actually
determined or changed the course of history.
Some believe that these people possessed
characteristics that made them great leaders.
Such important historical figures, such as
Caesar, Alexander the great, Hitler, and Gandhi

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Nursing Leadership and Management

have been studied to find the characteristics that
made these men leaders of their time.
C. Individual Characteristics- Many studies have
focused on ascertaining which individual physical
or

personality

traits

are

associated

with

leadership. Despite the fact that no single trait
has been discovered in all leaders, some popular
beliefs

remain

individuals'

and

positions,

influence
because

selection
they

of

seem

stronger and more dominating. A tall person can
be physically imposing and can literally “look
down” on other people.
There are also certain traits and behaviors commonly
associated with leadership abilities. For example, the
most outspoken person in a group is often assumed to
be a leader even when other evidence does not support
this assumption. The most intelligent or skilled person in
a group is often designated the leader because other
group members admire this person.
Charismatic Leaders- Charisma is the quality that sets
one

person

apart

from

others:

supernatural,

superhuman, endowed with exceptional qualities or
powers. Charismatic leadership can be good or evil.
Charismatic leaders emerge in troubled times and in
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Nursing Leadership and Management

relation to the state of mind of constituents. They
eventually run out of miracles even though the leaders
are magnetic; persuasive and fascinating.

Behavioral Theories
The behavioral theories, sometimes called the functional
theories of leadership, still focus on the leader. The
primary difference between the trait and behavioral
theories is that the behavioral theories are concerned
with what a leader does rather than who the leader is.
They are still limited primarily to the leader element in a
leadership situation, but they are far more action
oriented and do consider the co-actors.

Authoritarian-Democratic-and Laissez-Faire styles
The classic research done by Lewin, Lippitt, and White
(White, Lippitt, 1960) on the interaction between
leaders and group members indicated that the behavior
of the leader could substantially influence the climate
and outcomes of the group. The leaders’ behaviors were
divided into three distinct patterns called leadership
styles: authoritarian, democratic, and laissez-faire.
These styles can be thought of as a continuum from a

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Nursing Leadership and Management

highly controlling and directive type of leadership to a
very passive, inactive style as illustrated in fig.

.

The authoritarian leader maintains strong control over
people in the group. This control may be benevolent and
considerate (Paternalistic leadership) or it may be
dictatorial, with the complete disregard for the needs
and feelings of group members. Authoritarian leaders
give orders and expect group members to obey these
orders.

Directions

are

given

as

commands,

not

suggestions. Criticism is more common from the
authoritarian leader than from the other types, although
not

necessarily

a

constant

occurrence.

Mostly

authoritarian leaders are also quite punitive.
The leader alone, not by the group, does decisionmaking. Some will try to make decisions congruent with
the group's goals. The less benevolent leaders will make
decisions that are directly opposed to the group's needs
or goals. The authoritarian leader clearly dominates the
group, making the status of the leader separate from,
and higher than, the status of group members. This
reduces the degree of trust and openness between
leader and group members, particularly if the leader
tends to be punitive as well.

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Authoritarian leadership is particularly suitable in an
emergency situation when clear directions are the
highest priority. It is also appropriate when the entire
focus is on getting the job done or in large group when it
is difficult to share decision making for some reason. It is
often referred to today as a directive or controlling style
of leadership.
In contrast, democratic leadership is based on the
following principles:
1. Every group member should participate in
decision-making.
2. Freedom of belief and action is allowed within
reasonable bounds that are set by society and by
the group.
3. Each individual is responsible for him self or her
self and for the welfare of he group.
4. There should be concern and consideration for
each group member as a unique individual.
Democratic leadership is much more participative and
far less controlling than authoritarian leadership. It is not
passive, however. The democratic leader actively
stimulates and guides the group toward fulfillment of the
principles listed and toward achievement of the group's
goals.
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Rather than issuing commands, democratic leader offer
information, ask stimulating questions, and make
suggestions to guide the work of the group. They are
catalysts rather than controllers, more likely to say "we"
rather than" I" and "you" when talking about the group.
They

set

productivity.

limits,

enforce

Criticism

is

rules,

and

constructive

encourage
rather

than

punitive.
Control is shared with group members who are expected
to participate to the best of their abilities and experience.
The democratic style demands a strong faith in the
ability of group members to solve problems and to
ultimately make wise choices when setting group goals
and deciding how to accomplish these goals.
Most studies indicate that democratic leadership is not
as efficient as authoritarian leadership. While the work
done by a democratic group is more creative and the
group is more self-motivated, the democratic style is
also more burdensome. First, it takes more time to
ensure that everyone in the group has participated in
making decision, and this can be very frustrating to
people who want to get a job done as fast as possible.
Second, disagreements are more likely to arise and
must be resolved, which can also require much effort.
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Democratic leadership is particularly appropriate for
groups of people who will work together for an extended
time, when interpersonal relationships can substantially
affect the work of the group. It is often called supportive
or participative leadership today. There are variations in
the degree to which decision-making is shared with the
group, with styles midway between democratic and
autocratic. For example, a leader may encourage in put
from group members and consider their views but make
the final decision.
The laissez faire leader is generally inactive, passive,
and non-directive. The laissez- faire leader leave
virtually all of the control and decision making to the
group and provides little or no direction, guidance, or
encouragement. Laissez faire leaders offer very little to
the group: few commands, questions, suggestions, or
criticism. They are very permissive, set almost no limits,
and allow almost any behavior.
Some laissez faire leaders are quite supportive of
individual group members and will provide information or
suggestions when asked. The more extreme laissez
faire leader, however, will turn such a request back to
the group. When the laissez faire style becomes
extreme, no leadership exists at all.
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In a laissez faire group, members act independently of
each other, disinterest will set up, activity becomes
chaotic and the frustration level rises. The goals are
unclear and procedures are confusing or absent
altogether. In most situations, however, laissez faire
leadership

is

unproductive,

inefficient,

and

unsatisfactory. Laissez-faire leadership is often called
permissive or non -directive leadership today.

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Degree of

Authoritarian

Democratic

Laissez faire

Little freedom

Moderate

Much freedom

freedom
Degree of

freedom
High control

Moderate

control
Decision

No control

control
By the leader

making

Leader and

By the group or

group

by no one

together
Leader

High

High

Minimal

Assumption of

Primarily the

Shared

Relinquish

responsibility

leader

Output of the

High quantity,

Creative,

Variable may

group

good quality

high quality

be

activity level

poor quality
Efficiency

Very efficient

Less efficient

Inefficient

than
authoritarian

Fig- 6.1 comparison of authoritarian, democratic, and
Laissez-faire leadership styles

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Management Theories
Likert’s Management System
_Democratic_______________________

Authoritative

System 1

System 2

System 3

System 4

Consultative

Participative

Exploitative

Benevolent

Authoritative

Authoritative

Democratic

Democratic

Top management

Top management

Some delegated

Decision making

Makes all decisions

makes most

decisions made at

dispersed

decisions

lower levels

throughout
organization

Motivation by

Motivation by

Motivation by

Motivation by

coercion

economic and ego

economic, ego, and

economic rewards

motives

other motives such established

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as desire for new group participation
experiences
Communication

Communication

Communication

Communication

downward

mostly downward

down and up

down, up, and with
peers

Review and control Review and control Review and control Review and control
functions

functions

primarily functions

primarily functions shared by

Concentrated in top at top

at the top but ideas superiors and

management

are

solicited

lower levels

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Situational Theories
1. Contingency Theory (Fred Fiedler) In the contingency model, three situational variables are
used to predict the favorability of a situation for the
leader: the leader's interpersonal relations with group
members, the leaders' legitimate power, and the task
structure.

Variables affecting Leadership Effectiveness
1. Leader-member
relationships
members

of

relations-

between
the

the

group.

the
leader
(The

personal
and

the

better

the

relationships, the more favorable the situation).
2. Degree of task structure- how specifically the job
can be defined so that everyone knows exactly
what to do. (The more structured the task, the
more favorable the situation).
3. Position Power- the leaders place within the
organization and the amount of authority and
power given to the leader. Position power may
be strong or weak; it does not reflect the strength
of the individual leader’s personality; rather it
measures the leader’s status in the organization.

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(The greater the position power, the more
favorable the situation).

According to the contingency model, a nurse manager
should modify situations based on group relations,
personal power, and task structure to improve staff
productivity.

A

nurse

manager

who

uses

the

contingency model must have a thorough understanding
of her/his relationship with staff members, her/his power
and status within the organization, and the nature of the
group task.

2. Path -Goal Theory (Robert House)
Robert House's Path Theory, introduced in 1971, is
concerned with motivation and productivity. According to
this theory, the motivational function of management is
to help employees see the relationship between
personal and organizational goals, clarify the "paths" to
accomplishing these goals, remove obstacles to goal
achievement, and reward employees for the work
accomplished.

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3. Contemporary Leader-Manager Theories
Theories X and Y (Douglas McGregor)
In his 1960 book, the Human side of Enterprise,
McGregor (1960) compared two different sets of beliefs
about human nature, describing how these led to two
very

different

approaches

to

leadership

and

management. The first, more conventional approach, he
called Theory X, and the second, more humanistic,
approach was termed as Theory Y.
Theory X is based on a common view of human nature:
the ordinary Person is lazy, unmotivated, irresponsible,
and not too intelligent and prefers to be directed rather
than act independently. Most people do not really like to
work and do not care about such things as meeting the
organization's goals. They will work only as hard as they
must to keep their jobs, and they avoid taking on
additional responsibility. Without specific rules and the
threat of punishment, most workers would come in late
and produce careless work.
Based on this view of people, leaders must direct and
control people in order to ensure that the work is done
properly. Detailed rules and regulations need to be
developed and strictly enforced. People need to be told
exactly what to do, and how to do it. Close observations
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is necessary to catch mistakes, to make sure people
keep working, and to be sure that rules, such as taking
only 30 minutes for lunch, are obeyed.
Motivation is supplied by a system of rewards and
punishments. Those who do not obey the rules are
reprimanded, fined or fired. Those who do obey the
rules are rewarded with continued employment, time off
and pay rises.
According to theory Y, the behavior described in theory
X is not inherent in human nature but a result of
management emphasis on control, direction, reward,
and punishment. The passivity, lack of motivation, and
avoidance of responsibility are symptoms of poor
leadership

and

indicate

that

people's

needs

for

belonging, recognition, and self-actualization have not
been met.
Theory Y proposes that the work itself can be
motivating

and

rewarding.

People

can

become

enthusiastic about their work and will support the team
or organization's goals when these goals also meet their
need. They can be trusted to put forth adequate effort
and to complete their work without constant supervision
if they are committed to these goals. Under the right
conditions, the ordinary person can be imaginative,
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creative, and productive. Theory Y leaders need to
remove obstacles, provide guidance and encourage
growth. The extensive external controls of theory X are
not necessary because people can exert self-control
and self-direction under theory Y leadership.

4. Theory Z (Ouchi) /participative approach to
management/
Ouchi (1981) expanded and enlarged on theory Y and
the democratic approach to leadership to create what he
calls theory Z. Like theory Y, Theory Z has a humanistic
viewpoint and focuses on developing better ways to
motivate people, assuming that this will lead to
increased satisfaction and productivity.

Theory Z was developed in part from a study of
successful Japanese organizations. It was adapted to
the American culture, which is different in some ways
but similar in its productivity goals and advanced
technology. Elements of theory Z include collective
decision-making, long-term employment, slower but
more predictable promotions, indirect supervision, and a
holistic concern for employees.

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Collect

Decision-making

-

This

is

democratic,

participative mode of decision making which is extensive
and involving everyone who is affected by the decision.
Everyday problems are also dealt with in a participative
manner through problem solving groups called quality
circles; in which all members of a team or deportment
are encouraged to identify and resolve problems faced
by group or organizations.
Long-Term Employment- Employees move around
with in the organization, taking on different functions and
working in different departments. People who do this
become less specialized but more valuable to the Z
organizations, which is consequently more willing to
invest in training its employees and encouraging their
growth. In turn, they are better able to understand how a
department works and its problems and capabilities.
Slower promotions - Rapid promotions can be
misleading; if everyone is promoted rapidly, your relative
position in the organization does not really change. It
also means that close working relationships with in
groups do not have times to develop, nor is there any
incentive to develop them. Slower but more predictable
promotions allow sufficient time to make a thorough

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evaluation of the individual's long-term contribution to
the organization.
Indirect supervision- Workers become a part of the
culture of the organization and are intimately familiar
with

its

working

philosophy,

values,

and

goals.

Decisions are made not only on the basis of what will
work but also on the basis of what fits the culture of the
organization. A person who is well acquainted with
these characteristics of the organization does not need
to be told what to do or what decision to make as often
as a new, unassimilated employee is.
Holistic Concern- Trust, fair treatment, commitment,
and loyalty are all characteristics of the Theory Z
organization. These characteristics are part of the over
all consideration for each employee as a whole,
including concern for the employee's health and well
being, as well as his/her performance as a worker.

Motivating Staff
Why do you motivate people?
Motivation is unquestionable important in health care
institutions because, like in any other organization,
people are required to function effectively if they are to
provide adequate patient care. This implies that a health
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care institution must motivate qualified personal to seek
employment in the institution and then motivate them to
remain on the job. Continual turnover means continual
recruiting

and

training

costs,

inconvenience,

and

disruption of staff functions.
A leadership function is to arouse, excite, or
influence another person to behave in some role or
perform some action the person would not ordinarily
do.
Motivation Theories
Need hierarchy Theory (Maslow)
Maslow (1943; 1954) stated that a lower level need is
prerequisite, or controls behavior until it is satisfied, and
then the next higher need energizes and directs
behavior. The hierarchy, from the lowest to the highest
level, is as follows: (a) physiological needs (e.g. hunger,
thirst), (b) safety needs (i.e., bodily safety), (c) need for
love and sense of belongings (e.g. friendship) affection,
(love), and (d) need for self-esteem (e.g. recognition,
appreciation, self respect) and (e) self actualization (e.g.
developing one's whole potential).

Maslow's need theory is frequently used in nursing to
provide an explanation of human behavior. A patient's
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needs are viewed in this hierarchical order, with nursing
care directed toward meeting the lower level needs
before addressing higher needs.

Two Factor theories- Hertzberg (Theory of Job
satisfaction)
Hertzberg enlarged on the theory Y approach by
dividing the needs that affect a person's motivation to
work into two sets of factors: those that affect
dissatisfaction and those that affect satisfaction. The
first set, called hygiene factors are those factors that
meet a person's need to avoid pain, insecurity, and
discomfort. If not met, the employee is dissatisfied. The
second set, called motivation factors are those that meet
needs to grow psychologically, when met, the employee
feels satisfied. These are distinct and independent
factors according to Hertzberg. Meeting hygiene needs
will not increase satisfaction, and meeting motivation
needs will not reduce dissatisfaction.
Engineers and accountants were asked to describe
incidents at work that made them feel especially good or
bad. The hygiene factors include:


Adequate salary



Appropriate supervision
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Good interpersonal relationships



Safe and tolerable working conditions (including
reasonable policies and procedures)
The motivation factors include:



Satisfying, meaningful work



Opportunities for advancement and achievement



Appropriate responsibility



Adequate recognition

The leader manager's function is to ensure that both
sets of needs are met, some directly and others by
providing opportunities to meet them in a conducive
work environment.

Achievement Need Theory (McClelland)
McClelland claimed that human needs are socially
acquired and that humans feel basic needs for
achievement,

affiliation,

and

power.

Need

for

achievement is the drive to exceed one's former
accomplishments, to perform an activity more skillfully or
effectively than before. A person with high achievement
need to spend much time thinking about how to improve
personal performance, how to overcome obstacles to
improvement, and what feelings will result from success
and failure. McClelland claims that a person with high
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achievement need to set moderate, realistic goals, enjoy
problem-solving

activities,

and

desires

concrete

feedback on performance.

The need for affiliation consists of a desire for
friendship, love, and belonging that causes a person to
spend much time and planning how to establish friendly
personal relations. Persons' with high affiliation need are
sensitive to others' feelings, support others' ideas, and
prefer jobs involving conversational give and take.
Need for power is the desire to control the means of
influencing others and resisting control by others.
Persons with high power need to spend much time
thinking

about

how

to

gain

authority,

dominate

decisions, and change others' behavior. Such persons
are likely to be articulate, demanding, and manipulative
in dealing with peers and subordinates.

Equity Theory (Adams)
Adams's (1965) equity theory of motivation suggests
that an employee continuously compare her or his work
inputs (skill, effort, time) and outcomes (status, pay,
privileges) with those of other employees. The employee
perceives

inequity

whenever
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disproportionate to those received by other employees
for the same amount of input. Feelings of inequity
motivate an employee to resolve the inequity by
reducing input, attempting to increase outcomes,
selecting a different comparison worker, or resigning.
Equity does not in any way imply equality; rather, it
suggests that those employees who bring more to the
Job deserve greater rewards.

Expectancy Theory (Victor Vroom)
Victor Vroom's expectancy theory of human motivation
indicates that a person's attitudes and behavior are
shaped by the degree to which they facilitate the
attainment of valued outcomes. According to Vroom's
theory, the amount of an employee's job effort depends
on her or his perception of the relationship between
good performance and specific outcomes.

Transformational Leadership
A transformational leader is one who “commits people to
action, who converts followers into leaders, and who
may

convert

leaders

into

agents

of

change”.

Transformational leaders do not use power to control
and

repress

constituents.
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empower constituents to have a vision about the
organization and trust the leaders so they work for goals
that benefit the organization and themselves.
Leadership is thus not so much the exercise of power
itself as it is t he empowerment of others. The goal is
change in which the purpose of the leader and that of
the constituent become enmeshed, creating a collective
purpose. Empowered staffs become critical thinkers and
are active in their roles within the organization. A
creative and committed staff is the most important asset
that

an

administrator

can

develop.

People

are

empowered when they share in decision-making and
when they are rewarded for quality and excellence
rather than punished and manipulated. When the
environment is humanized and people are empowered,
they feel part of the team and believe they are
contributing to the success of the organization. In
nursing, empowerment can result in improved patient
care, fewer staff sick days, and decreased attrition.
Nurses who are transformational leaders have staff with
higher job satisfaction and who stay in the organization
for longer periods.

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Nurses Role- as- a Leader
Leaders make things happen! As a leader, your first
priority is to get the Job done. In order to do this, you
must:
1. Know your objectives and have a plan for
reaching them
If you are unclear about your goals, clarify them
with your manager.
On planning, list everything you have to do both
short & long-term goals.
Set priorities. Decide which t asks are the most
important in achieving your objectives.
Decide how much time you will need to complete
each task.
Check to see that resources needed to complete
the task are available.
Use wall calendars, desk calendars daily to do lists
and other aids to help you develop a plan for getting
jobs done.
2. Build a team committed to achieving those
objectives
3. Help each team member to give his or her best
effort.

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Achieving goals depends on teamwork
You simply cannot do everything on your own. As a
leader, it is your Job to build a team that values what it
does and knows that it is valued.

Set clear standards
Let your team know exactly what you expect in terms of
quality and quality of work, time keeping, and following
safety rules. Strive to maintain high but realistic
standards.

Explain the "Why" as well as the "What"
It is important for team members to understand why a
task is necessary and why it must be done in a certain
way and how it will be achieved.

Encourage Involvement
Whenever the situation allows, ask for team member's
ideas and opinions. Team members who are involved in
the decision making process are more likely to feel they
have a stake in achieving goals. However, be sure your
team understands that you are responsible for making
the final decision.

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Build positive working relationships
4. Strive to be fair with all employees at all times.
5. Be understanding. Keep in mind that everyone
makes mistakes occasionally. When you must
criticize, be constructive and tactful.
6. Build an atmosphere of respect among team
members.
7. Put the team first. Make it clear that you are
more interested in the group's achievements
than in the personal gain.
Keep your team informed
Provide as much information as you can as soon as you
can. The news you have to convey may not always be
pleasant. However, your team will appreciate hearing it
directly from you instead of through the grapevine.

Leader use different styles
In general, your leadership style will depend on your
personality, when you feel comfortable with, the abilities
of your team members and the situation at hand. For
example, you may use a:
8. Participative style, when it is appropriate to involve
members of your team in making decisions

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9. Directive style, when a situation requires you to give
specific instructions, such as when training new
employees. Flexibility and good judgment are
essential to successful leadership.

Leaders tend to share some important qualities
While no two leaders are exactly alike, in general,
leaders are:
10. Positive- they believe in themselves and others,
and the contributions they can make
11. Enthusiastic - they're willing to tackle tasks that
others may dismiss as possible
12. Committed to excellence - they're always looking
for new and better ways to do things
13. Self confident- they're willing to make decisions
even when these are unpopular
14. Sincere - when they make a promise, they do all
they can to keep it
15. Open to new ideas - they realize they do not
have all the answers.

What Makes a Leader?
The 20 most important qualities of a leader, as cited by
3,032 Latinos in a recent nation-wide survey. Some
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traits appear similar because they were named in
response to and open-ended question, not chosen from
a prepared list

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1. Honest/Trustworthy/Integrity

50.4%

10. Just/impartial/Fair

2. Intelligent/Educated/Experienced

7.5%

11. Strong leader/Assertive 1.7%

3. Respectful/Respects the people

4.6%

12. Skilled communicator 1.2%

4. Serve/Help the community

4.3%

13. Patriot/Loves country 1.2%

5. Loving/compassionate/kind

4.1%

14. Hard working/ethical 0.8%

6. Strong moral values/Ethical person

2.9%

15. Good listener/Accessible 0.6%

7. Good person/Responsible

2.8%

16. Dedicated/Committed 0.6%

8. Courageous/Tenacious

2.7%

17. Charismatic/Visionary 0.5%

9. Humble/Sincere

2.6%

18. Goal oriented/Efficient 0.3%

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Obtaining and Using Power
Power is the ability and willingness to influence
another’s behavior for the sake of producing intended
effects. When power is not linked to a worthwhile goal, it
is used as a personal possession, and becomes evil.
The essence of power is the ability to cope with life’s
demands; to impress one’s will on external events, to
achieve significance in the total schemes of things.

Bases of Power
In order to acquire power, maintain it, and use it
effectively, a manager must recognize power sources
and know the types of power needed to effect change.
There are six bases of social power common in
organizations.
ƒ

Reward power is based upon the incentives the
leader can provide for group members to
influence behavior by granting rewards. For
example,

a

nurse

manager

may

have

considerable influence in determining a vacation
time of a staff nurse and give incentives or
recommendations.

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Nursing Leadership and Management

ƒ

Punishment, or coercive power, is based in
influencing behavior through the negative things
a leader might do to individual group members or
the group as a whole by withholding rewards or
applying sanctions. Example, Giving undesirable
job assignment or salary cut.

ƒ

Information Power- is based upon “who knows
what” in an organization and the degree to which
they can control access to that information by
other individuals. The nurse manager, for
instance, is has private ground to information
obtained at meetings with the nursing director or
through

other

informal

channels

of

communication that either are not available to or
are unknown to members of staff nurses.
ƒ

Legitimate Power- stems from the group
members’ perception that the nurse manager
has a legitimate right to make a request; this
power is based on the authority delegated to the
nurse manager by virtue of his her/his job and
position within kith management hierarchy.

ƒ

Expert

Power-

is

based

upon

particular

knowledge and skill not possessed by staff
members. Nurse managers, by virtue of their
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experience and, possibly, advanced education,
frequently qualify as the persons who know best
of what to do in a given situation. For example,
newly graduated nurses might look to the nurse
manager

for

advice

regarding

particular

procedures or for help in using equipment on the
unit.
ƒ

Referent Power- is based upon admiration and
respect for an individual as a person. For
example, a new graduate might ask the advice of
the nurse manager regarding career planning.

Application to Nursing
ƒ

All nurse managers possess some degree of
legitimate

power-authority

to

carry

out

organizational decisions and goals.
ƒ

This authority is supplemented by the nurse
managers’ power to reward of coerces

ƒ

Nurse Managers become leaders through the
development of referent and expert power
bases that inspire others’ obedience and
loyalty.

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Nursing Leadership and Management

ƒ

By developing referent and expert power, a
nurse leader need not rely on legitimate
power

ƒ

A nurse manager and nurse leader can use
various sources of power to effect change at
the unit, organizational, and professional
level (Sullivan, 1990).

Reasons for Acquiring Power
A nurse manager should seek power for both selfish and
unselfish

reasons.

A

nurse

manager

will

need

considerable power to survive in the dog eat dog world
of institutional politics. Without strength to move others,
he or she cannot complete with the managerial elite for
scarce funds, scarce personnel and scarce materials.
He or she should also seek power to benefit patients
and subordinates.

Individuals and groups in heath agency may seek power
in order to manipulate others. Power holders at the top
of the hierarchy look for persons with similar values to
be their successors and to ensure the preservation of
cherished values.

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Skills Used in Acquisition
Basic skills for exerting power over others include: peer
skills, leadership skills, information processing skills,
conflict resolution skills and skills in unstructured
decision making.
ƒ

Peer skills are communication and interaction
skills by which a person builds a network of
supporters from whom to obtain help in a crisis.

ƒ

Leadership
motivation

skills
skills

are

communication

with

which

one

and

resolves

problems arising from power, authority, and
dependency phenomena.
ƒ

Information

processing

skills

are

skills

of

receiving, encoding, grouping, storing, retrieving,
translating, and sending information by which
one

interprets

the

world

and

transmits

interpretation to others.
ƒ

Conflict resolution skills are skills by which a
person finds agreement between candidates and
persuades disputants to collaborate in the
interest of mutual gain.

ƒ

Skills in the unstructured decision making is the
ability to analyze problems for the cause and
effect relationships, generate possible solutions,
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Nursing Leadership and Management

select the most effective course of action, and
assign responsibility for plan implementation.

Learning Activities
1. Discuss basic points that you consider for an
outstanding nurse leader
2. Kurt

Lewin

leadership

suggests

that

styles-Autocratic,

there

are

Democratic,

three
and

Laissez-faire;
2.1 Which leadership style does your supervisor
exhibit?
2.2 List three of his or her activities as decisions
that illustrate the style.
2.3 How does your supervisors' leadership style
affect your work and attitudes?
3.

From the theory of leadership described in this
chapter, describe and discuss actual examples of
leadership demonstrated by persons. Consider:
3.1 A charismatic leader
3.2 A transforming leader
3.3 McGregor's theory X and theory Y
3.4 Likert's authoritative and democratic systems
3.5 Leadership style.

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4. Choose a theory of leadership and describe how you
would implement it in your ideal nursing setting.

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CHAPTER SEVEN
MANAGING RESOURCES
Objectives:
At the end of this chapter, the student should be able to:
ƒ

Explain the mechanisms of acquiring and
retaining human resource.

ƒ

Describe the process of budgeting

ƒ

Discuss the points to be taken in controlling
and maintaining equipment.

ƒ

How do managers maximize their time?

Human Resource Management
Human resource management is the process of
acquiring and retaining the organization's human
resource.
Acquisition of human resource includes human
resource planning, recruitment, selection and orientation
Retention activities include performance appraisal,
placement, training and development, discipline and
corrective

counseling,

compensation

administration, safety, and health.

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A. Acquiring Human Resource
1. Human resources planning
Human resource planning precedes the other acquiring
activities.

Health

service

organizations

determine

staffing needs through human resources planning.
Because organizations are dynamic, these needs
change. The work force must be considered in the
context of a changing environment: present staff must
be retained and new employees recruited to meet
changing

needs.

Staff

needs

in

Health

Service

Organizations are driven by
1. Organizational
increased

growth:

demand

for

occurs
services,

through
higher

occupancy, facility expansion and the addition of
new services or intensifying services.
2. Employee

turnover:

through

resignation,

discharge and retirement

Human resource planning involves five steps
1. Profiling-to profile the personnel need of the
organization at some future point
2. Estimating-Projecting the type and number of
personnel needed

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3. Inventorying-human resource audit of present
employees
4. Forecasting-anticipating changes in the present
work force in terms of entries and exits
5. Planning-Assumptions made by following steps
1-4 to ensure the right number of personnel with
appropriate prerequisite knowledge and skill

Human resource Sources
1. Internal Sources-filling vacancies by transferring
or promoting from within. Advantage


It is cost effective, reduces recruiting and
relocation costs



Usually quicker, and



Enhances employee morale

Disadvantage
Seniority

rules

policy

rather

than

best

qualification
2. External sources -new employees may be
recruited

from

outside

through

advertising

vacancies, visits to colleges and universities,
contacts with public and private employment
agencies

and

participation

organizations
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Advantage

2. Recruitment
Recruitment is the process of attracting qualified people
to apply for a job. It involves searching for and attracting
prospective

employees

either

from

within

the

organization or outside the organization. It is the
process of making applicants available for selection.
You can select only from those people who apply for a
job, the odds of finding a strong candidate are less than
if you have many applicants to choose them.

3. Selection
Selection is the process of choosing for employment. It
is to choose among the applicants using job qualification
as a guide. The essence of selection is to determine
whether an applicant is suited for the job in terms of
training, experience and abilities

Sources of information for selection
1. Application forms and
2. pre employment interviews
3. Testing

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Selection Model
Step 1. Analysis of the vacant job(s)-Using job analysis
procedures the vacant job(s) are studied to find the
knowledge skills and abilities needed for job success.
Many problems in personnel selection stem from the fact
that there is often inadequate understanding of the job
and its requirements. The best person is best only
insofar as he/she optimally meets these requirements

Step2: Selection of criterion and predictor: this step
involves two procedures. First, based on the job
analysis, a criterion of job success is chosen. As always,
the criterion must be a sensitive indicator of work quality.
Secondly, a predictor must be chosen

Step 3: Measuring performance-After the criterion and
predictor have been chosen, the worker's performance
is measured on both variables.

Step 4: Assessing the predictor's Validity-determine if
differences

in

predictor

scores

correspond

with

differences in criterion scores, that is, does the predictor
have validity?

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Step

5:

Determining

the

predictor's

Utility-is

to

determine how useful it will be in improving the quality of
the work force

Step 6: Reanalysis-Any personnel selection program
should be periodically reevaluated to see if changing
employment conditions have altered the predictorcriterion relationship

The Classic Selection Model
3. Orientation
After

selection,

induction

and

orientation

occur.

Orientation programmes include information about the
organization, organizational structure, philosophy and
objectives of the organization, rules and regulations,
universal precautions enrolling new employees in
benefit plans, issuing an identification badge are
typically carried.
Advantage
ƒ

Builds employees sense of identification with the
health service organization

ƒ

Helps the gain acceptance by fellow workers

ƒ

Give them a clear understanding of the many
things??? they need to know
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ƒ

Enables the new employee to become familiar
with the entire organization as well as their own
work area and department

B. Retaining Employees
The Retaining activities include, performance appraisal,
training and development, discipline and compensation
administration.

Personnel Training
A personnel training is the formal procedure which an
organization utilizes to facilitate learning so that the
resultant behavior contributes to the attainment of
organization's goals and objectives
Personnel training should contribute to the goals of both
the organization and the individual. Training is a
management tool designed to enhance organization's
efficiency.

However,

in

the

process

of

attaining

organizational goals, many individual goals can also be
attained.

Assessing training needs
Assessing training needs usually involves a three-step
process
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1. Organizational analysis- is the study of an entire
organization-its objectives, its resources and the
way in which it allocates resources to attain its
goals. Organizational analysis can take several
forms. One form is that of a personnel audit for
manpower planning. A personnel audit is an
inventory

of

the

personnel

assets

of

an

organization and a projection of the kinds and
numbers of employees who will be required in
the future. A second approach to organization
analysis involves indicators of organizational
effectiveness. These are examined to see if
training

could

improve

the

organization's

the

orderly

performance
2. Operational

analysis-is

and

systematic collection of data about an existing or
potential task or a cluster of tasks that define a
job. It examines the task or job requirements
regardless of the person holding the job. It
determines what an employee must do to
perform the job properly. Operational analysis is
most directly concerned with what training should
cover

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3. Personnel analysis-is directed toward learning,
whether the individual employee needs training
and what training he/she needs. It is concerned
with ascertaining how well a specific employee is
carrying out his/her tasks and with determining
what skills must be developed, what knowledge
acquired, and what attitudes cultivated if the
employee is to improve his/her job performance.
A large portion of person analysis involves
diagnosis. We want to know not only how well
people are performing but also why they are
performing at that level. Personnel analysis
involves appraising an employee’s performance,
objective records and diagnostic achievement
tests.

Methods and Techniques of Training
After determining an organization's training needs and
translating them into objectives, the next step is to
design a training program to meet these objectives. This
is not an easy task, because each training method has
its strengths, weaknesses, and costs. Ideally, we seek to
choose the one that meets our objectives in a cost

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efficient manner. There are many training methods
available.

Performance Appraisal
Performance appraisal is a systemic review of an
individual employee's performance on the job, which is
used to evaluate the effectiveness of his/her work

Purpose:


Provide information upon which to base
management

decisions

matters

salary

as

regarding

raises,

such

promotions,

transfers, or discharges


Helps to assist employees in their personal
development



Performance appraisal information will help
to assess the effectiveness of hiring and
recruiting practices



Supply information to the organization that
will help to identify training and development
needs of the employees



Helps in the establishment of standards of
job performance often used as a criterion to

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assess the validity of personnel selection and
training procedures
Employee’s work should continually be assessed in a
formal or informal basis. A formal appraisal is more
accurate, fair and useful to all concerned

Common Problems in Performance Appraisal


Performance

appraisal

may

be

viewed

as

demanding too much from supervisors. Especially in
large number of span of control. It is difficult for a
first line supervisor to know what each of 20, 30 or
more subordinating is doing


Standards and rates tend to vary widely, with some
raters

being

tough and

others

more

lenient.

Leniency Errors-some raters are hard graders and
others easy graders. So raters can be characterized
by the leniency of their appraisals. Harsh raters give
evaluations that are lower than the true level of
ability. This is called severity of negative leniency.
The easy rater gives evaluations that are higher than
the true level called positive leniency. These errors
usually occur because the rater has applied personal
standards derived from his/her own personality or
pervious experience
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An appraiser may replace organizational standards
with personal values and bias. Halo errors-are
evaluations based on the rater's general feelings
about an employee. Thus, the rater generally has a
favorable

or

unfavorable

attitude

toward

the

employee that permeates all evaluations of the
person. Typically, the rater has strong feelings about
at least one important aspect of the employee's
performance. This is then generalized to other
performance factors, and the employee is judged
(across many factors) as uniformly good or bad.
Raters who commit halo errors do not distinguish
among

the

many

dimensions

of

employee

performance


Because of lack of information, standards by which
employees

think

they

are

being

judged

are

sometimes different from those superiors actually
use


The validity of ratings may be reduced by the
supervisor's resistance to making the ratings,
because of the discomfort they feel when having to
confront the employee with negative ratings and
negative

feedback.

Example,

central

tendency

errors: refers to the rater's unwillingness to assign
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extreme -high or low -ratings. Everyone is average,
and only the middle part of the scale is used

Characteristics

of

an

Effective

Performance

Appraisal


Relate performance appraisal to the job description



Understanding the criteria for evaluation

Tools of performance appraisal


Rating scales-the tool consists of a behavior or
characteristics to be rated and of some type of scale
that will indicate the degree to which the person
being evaluated demonstrates that behavior



The

checklist-

it

describes

the

standard

of

performance and the rater indicates by placing a
checkmark

in

a

column

if

the

employee

demonstrates the behavior


Management by objective- it focuses on the
evaluator's

observations

of

the

employee's

performance as measured against very specific
predetermined goals that have been jointly agreed
upon by the employee and the evaluator.

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Appraisal methods designed to avoid rater bias
a. The field review method- this method allows the
ratings of several supervisors to be compared for
the same employee
b. The forced choice rating method-the evaluator
choose from among a group statements those
that best describe the individual being evaluated
and those that least describe this person
The critical incident technique-the supervisor observes,
collect, and record instances of the employee carrying
out responsibilities critical to the job. These are used to
prepare the evaluation or serve as the evaluation itself
to be viewed with the employee during the feedback
interview. These written accounts of behavior tend to
focus on performance rather than personality traits

II. Budgeting


Is a plan for the allocation of resources and a
control for ensuring that results comply with the
plans

1. Prerequisite for budgeting


Sound organizational structure



Job descriptions



Goals and objectives
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Formal budgeting policies and procedures

The budgeting process should provide for
1. Plans of anticipated activity
2. A mechanism for measurement of work
effort on timely basis
3. Accountability by someone for variances
from budget
4. An awareness of costs by all participants
in the budgeting program
2. Major types of budgets


Operating/recurrent- estimates of operating
expenses, estimates of operating revenues and
estimates of activity

Example: personnel salaries, supplies, light water,
drugs, repairs and maintenance


Plant/Capital-estimates

of

expenditure

for

adding, replacing or improving buildings or
equipment for the budget period
Example: buildings, major equipment
3. Other types of budget
Cash Budgets
Cash budgets are planned to make adequate funds
available as needed and to use any extra funds
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profitably. They ensure that the agency has enough, but
not too much, cash on hand during the budgetary
period.

This is necessary because income does not

always coincide with expenditures.

Labor or Personnel Budgets
Personnel budgets estimate the cost of direct labor
necessary to meet the organization’s objectives. It
includes recruitment, hiring, assignment, lay off, and
discharge of personnel. The nurse manager decides on
the type of nursing care necessary to meet the nursing
needs of the estimated patient population. How many
nurses are needed during what shifts, what months, and
in what areas? The current staffing patterns, number of
unfilled positions and last year’s reports can provide a
base for examination and proposals. Patient occupancy
and the general-complexity of cases affect staffing
patterns.

Personnel budgets also are affected by

personnel policies, such as salary related to position
and number of days allowed for educational and
personal leave.

Overtime costs should be compared

with the cost of new positions.

Employee turnover,

recruitment, and orientation cost must be considered.

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Flexible Budgets
Some costs are fixed and do not change with the
volume of business. Other costs vary proportionately
with changes in volume. Some variable expenses are
unpredictable and can be determined only after change
has begun: thus the need for flexible budgets, to show
the effects of changes in volume of business on
expense items. Periodic budget reviews help managers
compensate for changes.

Relationships between the

volume of business and variable costs may be predicted
by a historical analysis of costs and development of
standard costs.

Strategic Planning Budgets
Long-range budgets for long-range planning are often
called the organization’s strategic plan and are usually
projected for 3 to 5 years. Program budgets are part of
the strategic plan that focuses on all the benefits and
costs associated with a particular program.
Business plans are detailed plans for proposed services,
projects, or programs.

The contain information to

assess the financial feasibility of the plan. The business
plan states the objectives of the project and links them
to the organization’s strategic plan.
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STANDARD COST
Standard cost may be developed to predict what labor
and supplies should cost.
Multiplying the standard cost by the volume predicts the
variable cost. Supervising community health nurses can
predict the standard number of clinic visits and the
number of birth control pills that will be required by each
family planning client who has chosen birth control pills
as a method of contraception. Multiplying the number of
pills needed by each client by the number of clients
using birth control pills, nurse mangers can predict the
inventory needed and the cost. They also can predict
the number of clinic visits needed and plan staffing.

ZERO-BASED BUDGETING
Many

budgeting

departments

procedures

based

on

allocate

their

funds

previous

to

year’s

expenditures. Then the department managers decide
how the funds will be used.

This procedure usually

allows for enrichment and enlargement of programs but
seldom

for

decreases

or

deletion

of

programs.

Obsolescence is seldom examined, and this leads to
increased costs.

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With zero-based budgeting, no program is taken for
granted. Each program or service must be justified each
time funds are requested. Managers decide what will be
done, what will not be done, and how much of an activity
will be implemented. A decision package is prepared.
The package includes a list of the activities that make up
a program, the total cost, a description of what level of
service can be performed at various levels of funding,
and the ramifications of including them in or excluding
them from the budget. The manager may identify the
activity, state the purpose, list related activities, outline
alternative ways of performing activities, and give the
cost of the resources needed.
After decision packages are developed, they are ranked
in order of decreasing benefits to the agency. They can
be divided into high, medium, and low-priority categories
and reviewed in order of rank for funding. Resources
are allocated based on the priority of the decision
package. The cost of each package is added to the cost
of approved packages until the agreed-on spending
level is reached.

Lower ranked packages are then

excluded.
A major advantage to zero-based budgeting is that it
forces managers to set priorities and justify resources.
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SUPPLEMENTARY BUDGETS
Some budgetary flexibility may be obtained through a
supplemental monthly budget.

A basic or minimal

budget is planned, usually for a year’s time, to outline
the framework for the agency’s plans, establish
department objectives, and coordinate departments.
Then a monthly supplementary budget is prepared
based on volume of business forecast for the month.

Moving Budgets
The moving budget may be used when forecasting is
difficult. The moving budget plans for a certain length of
time, such as a year. At the end of each month, another
month is added to replace the one just completed.
Thus, the budgetary period remains constant.

The

projections progress a month at a time but always for a
fixed period such as one year. It is an annual budget
revised monthly. As Sene is completed, Sene budget
for the forthcoming year is added to the moving budget.

4. The budget period
Most health care agencies budget on a monthly
basis for a 1-year period. The budget year often
begins July 1 and ends June 30.
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5. Advantages of Budgeting
Budgets plan for detailed program activities.


They

help

fix

accountability

assignment

of

responsibility and authority.


They state goals for all units, offer standard of
performance, and stress the continuous nature of
planning and control process.



Budgets encourage managers to make a careful
analysis of operations and base decisions on careful
consideration.



Consequently, hasty judgments are minimized.
Weaknesses in the organization can be reveled and
corrective measures taken.



Staffing, equipment, and supply needs can be
projected and waste minimized.



Financial matters can be handled in an orderly
fashion, and agency activities can coordinated and
balance.

6. Budgeting Process
Financial planning responsibilities need to be identified
before budget preparation begins.

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Steps
1. The first step in the budget process is the
establishment of operational goals and policies
for the entire organization.
2. The top management should approve a longrange plan of 3 to 5 years that reflects the
community’s future health needs and other
community health care providers’ activities.
Because the situation changes over time,
flexibility is built into the plan.
3. Then operational goals must be translated into
quantifiable management objectives for the
organizational units.
4. The department heads use the organizational
goals as a framework for the development of
department goals.
5. A formal plan for budget preparation and review
including assignment of responsibilities and
timetables must be prepared.
6. Historical, financial, and statistical data must be
collected monthly so that seasonal fluctuation
can be observed.
7.

Departmental budgets need to be prepared and
coordinated. During this phase, units of service,
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staffing

patterns,

salary

and

non-salary

expenses, and revenues are forecasted so that
preliminary rate setting can be done.
8. Next, departmental budgets are revised, and the
master budget is prepared.

At this point,

operating, payroll, non salary, capital, and cash
budgets can be incorporated into the master
budget.
9. Then the financial feasibility of the master budget
is tested, and the final documents is approved
and distributed to all parties involved.
10. During the budget period, there should be
periodic performance reporting by responsibility
centers.

7. Cost Implication to Budgeting
Cost Containment
The goal of cost containment is to keep costs within
acceptable limits for volume, inflation, and other
acceptable parameters.

It involves cost awareness,

monitoring, management, and incentives to prevent,
reduce, and control costs.

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Cost Awareness
Cost awareness focuses the employee’s attention on
costs.

It increases organization awareness of what

costs are, the process available for containing them,
how they can be managed, and by whom. Delegating
budget planning and control to the unit level increases
awareness.

Managers should be provided a course

about budgeting and be oriented to the agency
budgeting

process

before

being

assigned

the

responsibility. They should have a budget manual that
contains budget forms, budget calendar, and budget
periods.

Cost Monitoring
Cost monitoring focuses on how much will be spent
where, when, and why. Identifies, reports, and monitors
costs. Staffing costs should be identified recruitment,
turnover, absenteeism, and sick time are analyzed, and
inventories are controlled. A central supply exchanger
chart

prevents

hoarding

identification of lost items.

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supplies

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8. Costing Out Nursing Services
There are several benefits to costing out nursing
services.


Charging our nursing services makes it possible
for the customer to pay for what he or she gets.
The patient pays for the care rendered.



Customers start to realize that direct care has a
price value. This helps them comprehend costs
of health care and, ideally, to value it



Hospitals can receive compensation for what
they provide, to help maximize profits.



Nursing can be viewed as a revenue-generating
center rather than a cost.



Charging a fee for services helps enhance the
professionalism of nursing through the traditional
pattern of reimbursement for services.



Costing

out

nursing

services

stimulates

productivity by visualizing productivity measures
to enhance the use of human resources, contain
costs, and maintain quality.


Using a cost accounting system to assess and
change the nursing department helps establish a
reputation for innovation and leadership. Quick

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responsiveness to changes will help agencies
survive in a rapidly changing environment

The most commonly used methods for determining
nursing service costs are per diem, or cost per day,
of service; costs per diagnosis; costs per relative
intensity

measures

(RUMs);

and

patient

classification systems (costs per nursing workload
measures).

Per Diem
Per Diem methods are the oldest methods used for
both rate setting and reimbursement.

Average

nursing care cost per patient day is calculated by
dividing the total nursing costs by the number of
patient days for a specific period. Nursing costs are
usually considered as salary and fringe benefits for
staff and administrative nursing personnel. These
costs can be calculated for individual cost centers,
subdivisions, or the entire nursing service. Per Diem
relates nursing costs directly to length o stay but
does not identify patient needs, acknowledge
differences in diagnosis, specify nursing services

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Nursing Leadership and Management

needed, justify care given, or provide information for
management decisions.

Costs per Diagnosis
Information about the patient mix is often used to
reduce the variability in nursing care requirements.
The medical diagnosis is frequently used to identify
groupings.

DRGs use this method. Some people

recommend using nursing diagnosis or nursing care
standards for grouping patients according to their
nursing care needs. It seems logical that nursing
diagnosis could better predict nursing care needs
than DRGs based on medical diagnosis.

Costs per RIMS
RIMs were developed in New Jersey to allocate
nursing resources in such a way as to address the
complaints

that

DRGS

inadequately

represent

variability of nursing care requirements. A RIM is 1
minute of nursing resource use. RIMS are coasted
and allocated to DRG case-mix categories through
three steps: (1) The cost of a RIM is calculated by
dividing the total nursing costs for a hospital by the
total minutes of care estimated or nursing resources
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Nursing Leadership and Management

used to provide care to all patients. (2) The number
of minutes used by the total hospital population,
including adjustments for downtime, such as sick
leave and vacation time, is calculated. (3) The cost
of care for each patient is determined by multiplying
the RIM by the minutes of care required by the
patient as estimated by an equation.

The RIMs

development studies used data from New Jersey
Hospitals to measure the time used by nursing
personnel

performing

nursing

and

non-nursing

activities during the entire hospitalization.

Costs per Nursing Workload Measures
Patient classification systems were developed to
allocate

nursing

staffing

before

DRG-based

reimbursement. Some to calculate the cost of the
nursing component of room rate has used nursing
workload data. Cost accounting methods allow
calculations for whole patient care units and for
individual patients; consequently, t is possible to
generate a separate charge for nursing services for
individual patients. These methods are also used to
allocate nursing costs to DRGs or cost centers.
Unfortunately, there is limited irretrievability of data,
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Nursing Leadership and Management

because few hospitals record patient classification
data for individual patients in the patient record or on
a database, data collection and analysis are
expensive, and practice may not adhere standards.

III. Material management


Material management is the integrated function
of purchasing and allied activities to achieve the
maximum coordination and optimum expenditure
in the area of materials.



One of the objectives of materials management
is to have the right materials at the right place at
the right time. This depends on effective policies
of

forecasting,

inventory,

and

materials

distribution.

Materials/equipment can be divided into:
1. Expendable/consumable/recurrent-are
those materials/items that should be
regularly kept in stock for production
purposes or maintenance of the plant and
are used within a short time.
2. Non-expendable/capital/non-recurrent:
are

those

materials/items

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Nursing Leadership and Management

required only for specific purposes or jobs
and which are not to be automatically
recouped, lasts for several years, and
needs care and maintenance.
Managing equipment
Ordering-obtaining

equipment

from

stores of shops
Storing- recording, labeling and holding
equipment in a stock or store room
Issuing- giving, labeling and holding
equipment in a stock or store room
Controlling-

monitoring

expendable

equipment, maintaining and repairing
non-expendable equipment.
Important points in controlling and
maintaining equipment:


Convincing staff that equipment
must be cleaned, inspected and
kept in good order. Defects must
be

reported

Equipment

must

immediately.
always

be

returned to its correct place after
use.

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Use inspection check list and
inspection schedule



Detecting

discrepancies

and

explaining them
Good management takes care of equipment by:
ƒ

Motivating

staff

responsible

to

feel

for

the

equipment they use
ƒ

Ordering

supplies

when

needed
ƒ

Storing supplies safely

ƒ

Controlling

the

use

of

supply
Accurate records save time and contribute to the
economy, efficiency and smooth functioning of the
health service
In most of the government sectors in Ethiopia, receiving
and issuing of
Materials/equipment/items are carried out using the
following models
ƒ

Model

19-

model

confirming

delivery

items/drugs
ƒ

Model 20- Model for requesting items/drugs

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Nursing Leadership and Management

ƒ

Model 21- Model for approving item delivery by
person in authority

ƒ

Model 22- Model for issuing items/drugs

IV. Managing Time
Time is a non-renewable resource.
Maximize Managerial Time
1. Set goals- determines the short, medium and
long-range

goals.

Which

goals

must

be

completed before others? Which will take the
longest to achieve? Setting priorities helps
resolve goal conflict.
2. Once you have determined and ranked your
goals plan strategies to achieve them
3. Plan schedule
4. Improve reading
5. Improve memory
Planning time arrangements
ƒ

Events are arranged in daily, weekly,
monthly or yearly time periods.

ƒ

The periodicity depends on the frequency
or regularity of particular events.

ƒ

Time plans are written in various common
forms known as :
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Timetable: daily or weekly regularly recurring events.
Schedule: intermittent or irregular or variable events,
and where they take place.
Roster: duties planned for different staff members, for
different times in turn.
Preparing a health unit time table
ƒ

List all activities that happen regularly each
week.

ƒ

Then arrange them in an appropriate timetable
grid.
Preparing health unit schedule

ƒ

A schedule is required when a different activities
or the same activity in a different place is spaced
at intervals over time.

ƒ

To make a schedule, each different activity or
each different place is listed and passed through
the dates in turn, the whole cycle is repeated.

Preparing duty roster
ƒ

A duty roster is a time plan for distributing work
among staff members

ƒ

Duty rosters are needed for three purposes:

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1. To distribute work fairly and evenly outside
normal working hours, e.g. night duty,
weekend duty, holiday duty
2. To distribute uninteresting or difficult work,
and interesting or varied work.
3. To divide extra duties among the whole staff.

Learning activities
1. What are the mechanisms of acquiring and
retaining human resource in nursing?
2. What are the procedures and process to be
followed in forecasting the budget of the
nursing department?
3. How do we maximize the best use of nursing
equipment in an organization?
4. What are the principles of effective time
management?

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CHAPTER EIGHT
EVALUATING HEALTH ACTIVITIES
Objectives:
At the end of this chapter, the student should be able to:
ƒ

Define evaluation

ƒ

Describe the roles of evaluation

ƒ

Explain the types and levels of evaluation

ƒ

Discuss the steps of evaluation

Evaluation


Is the process of finding out the value of
something



Determining the value or worth of objects of
interest against standard of acceptability



In evaluation we have to ask two broad
questions:


Are the results those that were intended?



Are they of value?

Roles of Evaluation
1. As a step ensuring the delivery of
high quality health care
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2. An important tool for controlling
health

care

expenditures

and

ensuring accountability

Levels of Evaluation


Effort-to assess the resources or capacities



Performance-to assess the output or outcome of
the program



Adequacy of performance-the extent to which
performance meets the program objectives



Effectiveness-the

amount

of

the

intended

objectives that have been attained


Efficiency-the degree to which the program
achieved its result at the lowest possible cost

Steps of evaluation
1. Decide what is to be evaluated?
2. Collect the information needed to provide the
evidence
3. Compare

the

results

with

the

targets

or

objectives
4. Judge to what extent the targets and objectives
have been meet

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5. Decide whether to continue the programme
unchanged, to change it or to stop it

How to evaluate work progress?
Work progress is evaluated in order to measure the
efficiency of the nursing/ midwives team, i.e. to find out
whether the team completed the work which was
assigned to it in order to reach its targets, the work was
of expected quality, was carried out in time and its
budget was not overspent?

Types of evaluation


Process
obtained

evaluationduring

the

measurements
implementation

of

program activities to control or assure or
improve

the

quality of

performance

or

delivery.


Impact

evaluation-

focuses

on

the

immediate observable effects of a program
leading to the intended outcomes of a
program


Formative evaluation- measurements and
judgments made
program
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Summative evaluation

Learning activity
1. What is evaluation?
2. Explain the roles and levels of evaluation
3. How can we evaluate work progress?

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CHAPTER NINE
COMMUNICATION
Objectives:
At the end of this chapter, the student should be able to:


Define

verbal

communication

and

non

verbal

communication


List

down

the

components

of

communication

process using a diagram direction


Discuss the ten basics for good communication



Use an assertive style of communication using the
nurses Bill of Rights as identified by Hermann and
differentiate between aggressive and passive style
of communication



List down common blocks to communication and
discuss on how to improve them



Use through examples the common patterns of
communication networks.

Communication
Communication

by

definition

is

the

transfer

of

information and understanding from one person to
another. To be a leader, the student must have a basic
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understanding of the communication process, which
consists of a sender, a message and a receiver, all of
which are influenced by an environment. Each of the
components of the communication process is capable of
enhancing or inhibiting the understanding of the
message.

The Message
The message is that which is being conveyed. The
leader must remember that the meaning of words
resides not in the message but in the person receiving
the message. Words mean different things to different
people. Individuals assign their own meaning to what
has been suggested, and their meaning may be different
from what was intended by the leader. The message is
composed of what it is you are trying to convey through
verbal and nonverbal symbols. Since words are more
symbols with meaning residing in people, it is possible
for everyone to hear the same thing and interpret the
message differently. The second aspect of a message is
nonverbal behavior. Nonverbal behavior consists of
facial expressions, pauses, gestures, posture, and tone
of voice that reinforces or contradicts what is being said
in the primary message. The message through both
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verbal and non-verbal means is conveyed by means of
the communication process.
The message
1. Verbal
What you talk about
2. Non -verbal
How it is communicated - facial expression, pauses,
gestures, posture, tone of voice (accepting or rejecting) body language
3. Communication climate
Positive-enhances the message or Negative-detracts
from understanding the message.
Fig.9.1 The essential elements of communication
components: the message and communication in which
the message is delivered.

The Communication process
In technical terms, the communication process consists
of six steps: ideation, encoding, transmission, receiving,
decoding, and response (Fig. 9.2). Ideation refers to the
message, the idea or thought to be conveyed to an
individual or a group. Encoding is the manner in which
the message is conveyed and may be other than verbal,
such as a written message or a visual or audible cue.
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Encoding also takes into account the nonverbal
behaviors that accompany the message, such as a
gesture or an expression. Transmission is the actual
expression of the message. For the listener or reader to
receive the message, he or she must have appropriate
listening or other abilities. Decoding refers to the
receiver's under standing or interpretation of the
message. The response, or feedback, should convey to
the leader the degree of understanding held by the
individual or the group. The communication process is
now reversed so that the leader has the task to
understand the new message using the same process.
The nurse leader or manager uses communication skills
in all aspects of organizational life. Different skills are
required to communicate effectively with groups of
professional workers. The professional person is an
educated individual with a very specific contribution to
the work place. Therefore, appropriate manner of
communication process is essential.

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Ideatio

Encoding

Transmission
Respons
Receiving

Decoding

Fig.9.2.

The

conceptual

components

of

the

communication process. The circle is used to denote the
dynamic and reciprocal properties of the communication
process.

Ten Basics for Good communication
1. Clarify your ideas before communicating to others.
Before speaking to an individual or a group, plan and
organize what it is you are going to say. Analyze
your thoughts carefully, and keep in mind the
objective you wish to meet as well as the
uniqueness of the individual or the group. Provide an
opportunity for questions and answers to enhance
the clarity of the message.

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2. Consider

the

psychological.
conducive

or

setting,
The

both

physical

can

be

physical
setting

serious

and

can

be

block

to

communication. Take for instance the backdrop of a
busy emergency department currently understaffed.
This would not be a place to discuss an employee's
performance appraisal, but it might be the perfect
setting in which to discuss the shortage of nurses
with the administrator.
The psychological environment is also important. This is
referred to as the communication, or social, climate. If
you as a leader have less difficulty, communicating with
your staff than you would with in a defensive and hostile
(negative) environment.
Positive climate behavioral characteristics
Listening
Empathy
Acceptance
Shared problem solving attitude
Openness
Evaluating
Advice giving
Superiority
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Fig.9.3. The characteristics of both a negative and
positive communication climate.
The leader or the followers or both exhibit these
behaviors.
A psychological and emotional relationship results
between and among the work group and the manager
and may be either supportive or defensive. A supportive
communication climate means that communication
patterns are characterized by a leader who listens; is
empathetic; offers acceptance of individuals; exhibits a
shared, problem-solving attitude; is open; and values
equality in the work place. The members of the group
exhibit the same attitudes and behavior. A defensive
climate, on the other hand, is characterized by a leader's
communication

pattern

that

may

be

controlling,

punishing, evaluating, advice giving, and reinforced by
leader behavior that says, "I am superior and always
right". The followers, on the other hand, are submissive
or aggressive, and communication is usually nonproductive and unpleasant.
The value of a positive communication climate is
that it fosters behaviors among the leader and
followers that lead to trustful and cooperative
working relationships. It is a kind of climate that will
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foster innovations in the work place, making change
a possibility.
3. Consult with others when necessary to be exact and
objective. The worst mistake a leader can make is to
communicate incorrect information to the members
of the group. If misinformation is given to an
individual or to the group, the leader should
acknowledge the error and correct the situation. This
demonstrates to the staff and to superiors that the
leader deals with mistakes in a direct, honest and
forthright manner.
4. Be mindful of the overtones as well as the message
itself. Non-verbal cues may be saying something
opposite from the words nature. It may give mixed
messages, making it very difficult for the listeners to
know what you are trying to convey. Non-verbal
behavior should support your message, not detract
from it.
5. Take the opportunity to convey something to help,
value, or praise to the receiver. People need to know
that their contributions are useful and respected.
This is not just limited to subordinates; you also
might wish to acknowledge the helpful contributions
of superiors.
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6. Follow up your communication. You must get feed
back to make sure that the message is understood
as you intend it to be understood. Ask questions and
encourage the receiver to express his or her reaction
by follow up contacts.
7. Be sure your actions support your communication. In
other words, "What I say. I do". If action and
attitudes are in conflict, there will e confusion, and
people will tend to deny what has been said. For
example, if you tell your staff that, they must be on
time for work and then you are late on a regular
basis; your message will not be taken seriously.
8. Be an active listener. Practice what you preach.
Listen to what the person has said as well as the
way in which it was said. Probably one of the least
developed skills in the communication process is
active listening. Listening takes effort and often time
to develop because it demands discipline. It is
difficult to listen to non-stop talkers or to people who
use other communication patterns that get on your
nerves. A true leader must develop the self-mastery
to be silent when someone else is speaking. To do
that you must consider the other person's ideas to
be more important than your own.
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Active listening, however, does not imply agreement on
your part, nor does it imply that you do not have the right
to interrupt the conversation. It does mean that you must
learn the other's point of view by hearing and trying to
understand the message. It only through understands
what the differences are that the potential for positive
solutions exist.
9. Give credit for the contributions of others when
genuinely deserved. It is amazing how powerful
praise can be in establishing positive feelings in
other people. Everyone needs to know when he or
she have done something especially well
10. Be an assertive when expressing your view.
Communication patterns exist on a continuum from
passive to aggressive. Assertiveness is the desirable
style for the nurse leader and manager. Assertive
communication and behavior maintains a balance
between

aggressive

and

passive

styles.

The

assertive style considers the rights of all persons
involved in the communication process.
The nurse's Bill of Rights, identified by Herman, states
very clearly what these rights are :( Hermann)


The right to be treated with respect



The right to be listened to
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The right to have and to express thoughts, feelings,
and opinions



The right to ask questions and to challenge



The right to understand job expectations as well as
have them written



The right to say "no" and not feel guilty



The right to be treated as an equal member of the
health team



The right to ask for change in the system



The right to have a reasonable workload



The right to make a mistake



The right to make decisions regarding health and
nursing care



The right to initiate health teaching



The right to make decisions regarding health and
nursing care



The right to initiate health teaching



The right to be a patient advocate or to help a
patient speak for himself or herself



The right to change one's mind

The assertive style is demonstrated by communication
that says directly and clearly, what is on y our mind. It is
also demonstrated by listening to what others say. The
leader uses objective words, uses "I" messages, and
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makes honest statements about the leader's ideas and
feelings. Part of assertive style is the use of direct eye
contact,

spontaneous

verbal

expressions,

and

appropriate gestures and facial expressions while
speaking in a well-modulated voice. Assertiveness is
also a process that comes with maturing in role gaining
self-confidence in one's own knowledge and experience.
An assertive style is appropriate and is based on selfrespect and consideration for other people.

Aggressiveness, on the other hand, is concerned only
with the rights of one position and may be loud,
inappropriate, confronting, or hostile. This style uses
subjective words, makes accusations, and sends "you"
messages that blame others. A confronting, sarcastic,
verbal approach with an air of superiority and rudeness
may be usual. This individual often belittles others while
seeming to take charge of the situation. There is
absolutely nothing to be gained by this style. The
individual may win the battle but will surely lose the war.
The rights of all individuals have not been considered.

A Passive Communication style is one that does not
consider any rights. It may be viewed as being
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uninvolved or unable to share thoughts. This style may
be withdrawn and shy or purposefully withholding.
Women in particular may tend to be quiet in-group
situations, and beginning leaders may have to overcome
some hesitation about speaking to groups. Some
suggestions that can help include recognizing your
value and rights in a situation. Try to make one
contribution in each group situation. Gradually you will
feel more comfortable speaking in groups.

Communication among professionals is an essential
hallmark of health care. Keep in mind that the leader
and followers have a basic right to give and to receive
information in a professional manner. Communication
skills grow and develop over time and are the means by
which leadership is exercised. It is important to
remember that communication does not necessarily
mean agreement or harmony over every issue but is
rather an attempt to achieve understanding of the
message between leader and followers.

Case Study
Dr. Hailu is a well-known and experienced surgeon. At
the very least, he is known to be a "difficult individual".
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He has gained this reputation because he shouts before
he thinks, blames before he knows the facts, and
generally has a short fuse.
Alemnesh Sium, RN, did not know Dr. Hailu's and
unintentionally walked into the unit to transfer a patient.
In typical fashion, Dr. Hailu could not find the laboratory
work on the chart and began a temper tantrum aimed at
Alemnesh Sium. Alemnesh looked him in the eye, told
him to stop shouting, and, when he could be
reasonable, to restate his request. The spectators to this
event were speechless.
Difficult individual's impositions of relative power can be
problematic for a staff. However, appropriate behavior
and the rights of all individuals have to be considered if
good working relationships are to exist.
What kind of communication technique did Alemnesh
Use?
What would you have done?

Blocks to Communication
Blocks to communication refer to obstacles that
somehow prevent the message from being delivered or
understood. Some common reasons for blocks to
communication are poor listening habits, Psychological
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blocks,

Environmental

distractions,

and

semantic

barriers (Davis). Blocks to communication are the
reason why people leave meetings with half messages
and incomplete or inaccurate information.

Listening Skills-To improve your listening skills, certain
behaviors must be learned and practiced as you interact
with people. Active listening begins as you give full
attention to the person speaking. This means that you
listen carefully with your mind as well s with your
gestures and facial expressions. Look directly at the
person to whom you are speaking. Direct eye contact
conveys your undivided attention to the speaker. It is a
good idea to indicate your desire for understanding by
asking for clarification, paraphrasing, or summarizing or
by requesting information as necessary. Probably the
most important aspect of active listening and the most
difficult are keeping silent, which is a means of showing
respect for the other person. Active listening will
enhance the understanding of messages by facilitating
communication through appropriate feedback.
Feedback allows the leader to judge the listener's
understanding and can be gained by asking the right
questions. This means phrasing questions within a
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frame or reference and requesting that questions asked
of you be also placed in a frame or reference. As
always, acknowledge the message and affirm that both
you and the speaker have the same understanding. If it
is appropriate, thank the other person for the honesty
and true expression of feelings. Listening is a skill for
which you as a leader will be rewarded because it will
lead to effective behavior.

Psychological Blocks-Consider the following situation.
An individual hears something that produces a profound
emotional

reaction.

An

intense

response

to

a

communicated message very likely will produce a
temporary block to the rest of the message. It is highly
unlikely that constructive communication can continue
until feelings have been defused. The individual stops
listening, focuses on part of the message, and may
close his/her mind to other ideas. Emotions are powerful
forces that may interfere with reason and must be
recognized

and

respected

before

constructive

communication may continue.

Environmental
environment

is

Distractions

-

The

considered

to

be

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problem
a

block

of
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communication

when

it

interferes

with

the

communication process. People may be trying to have a
serious conversation when a sudden, distracting noise
occurs that directs attention away from the message
and toward the environmental stimuli. For example, the
head nurse is telling one of her staff nurse about his
performance of the last four months and the phone rings
or there is a knock at the head nurse's door. This is
distracting, and both parties will have to compensate for
the interruption before they are ready to continue their
conversation.

Semantic Barriers- Semantics is the study of words.
Since words are symbolic, their meaning is subject to
multiple interpretations. The leader should try to be
aware of the choice of words or phrases used in
conveying a message to avoid misinterpretation or
sending the wrong message to

the group. In addition,

the leader should consider the context of words or their
relationship to a particular idea. Using messages in the
proper

context

will

reduce

misinterpretation.

For

example, a head nurse wishes to convey to the staff that
they have been especially competent and productive
during an extremely hectic period and that she is
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pleased with their performance. The words the head
nurse chooses to use are, "You are guilty of doing and
unbelievable job!" Unfortunately, it is really not clear
what the head nurse is trying to say or for what period of
time or particular activity. In this case there is a great
deal of room for misunderstanding the message.

Communication Networks
Communication patterns, or networks, allow information
to be circulated among the group. These same networks
also affect the ways groups solve the problem. The
actual pattern of the communication network may be as
varied as the number of groups in existence. Common
patterns include downward, upward and downward,
circular, or multi-chaneled. Fig. 9.4 illustrates the
communication networks. In essence, the leader either
talks in downward pattern to the group or there is
sharing both up and down with the participants of the
group as well as communications that are shared
among the participants. The real issue is not whether
every participant shares a two-way communication
channel with every other member but whether the
communication is adequate as measured through the
appropriate performance of the group. Attempts at open
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communication

are

preferable

to

restricted

communication patterns.

and upward

Fig. 9.4 some of the ways communication networks can form

Learning Activities
1. Ho you personally prepare for small
group interactions?
2. Select a recent situation in which you
interacted with several people in a formal
group

structure.

How

do

you

communicate verbally and non-verbally?

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CHAPTER TEN
GROUP DYNAMICS
Objectives:
At the end of this chapter, the student should be able to:


Differentiate among primary and secondary groups
in a group dynamics



Analyze the functions and roles of a group



Discuss nonfunctional and unhelpful roles in the
group dynamics



Demonstrate in class the five phases of small groups
using a role play



Develop a skill of decision making in small groups
using brainstorming and nominal group technique
exercises in a classroom.



Explain the major guideline to increase team
cohesiveness



Describe the guideline for making a committee
effective

Group Dynamics
Communication skills are only one aspect of leadership
development,

the

other

is

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dynamics. Group dynamics include the study of how
people form and function within a group structure. The
group becomes a unit when it shares a common goal
and acts in union to either achieve or thwart the
accomplishment of the goal.

Primary and Secondary Groups - A group may be
defined as a collection of individuals who interact with
each other on a regular basis, who are psychologically
aware of each other, and who see themselves as a
group. Groups are categorized as primary or secondary.
Primary groups are composed of individuals who
interact on a "face to face" basis, and the relationships
are personal. In addition, there are no written, formal
rules or regulations because they are unnecessary.
Examples of primary groups are families or groups of
friends. In the workplace, primary groups also exist in
the form of those who affiliate because of something
held in common. Similarity distinguishes this group. For
instance, the group members may be all women in the
administrative field or all graduates from the same
institution, or they may all be of the same ethnic
background.

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Secondary groups are larger and more impersonal.
These groups are organized around formal rules,
procedures, policies and other regulations. The work
place is composed of secondary groups that are found
in departments or at levels and that form the work
group.
The leader deals with the secondary group in the work
place. Secondary groups may also be categorized as
formal or informal groups. Formal groups are the official
or legitimate work group, while informal groups form for
different reasons. The leader must be able to influence
both groups and thus move the work group toward
meeting its objectives.
An effective work group is characterized by the ability to
meet its goals through a high degree of appropriate
communication and understanding among its members.
This type of group makes good decisions based on
respect for all members' "points of view". Another
characteristic is the ability to arrive at a balance
between group productivity and satisfying individual
needs. The leader does not dominate a group like this;
instead there is flexibility between the leader and
members

to

appropriately.

use

different

This

group
180

and
is

individual

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and

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objectively review its own work and face its problems in
a way that balances emotional and rational behavior for
a productive group effort. The leader who enhances
cohesion and cooperation will be moving the group
toward completion of its goals.

Characteristics of a Group- One of the characteristics
of the group is a value structure that is created in
groups that comes about because of the influencing
process among and between its memberships. For
example, some groups value their expertise, they value
friendship, or they value higher wages. Another
characteristic of a group is the sharing of norm. Norms
refer to the expected behavior within a group. If the
individual violates these norms, he/she will take the risk
of being an outcast. Norms of a group are powerful
enforcers for human behavior. Compliance to the norms
means a group membership.

Task Behaviors of a Group
Some of the available behaviors that participants in the
group may exhibit are broadly grouped as task or
maintenance behaviors. Task behaviors serve to
facilitate and to coordinate group effort in the selection
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and definition of a common problem and in the
solution of that problem. Behaviors that fall in this
category are:


Initiating-suggests new ideas, or a different way of
looking at an old problem, or proposing new
activities



Information seeking- asks for relevant facts and
feelings about the situation at hand



Information giving- provides the necessary and
relevant information



Clarifying- probes for meaning and understanding in
whatever the group is considering



Elaborating- builds on previous comments and
thoughts and thus enlarge the concept under
consideration



Coordinating- clarifies the relationships among the
various ideas and attempts to pull things together



Orienting- defines the progress of the discussion in
terms of goals to keep the discussion in the right
direction



Testing- checks periodically to see if the group is
ready to make a decision or to recommend some
action



Summarizing- reviews the content of past discussion
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Maintenance functions are carried out through behavior
that maintains or changes the way in which the group is
working together. These behaviors seek to allow the
group to develop loyalty to one another and to the group
as a whole. These behaviors include;


Encouraging- the giving of friendly advice and help.
Praising and agreeing with others also define this
behavior.



Mediating

or

harmonizing-

helps

others

to

compromise or to resolve differences in a positive
way.


Gate keeping- allows the fair and equal participation
of all members of the group by such comments as."
We haven't heard from Seifu."



Standard Setting- the action that determines the
yardstick the group will use in choosing its subject
matter, procedures, rules of conduct, and , most
important its values.



Following- Going along with the group passively or
actively either during a discussion or in response to
the group's decision.



Relieving tension- diverts attention from unpleasant
to pleasant matters. Often this behavior smoothes
the way for constructive communication.
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The third and last category of group roles is the one,
which is nonfunctional and unhelpful to the group. Group
members to satisfy their own particular needs use
individual roles. These roles do not help the group to
accomplish its task or to facilitate good member
relationships. The roles in this group category are listed
below:


Aggressor: Attacks or disapproves of
others' suggestions, feelings, or values.



Blocker: Resists, without good reason, or
becomes extremely negative to others
suggestions.



Recognition

seeker:

Calls

attention

repeatedly to own accomplishments and
diverts the group's attention.


Self-confessor: Uses the group's time to
express personal, non-group oriented
feelings or comments.



Play boy-Playgirl: Plays around and
displays other behavior that indicates
he/she is not involved in the group
process.

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Dominator: Tries repeatedly to assert
own authority and often interrupts other
group members.



Help seeker: Tries to elicit sympathy from
other group members.

Phases of Small Groups
Orientation Phase: The beginning period in the small
group process is called the orientation phase. During
this phase, individuals spend time assessing their
purpose for joining the group and figuring out where
they fit in the group. Orientation phase is also called the
forming phase. Members engage in testing the other
members

and the leader to determine what is

appropriate and acceptable behavior within the group.
Members spend time at this point trying to identify the
nature of the task and the ground rules.
Conflict Phase: During this phase, members become
less interested in orientation issue, such as how they
are fitting into the group, land more interested in control
issues, such as how they are influencing the group.
Each member wants to be perceived by others as a
competent group member with something to offer
others. In addition, frequent discussions typically occur
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about what task needs to be completed, which rules of
procedure will be followed, and how decisions will be
made in the group. Here leaders can assist group
members to satisfy their needs for control or influence
within the group during the conflict phase.
Cohesion Phase (Norming Phase): This phase is the
developmental phase and members of a task group may
become aware of time pressures and realize that they
need to start moving toward consensus in order to meet
their objectives. Members of a therapy group may
become more understanding of one another differences
and more able to accept these differences in the group.
Still others may observe the splits and factions of the
previous stages and feel the need to move closer rather
than farther away from others. Essentially, members
want to develop more unity during this phase. During
this phase, there is greater expression of the ideas,
opinions, and observations on task issues.
Leadership during this phase poses fewer problems
than during other phases because of the positive
feelings and the unified sense of directions in the group
at this time. The leader can put the group on "automatic
pilot" during this phase as members work in harmony on
group objectives. The leader provides guidance and
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direction only as needed during this phase and
essentially assumes a non-dominant role.
Working Phase (Performing phase): This phase is
similar to the cohesion phase but it involves more time,
greater depth, and increased disclosure among group
members. At this point members feel secure to express
both positive and negative emotions in task groups, yet
communication usually remains positive, even to the
point of members joking and praising each other. The
group spirit and the feeling of unity among members are
often high during the working phase.
Termination Phase: This phase usually occurs when
the goals of a group have been fulfilled or when the
allotted time has run out and the members begin to
consider the implications of lending the group. During
the termination phase, leaders need to summarize the
work of the group, emphasize goal achievement, and
help group members find a sense of closure as they
confront their feelings about the approaching end of the
group and the members' relationships.

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Orientation

Conflict

Cohesion

Working

Termination

Sale topics

Disagreement

Supportive

Positive

Summary of

s and

comments

comments

discussions

debates

Consensus

Discussions
Goblet

about rules

Greater self

issues

and

disclosure

statements

Expression
of feelings

procedures
"Top or
bottom"

Suppression

Problem

Closure

discussions

of negative

solving

statements.

disclosure

feelings

comments

"In or Out"

"Close or far"

In-depth self

discussions

discussions

disclosure

Little self

Table 10.1. Typical kinds of communication in different
Phases of Groups

Techniques for Decision Making in Small Groups
There are three useful procedures for a small group of
people that helps them to arrive at a decision for a
problem. These include Brainstorming, the nominal
group

technique

and

the

Delphi

method.

Each

procedure provides a different but practical approach to
group decision-making.

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Brainstorming
Brainstorm is a discussion technique developed by
Osborn

(1957)

to

stimulate

the

production

and

generation of creative ideas in groups. Brainstorming
enhances by allowing them to express their ideas freely
without being inhibited by the fear of criticism. The
assumption that underlies brainstorming is that if group
members feel uninhibited about expressing their ideas,
more ideas and better ideas will emerge from the group.
The brainstorming technique is relatively easy to use in
small group discussions.

The rules for brainstorming technique include:
1. Generate numerous ideas about an issue
2. Welcome free thinking and facilitate open
expression of ideas
3. Withhold any evaluation or criticism of the ideas
that are expressed
4. Build and improve on ideas already expressed
For brainstorming to work effectively; group members
must not judge or criticize the ideas expressed by
others. This nonjudgmental approach is often difficult to
master because most people are conditioned to
evaluate the pros and cons of a new idea as soon as it
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is introduced in a group. Criticism, is however
counterproductive of the overall goal of brainstorming
because members who fear criticism will most likely
express conventional solutions and withhold wild or
innovative ideas.

Nominal Group Technique
This technique is designed to promote the expression of
many high quality ideas from members who initially work
independently and then share their ideas with the group.
Unlike

the

free

willing

expression

of

ideas

in

brainstorming, this technique uses a more systematic
procedure that ensures that each member will have the
opportunity to present an idea to the group for
consideration. The overall goal of the nominal group
technique is to arrive at a group decision that represents
a pooled judgment that is based on the independent
ideas of all group members.
The steps for nominal group technique include:
1. Group

members,

without

any

discussion,

independently write down their ideas about a
problem or task
2. Each group member presents an idea to the
group without discussion. This process continues
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around the table until all ideas have been
expressed. The ideas are summarized and listed
on either a chart or a chalkboard
3. Members discuss each of the recorded ideas for
the purpose of clarification and evaluation
4. Members independently give their own priority
ranking of ideas. These independent rankings
are added together and averaged. The final
group

decision

emerges

from

the

pooled

outcome of the independent rankings.
The format utilizes both the independent thinking of
members (example, writing down ideas) and group
interaction, (example, discussing the ideas) in order to
arrive at a joint decision. The nominal group technique is
used when individuals can be brought together at one
location and when the problem requires a relatively
quick solution. In health care, this method can be used
for determining program priorities or for identifying
needed program content in areas such as staff
development.
As a decision-making procedure, the nominal group
technique

has

several

advantages.

First,

when

members are given opportunity to write down their own
ideas independently, their ideas tend to be more
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problem centered and of higher quality. Second, the
technique allows all members an equal opportunity to
express their views and also an equal opportunity to
vote on the group decision. This technique prevents a
group discussion from being dominated by a few
influential members. On the negative side this technique
can be time consuming and somewhat difficult to
implement in all situations.

Delphi Method
The Delphi method of decision-making was initially
developed by Dalkey and his associates (1963, 1969)
who used this method to gather data from groups of
experts for the purpose of making forecasts about future
events. More recently, in health care, the Delphi method
has been employed to determine priorities in such areas
as nursing research and cancer nursing. In this method,
participants

are

usually

in

different

geographical

locations and they do not meet for face-to-face
interaction as they typically do in the brainstorming and
nominal group technique procedures. The Delphi
method structures the group communication process so
that a large group of individuals can work together as a
whole and solve a complex problem.
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Steps in the Delphi Method of Group Decision Making
include:
1. Group members are sent a questionnaire which
asks them to identify important questions or
issues on a specific topic
2. Members responses are compiled and a second
questionnaire

is

administered

which

asks

members to assess and prioritize the list of
responses derived from the first round
3. Step 2 is repeated in subsequent rounds. Each
time the priorities of members are summarized
and narrowed down to those, which are the most
important. The results are returned to each group
member for further ranking and evaluation.
4. In the last phase, a final summary and ranking is
provided to each member of the group. This
represents a synthesis of the series of sequential
rankings completed in all prior rounds.
The major disadvantage of the Delphi method are that it
does not allow for the development of emotions and
feelings in the group, and it does not allow for face to
face feedback and clarification. Overall, however, the
Delphi method is a very useful, though time consuming,
decision-making technique.
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Team Work
A team is defined as two or more people who interact
and influence each other toward a common purpose

Types of teams
1. Formal Team: is a team deliberately created by
managers to carry out specific activities, which help the
organization to achieve its objectives.
Formal team can be classified as
a. Command team: is a team composed of a
manager and employees that report to the
manager.
b. Committee: a formal organizational team
usually relatively long lived, created to
carry out specific organizational tasks
c. Task force or project team: A temporary
team to address a specific problem

2. Informal team: emerge whenever people come
together and interact regularly. This group has a
function of:
a. to hold in common the norms and values of
their members

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b. give to their members status, security and
social, satisfaction
c. help their members communicate
d. help solve problems
e. act as a reference groups
3. Super teams: a group of workers drawn from
different departments of the organization to solve
problems that workers deal with their daily performance
4. Self managed team: are super teams who manage
themselves without any formal supervision

Characteristics of a team
Awareness of the characteristics of a team helps to
manage effectively the group.
Effective teams are built on:


Communication



Trust



Shared decision-making



Positive reinforcement



Cooperation



Flexibility



Focus on common goals



Synergy

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Teams that are effective can achieve more together
than they would as individuals all working alone

Stages of team development
Teams move through five stages to develop
a. Forming: during the initial stage the team forms and
learns the behaviour acceptable by the group
b. Storming: as the group becomes more comfortable
with one another they begin to assert their individual
personalities
c. Norming: the conflicts that arose in the previous
stages are addressed and hopefully resolved. Group
unity emerges as members establish common goals,
norms and ground rules.
d. Performing: it is a stage by which a group begins to
operate as a unit
e. Adjourning: it is a time for a temporary group to wrap
up activities

Team cohesiveness
Team cohesiveness is the degree of solidarity and
positive feelings held by individuals towards their group.
The more cohesive the group the more strongly
members feel about belonging to it. Highly cohesive
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teams have less tension and hostility and fewer
misunderstandings than less cohesive groups do.
Studies have found that cohesive teams tend to produce
more uniform output than less cohesive groups.

Ways to improve team cohesiveness
1. Introduce competition
2. Increase interpersonal attraction
3. Increase interaction
4. Create common goals

Guidelines for effective committee functioning
1. Goals should be clearly defined, preferably in
writing
2. Specify committees authority
3. Determine the size of the committee
4. Select a chairperson on the basis of the ability to
run the meeting efficiently
5. Distribute

the

agenda

and

materials before the meeting
6. Start and end meeting on time

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Conflict within teams
Conflict may arise within teams when they go along in
their activities. Some of the conflicts are essential for
effective functioning of the team. Some of the common
conflicts in teamwork are:
1. The paradox of identity-the feeling of people in a
team that the group diminishes their identity
2. The paradox of disclosure: disclose only what
they think acceptable to others because of fear
of rejection
3. The paradox of thrust: for a trust to develop in a
group members must trust the group
4. The paradox of individuality: feeling of members
that their individuality is threatened by the group
5. Paradox of authority: diminishing individual
power by putting it at groups disposal
6. The paradox of regression: : the groups pressure
on individual progress may lead to regression
7. Paradox of creativity: treat to the groups creative
potential

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Determinants of work group effectiveness
1. Task independence: the extent to which a
group’s work requires its member s to interact
with one another
2. Sense of potency: collective belief of a group that
can be effective
3. Outcome independence: the degree to which the
work of a group has consequences felt by all its
members

Checklist for Evaluating Meeting Effectiveness
Standards
ƒ

The meeting started on time

ƒ

A quorum existed

ƒ

The meeting agenda is on a schedule

ƒ

The chair acts as and equal member of the
group, taking no special considerations.

ƒ

The chair follows the agenda
Dull items are scheduled early, star items last
Important items have a starting time
The agenda avoids “any other business”
Meetings are scheduled for one hour before
lunch or one hour before end of workday
The chair is well prepared for the meeting
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The chair referees, paces, summarizes and
clarifies discussion
The

meeting

concludes

with

definitive

decisions and a commitment to them
Useful information is circulated with the
minutes
ƒ

The

chair

allows

adequate

time

for

discussion
ƒ

The chair facilitates participation by all
members

ƒ

Items requiring further study are referred to
smaller groups as projects. Timetables for
results are established.

Technical assistance is provided to facilitate meeting
success.

Learning Activities
1. Observe the group dynamics in one of your
classes or groups. What do you see in terms
of roles played by the different participants?
What is your role?
2.

Compare
experiences

from

your

positive

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own

individual

and

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communication

climates.

Discuss

the

characteristics in each.
3. Try to find people in your experience that fit
the various roles played by group members.
Do they consistently use the same behaviors,
or do they alter, as the situation requires?
Share with the class your observations, and
discuss the relative effectiveness of the
different behaviors in influencing the group.
4. What are the major types of teams?
5. How

can

managers

increase

team

cohesiveness?
6. How

can

committees

be

made

more

effective?
7. How can managers deal with conflicts within
their team?
8. What are the determinant factors of team
effectiveness?

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CHAPTER ELEVEN
CONFLICT RESOLUTION
Objectives:
At the end of this chapter, the student should be able to:


Identify aspects of your professional role that
predisposes to conflict with nurse administrators or
physicians



Analyze an ongoing conflict in your organization and
identify the manifest conflict, the felt conflict,
antecedent conditions and internal and external
factors influencing the conflict;



Differentiate the three common methods of conflict
resolution



Elaborate the different ways of conflict management
and

identify

the

most

preferred

of

conflict

management;

Conflict Resolution
Conflict is inevitable in human organizations. In health
care organizations the potential for conflict is heightened
because within these settings individuals must address
life and death issues; they have to function both
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independently and interdependently within a system
containing considerable role ambiguity and complex
lines of authority. Health care workers also need to be
highly skilled both in technical areas and in human
relationships. Other organizations may demand similar
qualities from individuals, but seldom to the same extent
that they are required of professional in health care.
These demands on health professionals make conflict
unavoidable.

What is Conflict?
Conflict is an expressed struggle between at least two
interdependent parties, who perceive incompatible
goals, scarce rewards, and interference from the other
party in achieving their goals. They are in a position of
opposition in conjunction with cooperation. Conflict
produces a feeling of tension, and people wish to do
something to relieve the discomfort that results from
tension.
Five characteristics of a conflict situation may be
identified: (1) at least two parties are involved in some
form of interaction; (2) difference in goals and/or values
either exists or is perceived to exist by the parties
involved; (3) the interaction involves behavior that will
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defeat, reduce, or suppress the opponent, or gain a
victory; (4) the parties come together with opposing
actions and counteractions; and (5) each party attempts
to create in imbalance, or favored power position (Filley,
1975).

Types of Conflict
Interpersonal Conflicts
Interpersonal conflicts are those that arise between two
individuals, and these are the most frequent type,
because people are constantly interacting and therefore
differing. Two staff nurses who disagree about the
approach to use with a depressed patient are involved in
a conflict, as are two children who want to play with the
same toy.

Inter-group conflicts
Inter-group conflicts can occur between two small
groups, two large groups, or between a large group and
a small group. A small group may be a family or a group
of 10 or fewer persons, or it may be a group that is a
small in relation to another group.
Regardless of a size of the groups involved, inter-group
conflict has certain predictable consequences. Within
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each group cohesiveness increases, but members
become more task oriented and less concerned with the
needs of individual members. Group leadership tends to
become more autocratic, but members nevertheless
accept it. The groups become highly structured, so that
a unified front will be presented to the opposition. If the
groups are required to meet, they will see and hear only
those aspects of the other group that support their
opinions.
These consequences of conflict are both positive and
negative. The increased cohesion and structure will
probably increase production, but the stereotyping and
hostile behaviors toward the other group are likely to be
destructive

to

the

persons

involved.

Conflict

management strategies should therefore be used to
ensure that the conflict will have a healthy outcome.

Personal Group Conflicts
Conflicts between an individual and a small group or
between an individual and a large group are called
personal –group conflicts. In this type of conflict an
individual is at odds with a group. The nurse who does
not finish giving her patient’s bath before she goes to
lunch will be in conflict with the rest of the staff if they
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believe that all baths should be completed by noon. This
type of conflict is very difficult for the individual because
he or she typically feels overwhelmed and powerless in
the situation. The odds are all against the individual.

Intrapersonal Conflicts
Conflict may also be intrapersonal (i.e., within a person).
The individual feels tension because of a disagreement
within him-or herself. Intrapersonal conflict may result
from having to make a choice between two things of
generally equal value (positive or negative), from
ambivalence about doing or not doing something, or
from problems related to decision making between two
or more of the individual’s roles. A nurse leader who is a
mother may experience intrapersonal role conflict when
she must choose between going to apparent teacher
conference about her child or going to a professional
nursing meeting.
Management of intrapersonal conflict must come from
the individual involved. Several options are available,
but the individual must first decide what is most
important, and then work to change the environment or
his or her attitudes, or else use a systematic decision
making process to identify a solution.
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Conflict Resolution Theory
Filley (1975), Proposed a model of conflict resolution
represented in Fig. 11.1, which provides a framework
that helps explain how and why conflict, occurs and,
ultimately, how one can minimize conflict or resolve it
with the least amount of negative aftermath? Filley
argues that the conflict resolution process moves
through six steps: (1) antecedent conditions, (2)
perceived conflict, (3) felt conflict, (4) manifest behavior,
(5) conflict resolution or suppression, and (6) resolution
aftermath.

Antecedent

Conditions

(Preexisting)

-

certain

conditions exist which can lead to conflict, though they
do not always do so.
Conflict may develop from a number of antecedent
sources, including:
ƒ

Incompatible goals

ƒ

Distribution of scarce resources when individuals
have high expectations of rewards

ƒ

Regulations, when an individual’s need for
autonomy conflicts with another’s need for
regulating mechanisms

ƒ

Personality traits, attitudes, and behaviors
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ƒ

Interest in outcomes

ƒ

Values

ƒ

Roles,

when

two

individuals

responsibilities

but

actual

unclear,

or

when

they

have

equal

boundaries
are

are

required

to

simultaneously fill two or more roles that present
inconsistent or contradictory expectations.
ƒ

Tasks, when outputs of one individual or group
become inputs for another individual or group, or
outputs are shared by several individuals or
groups..

Perceived Conflict - two or more individuals logically
and

objectively

recognize

that

their

aims

are

incompatible.
Felt Conflict- Individuals experience feelings of threat,
hostility, fear or mistrust.
Manifest behavior- overt action or behavior takes place
- oppression, competition, debate, or problem solving.
Conflict Resolution or Suppression- the conflict is
resolved or suppressed either by all parties' agreement
or else by the defeat of one party.
Resolution Aftermath- Individuals experience or live
with the consequences of the Resolution
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Antecedent condition
Felt
conflict

Perceived
Conflict

Manifest
behavior

Conflict resolution or
suppression

Resolution aftermath

Fig.11.1

The conflict process

Manifest behavior
Manifest behavior refers to the behavior and action of
individuals in response to conflict. These are the signs
of conflict that are observable to bystanders. Individuals
manifest primarily two kinds of behaviors in response to
perceived and felt conflict: (1) Conflictive behaviors
(negative) and (2) Problem solving behaviors (Positive).
Conflictive behavior is characterized by the conscious
attempts of one person to compete, dominate, and win
over a second behavior. For example, conflictive
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behavior would be manifested by a health professional
in an interdisciplinary meeting who consciously tries to
block the innovative program suggested by another
health professional. The dominating professional may
try tactics such as discrediting the proposed program or
diverting the discussion to a completely different topic in
order to prevent program adoption. Problem solving
behaviors, on the other hand, are conscious attempts to
find mutually acceptable alternatives- to find approaches
to problems that have positive outcome for both parties.

Conflict Resolution or Suppression
In conflict situations, individuals can either suppress
conflict or engage in activity, which will lead to its
resolution. Behavior directed toward the resolution of
conflict

can

be

characterized

by

three

different

communication strategies: (1) Win- Lose, (2) LoseLose, or (3) Win -Win.
Win -Lose Strategies- The win- lose strategy of conflict
resolution is quite common, and most of us have used it
at one time or another. It is not the optimal way of
resolving conflict because one of the participants loses.
This strategy is characterized by attempts of one
individual to control or dominate another so as to obtain
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his/her own goal(s) even at the expense of another’s
goal(s).
Lose – Lose Strategies- the lose –lose approach to
conflict is obviously one we would all like to avoid when
possible. Most people do not intentionally select a loselose strategy, but they end up with this outcome when
other strategies, such as when a win-lose strategy, fail.
In lose-lose conflicts both parties try to win over the
other but both end up losing to each other. Neither
person’s goals are achieved and the relationship is
weakened. Attempts by individuals to dominate over
each other result in mutually destructive communication
between the participants and negative outcomes.

Case Study
A school of nursing was seeking a new director.
Administrators at the college strongly desired to have an
“in-house” person assume the position, since that
person would already be familiar with the program and
would have faculty support. Two faculty members said
that they would like the position and both tried to line up
faculty support. In their attempt to gather faculty support,
strong disagreements developed between the two
candidates and two distinct factions developed within
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the faculty. Both factions of faculty members threatened
to quit if the person of their choice was not selected. In
the end, neither in-house candidate was appointed as
director of the program; instead a person from the
outside who was less qualified had to be hired for the
position. The tension and conflict that were generated
within the two quality groups produced what could be
called a lose-lose, destructive outcome.

Win- Win Strategies
Individuals who employ win-win strategies approach
conflict in ways that are significantly different from the
strategies used by individuals who take win-lose or loselose approaches toward conflict. The win-win strategy is
an approach that allows both individuals to feel they
have accomplished all or part of their goals. This
strategy tries to satisfy mutual needs, to solve problems
creatively, and to develop relationships. There is no
attempt by one party to win over or control another party
in this approach.
Finding win-win conflict solutions mean suppressing but
not sacrificing our own needs in order to listen for the
needs of others. Whether it is a conflict over a policy or
procedure or conflict for control or esteem, win-win
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strategies mean both parties communicate in ways that
allow each of them to satisfy at least some of their
needs. Win-Win solutions strengthen relationships. They
make individual feel better about how they are related to
others. Overtime, the strengthening of relationships has
the advantage of helping individuals in future conflict
resolution.

Example: Development of a joint appointment program in which
staff could spend part of their time working for
governmental school of nursing and part of their time
working for the private school. This type of programs
where there is scarcity of instructors would benefit both
institutions as well as the individual staff members.

Resolution Aftermath
The final aspect of conflict in the Filley conflict model is
resolution aftermath. During this phase, participants
experience feelings directly related to the outcomes of
the resolution process. If the conflict is resolved in a
positive fashion, the participants will have good feelings
about themselves, about each other and the situations.
This was the case in win-win strategies. On the other
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hand if the conflict is resolved in an unproductive style,
participants

will

have

negative

feelings

about

themselves, each other, and the relationship. This is
common in win-lose or lose-lose situations, where
participants may feel less cooperative, more distrustful
and very prone to further conflicts (Filley, 1975).
Obviously, the preferred goal of conflict resolution is to
arrive at solutions that result in positive feelings,
productive interactions, and cooperative relationships
among the participants.

Conflict

Management

/Styles

of

Approaching

Conflict/
We have discussed the nature of conflict, different kinds
of conflict, and theoretical perspectives on conflict and
strategies for resolving conflict. Now we would like to
address the questions, do individuals have different
ways of handling conflict? In addition, how do the styles
employed by individuals affect the outcomes of the
conflicts?
Researchers have found that individuals approach
interpersonal conflict utilizing five styles: (1) avoidance,
(2) Competition, (3) accommodation (4) compromise,
and (5) collaboration. This five-category scheme for
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classifying conflict was developed by Kilmann and
Thomas (1976) and is based on the work of Blake and
Mouton (1964). In the next section, each of the five
conflict styles will be discussed in more detail. As you
read the descriptions of these styles, perhaps you can
identify which style of the conflict management you must
commonly use in your communication with others. Is
that style productive or counter productive? Of all the
styles described, is there one or more that you could
develop to enhance your conflict handling skills?

Avoidance
Avoidance is a style characteristic of individuals who are
passive and who do not want to recognize conflict.
These persons generally prefer to ignore conflict
situations rather than confront them directly. In conflict
producing circumstances, these individuals are not
assertive about pursuing their own interests nor are they
cooperative in assisting others to pursue their concerns.
In health care settings, avoidance is not and uncommon
conflict style. In fact, there times when avoidance may
almost be necessary. For example, on department in a
hospital may frequently be in conflict with another
department that is always slow in responding to
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requests. If the request is directly related to the survival
of a patient, the interdepartmental conflict becomes less
important than just getting the service immediately- and
avoiding conflict may be the best way. Health care
practitioners are frequently dealing with life and death
decisions for patients; consequently they often need to
suppress their own concerns or conflicts with other staff
members’ in order to perform the necessary services. In
these critical situations, avoidance of conflict may
facilitate the health care delivery process.
In general, however, avoidance is not a constructive
style of confronting conflict. Health professionals who
are continually required to avoid conflict experience a
great deal of stress. They bottle up their feelings of
irritation, frustration, or anger, inside themselves,
creating more anxiety, instead of expressing them or
resolving the situation. Furthermore, avoidance is
essentially a static approach to conflict: It does nothing
to solve problems or to make changes that could
prevent conflicts. In health, care organizations, the
problems that exist will seldom be alleviated or resolved
of avoidance is employed in conflict situations.

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Competition
Competition

is

a

conflict

style

characteristic

of

individuals who are highly assertive about pursuing their
own goals but uncooperative in assisting others to reach
their goals. These individuals attempt to resolve a
struggle by controlling or persuading others in order to
achieve their own ends. A competitive style is based on
a win-lose conflict strategy.
Competition is spreading in our culture and can produce
solutions to conflicts that are more effective and more
creative than if competition were not present. For
example, in a community in which school of nursing are
competing to provide specific training, the quality of
trainings will be higher, and the costs to the public will
eventually be lower than if there were no competition. In
the area of cost containment, a competitive approach to
conflict can generate innovative cost solving solutions to
complex problems. Similarly, on the interpersonal level,
when two professionals compete to provide quality care,
the
Outcomes can be very positive for clients. In effect,
competitive approaches to conflict can challenge
participants to make their best efforts, and this can have
positive results.
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Generally, though, competitive approaches to conflict
are not the most advantageous approach to conflict
because they are more often counterproductive than
productive. In failing to take other’s concerns into
account, we do others damage. When we attempt to
solve

conflict

communication

with
can

dominance
easily

and

become

control,

hostile

and

destructive. Too much competition among health
professionals can direct energy away from patient care
objectives

toward

unnecessary

inter-professional

struggles. Too much competition between health care
facilities can lead to a duplication of services within
communities (example, two CAT scans, two dialysis
units, etc.) and duplication increases healthcare costs.
Competitive approaches to conflict create unstable
situations as one party is constantly striving to attain or
maintain dominance over the other party. Finally,
competition

creates

discomfort;

and

competition

individuals fail to recognize the concerns and needs of
others.

Accommodation
Accommodation is a conflict style that is unassertive but
cooperative. An accommodating individual attends very
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closely to the needs of others and ignores her or his
own needs. Using this style, individuals confront
problems by deferring to others.
Accommodation is one way for individuals to move away
from the uncomfortable feelings of struggle that conflict
inevitably produces. By yielding to others, individuals
can lessen the frustrations that conflict creates. By
yielding to others, individuals can lessen the frustrations
that conflict creates. In accommodating, an individual
essentially communicates to another, “You are right, I
agree; let’s forget about it.”
The problem with accommodation is that it is in effect a
lose-win strategy. Individuals who accommodate may
lose because they fail to take the opportunity to express
their own opinions and feelings. Their contributions are
not fully considered because they are not actively
expressed or forcefully advocated. This style is primarily
a submissive style, which allows others to take charge.
To illustrate accommodation, consider the following
conflict between a nurse and a physician regarding the
use of pain medication with a terminally ill cancer
patient. The physician believes that pain medication
should be given no sooner than every four hours. In
contrast, the nurse believes that the patient should be
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allowed to request pain medications as necessary and
should not have to adhere to a rigid four-hour schedule.
After only brief discussion of their differences, the nurse
decides to give in-to accept the physician’s approach to
the situation. The nurse in this situation suppresses
his/her values regarding pain management in order to
maintain a friendly nurse –physician relationship and in
order to prevent further conflict.
From a positive perspective, accommodation can be
useful I situations in which preserving harmony is
necessary. For ex. If two professionals differ on an issue
but one professional is deeply interested in the particular
issue while his/her colleague is less involved in the
issue, then it can be useful for the professional who
finds the issue less important to go along with the
concerned professional in order to maintain good
personnel relations. In general, accommodation can at
times be an effective means of eliminating conflict. As a
rule, however, accommodation is not a preferred conflict
style.

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Compromise

Fig. 11.2 A diagrams depicting the relationship between
assertiveness, cooperativeness, and styles of approaching
interpersonal conflict.

As. Fig.11.2 Indicates, compromise occurs halfway
between competition and accommodation, which means
it, includes both a degree of assertiveness and a degree
of cooperativeness. In using compromise to approach
conflict, an individual attends to the concerns of others
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as well as to her or his own concerns. On the diagonal
axis of fig. 11.2, Compromise occurs midway between
avoidance and collaboration. This means that persons
using

this

approach

confrontations

but

do

neither

not
do

completely
they

struggle

ignore
with

problems to the fullest degree. This conflict style is often
chosen because it is measure and provides a quick
means to find a middle ground. It partially satisfies the
concerns of both parties.

Compromise is a positive conflict style because it
requires that individuals attend to others’ goals as well
as their own. Compromise reminds us of the golden rule:
“Do unto others as you would have them do unto you.”
The problem with compromise is that it does not go far
enough in resolving conflict. As two persons give in to
one another’s demands, both individuals also pull back
from

fully

expressing

their

own

demands.

Both

individuals suppress personal thoughts and feelings in
order to reach solutions that are not completely
satisfactory for either side.

In health care, the compromise strategy may sometime
be

seen

in

the

communication
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among

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professionals in interdisciplinary team meetings. One
person may quickly agree with another person in order
to resolve a problem so that each of them can get back
to other responsibilities. Although this may be efficient
and conserve time, innovative solutions are sacrificed in
favor of quick solutions.

Collaboration
Collaboration, the most preferred of the conflict styles,
requires both assertiveness and cooperation. It involves
attending fully to others’ concerns while not sacrificing or
suppressing one’s own concerns. Although collaboration
is the most preferred style, it is the hardest to achieve.
Collaboration
participants.

requires
To

energy

resolve

and

work

incompatible

among

differences

through collaboration, individuals need to take enough
time to work together to find mutually satisfying
solutions.

The results of collaboration are positive because both
individuals

win,

communication

is

satisfying,

relationships, are strengthened, and future conflicts can
be resolved more easily. An effective style such as
collaboration and productive strategy such as win-win
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approach both require that participants attend closely to
one another’s opinions and proposals and interact in
ways that result in solutions acceptable to all parties.
Effective communication is the pivotal element that
prevents difference among individuals from escalating
and

facilitates

constructive

resolution

to

conflict

situations.

Learning Activities
1. Observe the interaction, which a conflict
occurs. Determine the type of conflict and the
strategies used to manage the conflict.
Propose alternative approaches to resolve
the conflict.
2. Case Study: You are called to a ward to
resolve a conflict between an RN and
assistant nurse. As you approach them you
hear the following dialogue:
RN: I asked you to get Mr. Nuru ready to go to X-ray,
and you ignored me. The technician was here and left
because you have not prepared the patient.
Ass. nurse: I was busy with Wro. Hanna and could not
leave her. Why didn't you get Mr. Nuru ready? You
actually knew about it.
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RN: It was your job. I assigned Mr. Nuru to you.
Ass.N. I do my own work and part of yours. You are the
RN. You are supposed to be the leader on this ward.
RN: Do not get sarcastic with me. I do not have to put
up with it. I am going to call the supervisor and report
you for your rudeness.
Ass.N. My rudeness! Go ahead and report me! I will tell
the supervisor what a lazy nurse you are!
Outline a plan to deal with this conflict. You may use the
following format.
2.1. What is (are) the cause (s) of the conflict?
2.2. Decide on aims, strategies, and specific skills for
resolving the conflict and list them.
3. Describe a recent instance of a conflict in
which you are involved. Was it resolved
satisfactorily? Can the group help in finding a
better solution? Discuss.

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CHAPTER TWELVE
MANAGEMENT OF CHANGE
OBJECTIVES:
At the end of this chapter, the student should be able to:


Describe the importance of change and appreciate
its nature



Explain key factors in management of change



Discuss the source of resistance to change and the
ways this resistance can be overcome



Play a leading role in initiating and managing change
in your organization of work environment



Discuss

Lewin's

3-step

model

of

change

management.

Management of Change
Change is defined as "the process of alteration or
transformation of individuals, groups, and organization
undergo in response to internal factors."

Purpose of change


To meet changing clients needs



To meet changing market conditions
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To respond to internal pressures



To take advantage of new opportunities



To respond to competitive pressure

Factors that cause change
A number of internal and external forces, often
interacting to reinforce one another, stimulate changes
in organization. Pressure for change may arise from a
number of sources within the organization, particularly
from new strategies, technologies, and employee
attitudes and behavior. For example, a top manager's
decision to seek a higher rate of long term growth will
affect

the

goals

of

many

departments

of

the

organization. Unexpected opportunities may arise that
permit the innovators inside the organization to develop
new

ways

of

doing

things.

This

can

stimulate

organizational change.

An

enormous

variety

of

external

forces,

from

technological advances to competitive actions can
pressure organizations to modify their structure, goals,
and methods of operation. Outside pressures come from
changes in the organizations technological settings,

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economic, political, legal, social, and competitive
environments.

Managing Change in an Organization
Change can be planned or unplanned. The latter just
happens in the natural course of events. Planned
change, on the other hand, is the result of consciously
designed preparation to reach a desired goal or
organizational state. An effective management of
change involves change agents, performances gaps,
levels and targets of change, systems approach, and
content and process.

a. Change Agent - In every situation in which a change
is desired, some person or group must be designated as
the catalyst for change. That person or group is called
the change agent. The change agent is the individual
who is responsible for taking a leadership role in
managing the process of change. The individual, group,
or organization that is the target of the change attempt is
called the client systems. Managers or staff at various
levels in organizations can serve as change agents.
Consultants brought in from outside can also be change
agents. Their role is to recognize the need for altering
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the status quo and to plan as well as to manage the
implementation of the desired changes.
b. Performance Gaps - It is the difference between the
status

quo

and

the

desired

new

standard

of

performance or desired organizational state. The
change agents think in terms of performance gaps.
c. Levels and Targets of change - Change agents
must identify the level at which their efforts will be
directed. Effects can be made to change individuals,
groups, and entire organizations. Each represents a
different level, or unit of change. Besides, change
agents’ focus on targets to alter in attempting to close
performance gaps and reach desired objectives. These
targets of change include people, technology, Jobs and
workflow,

organizational

structure

and

processes,

culture, and management. The following examples
illustrate how managers can change some of these
targets.

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Target
Individual

Example


Fire a person and replace him/her
with some one else.



Change knowledge, skill, attitude,
or behavior

Technology



Replace existing technology with
a more modern machine or way
of doing work

Structure



Change from functional structure
to a product division structure



Add a new department or division,
or consolidate the existing ones

Processes



Change the pay system from
hourly wages to salaries

Culture



Implement

a

program

to

encourage valuing quality and
service
Management



Encourage participation in the
diagnosis

and

solution

of

problems by people at lower
levels to replace a top-down
approach

d. Systems Approach- since various elements of an
organization are all part of an inter- dependent system,

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a change in any single target often leads to changes in
the others. For example, when intensive care unit
introduces ECG machines to improve diagnosis of
patients, a series of changes followed. First, nurses
have to learn on how to monitor the ECG and all have to
learn the concepts and its interpretation.

E. Content and process: - Two key concepts in
managing change are content and process. Content is
the what aspect of change, and process is the how
dimension of change. For example, assume a manager
is concerned about decreasing productivity among the
clerical staff. She thinks the cause might be excessive
talking among staff members. In order to discourage
talking among the clerical staff, she may decide to move
their desks farther apart or place partitions between
them. This is a content change.

How this manager introduces and implements the
change is the process. For example, she may decide to
announce the change by memo or in a staff meeting, or
she might have the desks moved during the night so
that the clerks find out about the change when they
come to work the next day.
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Programming Change
The realization of organizational change requires
effective planning or programming. A change program
should incorporate the following processes.
1. Recognizing the need for change – The need
for change is sometimes obvious, as when
results are not inline with expectations, things
clearly are not working well, or dissatisfaction is
apparent.
2. Setting Goals – Defining the future state or
organizational conditions desired after change.
3. Diagnosing the present conditions in relation to
the stated goals.
4. Defining

the

transition

state

activities

and

commitments required on meeting the future
state.
5. Developing strategies and action plans.

Lewin’s 3 Step model of the change Management
Sociologist Kurt Lewin (1951) envisioned that any
potential change is interplay of multiple opposing forces.
These forces are broadly categorized under two major
fields: the driving forces and restraining forces. The
driving forces are the factors that encourage or facilitate
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the change, while the restraining forces are the factors
that obstruct change. If these opposing forces are
approximately equal, there will be no movement away
from status quo. For change to occur the driving forces
must be increased and/or the restraining forces must be
reduced. This requires thorough understanding and
analysis of the forces likely to resist change as well as
those creating the need for change. Lewin called this
process “force field analysis”. He noted that force field
analysis is an important diagnostic and problem solving
technique. It involves:

1. Analyzing the restringing forces or driving forces,
which will affect the transition to the future state.
These

restraining

reactions

of

forces

will

include

who

see

change

those

the
as

unnecessary or constituting a threat.
2. Assessing which of the driving or restraining
forces are critical
3. Taking steps both to increase the critical driving
forces and to decrease the critical restraining
forces.
Kurt Lewins further studied the process of bringing
about effective change. He noted that individuals
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experience two major obstacles to change. First, they
are unwilling (or unable) to alter long-established
attitudes and behavior. Second, their change of
behavior frequently last only a short time. After a brief
period of trying to do things differently, individuals often
return to their traditional behavior.
To overcome obstacles of this sort, Lewin developed a
three – step sequential model of the change process.
The model involves “unfreezing” the present behavior
pattern, “Changing” or developing a new behavior
pattern, and then “refreezing” or reinforcing the new
behavior.
Unfreezing

Changing

Refreezing

Raised state

Changes

Behavior

of tensions,

advocated

stabilized;

dissatisfacti

and

desired

on with

implementati

attitudes

status quo;

on begins;

and values

climate

changes

internalized

adapted to

tested/adapt

and

minimize

ed for

reinforce

resistance.

desired
results

Fig. 12.1, the three step of change process

234

Refre
Behavior
desired att
values int
and rei

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1. Unfreezing- it involves making the need for
change so obvious that the individual, group, or
organization can readily see and accept it. It is
the process of creating a climate ready for
change. In this stage, the management realizes
that the current strategy is no longer appropriate
and the organization must breakout of (unfreeze)
its present mold. As such, it tries to make other
people (employees) realize that some of the past
ways of thinking, feeling, and doing things are
obsolete. It convinces individuals and groups that
present conditions or behavior are inappropriate.
2. Changing- once the members have been
prepared to accept change, their behavioral
patterns have to be redefined. There are three
methods of reassigning individuals' new patterns
of behavior. These are:
a. Compliance – It is achieved by strictly
enforcing the reward and punishment
strategy for good or bad behavior. The
fear of punishment or actual reward
seems to change the behavior for the
better.

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b. Identification



Identification

occurs

when the members are psychologically
impressed upon to identify themselves
with some given role of models, whose
behavior they would like to adopt and try
to become like them.
c. Internalization – Internalization involves
some internal changing of the individual’s
thought processes in order to adjust to a
new environment. Members are left alone
and given the freedom to learn and adopt
new behavior in order to succeed in the
new set of circumstances.
As a whole, in this stage, new behavior is
developed and change is effected through a
conscious process as individuals seek to
resolve the anxieties that surfaced during
unfreezing stage.
3. Refreezing – It means locking the new behavior
pattern into place by means of supporting or
reinforcing mechanisms, so that it becomes the
new norm. It is the process of institutionalizing
the new state of behavior or work by rewards
(praise, etc).
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Making the change process Effective
The important aspects of Kanter’s Ten Commandments
have been summarized as follows (Lovell, 1994).
1. Analyze the organization and its need for
change- any change process should start with a
meticulous

understanding

of

how

the

organization works; what are its strength and
weakness, what are its relationships with the
environment and what are its needs to change.
2. Create

a

shared

vision

and

common

Direction- One of the key first steps is to unite
the organization around a vision of the future.
3. Separate from the past- This is a similar idea to
Lewin’s (1947) unfreezing process. This is an
absolute

detachment

from

the

past.

The

organization must identify what aspects of its
operations are no longer relevant.
4. Create a sense of urgency
A sense of urgency seems to be important for the
organization to unfreeze and develop support for the
changes. Sense of urgency is accelerated as a result of
crisis. But preferably organizations should be productive
in their change strategies and change before crises
occur.
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5. Support a strong leader (transformational leader)
Several studies demonstrated that a strong leader is a
factor to vision creation, motivating the organization
behind the vision and rewarding who strive towards its
realization.
6. Line up political support
Although leader ship is a very important prerequisite for
propelling change, it is not enough in its own.
Successful change needs a broad-base support from all
the stakeholders, including those who will lose, as well
as those who will profit from change.
7. Craft an implementation plan
While visions are of paramount importance in effecting
changes, the organization needs clear information about
what will be done to achieve it. A road map has to be
prepared, giving clear direction and a route to take.
8. Developing enabling structures
The old structures and methods of working are unlikely
to be satisfactory to support and sustain the change
process on their own. Enabling structures are systems
and

structures,

which

support

the

transformation

process during the transition from the old to the new
state. They include new institutional names, new logos
and uniforms and office relocations and renewal.
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9. Communicate, involve people and be honest
Wherever or whenever possible, there should be open
communications and the involvement and trust of people
in the organization.
10. Reinforce and institutionalize the change
Managers

need

constantly

to

demonstrate

their

commitment to the change. They should reward the new
desired behaviors and ensure they become part of
normal day to day operations.

Resistance to change and gaining support
1. Reasons for resistance
Change is neither always accepted nor always rejected.
Some

people

desire change

and

welcome

new

experiences as a break from monotony, on the other
hand, there are a good number of people who resist
change for various reasons than one. Management may
recognize the need for change, but most employees
may resist the process.
No matter what the resistance might arise, the change
must occur continually in order to adjust to dynamic
forces that are continuously at play. The society will
become stagnant if no changes took place. The reasons

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for resistance to change must be studied carefully, but
four main reasons are common.
1. Parochial self interest


Threat to core skills and competence



Threat to status



Threat to power base

2. Misunderstanding and lack of trust


Lack of information



Misinformation



Historical factors (poor timing)



Low trust of organizational climate



Poor relationships (quarrelsome)

3. Contradictory Assessments


No perceived benefits



An assessment that the proposed change is
wrong/ill thought out



Strong peer-group norms, which may shape
such contradictory assessments

4. Low tolerance of change


Fear of unknown



Fear of failure



Customer bound (inertia-unwillingness to
disturb status quo)



Reluctance to let go
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A variety of reasons thus exist for resistance to change.
The change itself or the methods of implementation may
be opposed. But if managed correctly, the opposition
can be minimized or completely eliminated.

Managing resistances to change
If the change is to be implemented successfully, it
needs full acceptance and cooperation from employees.
More specifically, Kotter and Schlesinger (1979:110)
have put forward six valuable ways of overcoming
resistance to change. The techniques include:
1. Education and communication - Management
should

educate

employees

about

upcoming

changes before they occur. It should communicate
not only the nature of the change but its logic. The
process

include

one-on-one

discussions,

presentations to groups (variety of conferences),
brochures, or reports and memos.
2. Participation and Involvement - If management
involves those who might resist change with the
design

and

implementation

of

the

change,

resistance may be prevented.
Considerable research has demonstrated that, in
general,

when

employees
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decision to change, they are committed to
implementing it. Therefore, employees should also
be

involved

in

the

change's

design

and

implementation.
3. Facilitation and support - Management should
make the change as easy as possible for
employees and be supportive of their efforts. This
could be achieved through providing training new
skills, or giving employees' time off after a
demanding period of change, or simply listening
and providing emotional support.
4. Negotiation and Agreement - When necessary,
management can offer concrete incentives for
cooperation with the change. Rewards such as
bonuses, wages and salaries, recognition, Job
assignments and perhaps restructured to reinforce
the direction of change.
5. Manipulation and co-optation - This process
involves

making

covert-attempts

to

influence

others. One common form of manipulation is cooptation. Co-optation involves giving an informal
leader (a resisting individual) a desirable role in the
design or implementation of a potential change.
For instance, management might invite a union
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leader to be a member of an executive committee
or ask a key member of an outside organization to
join the company's board of directors. As a person
involved in the change, he or she may become
less resistant to the actions of the co-opting group
or organization.
6. Explicit and Implicit coercion - Some managers
apply punishment to those who resist change. With
this approach, managers use force to make people
comply with their wishes. For instance, a boss may
force employees to go along with a change by
threatening them with dismissed, with being
passed over for promotion, with unattractive Job
assignment,

or

through

other

negative

suggestions.

Learning Activities
1. Analyze a change that has occurred. Was the
change planned or unplanned? Who was the
change agent? What strategies did the change
agent used?
2. Interview a nurse leader about changes that
have occurred in the past month. How was the

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nurse leader and her group involved in the
change process?
3. Propose a plan for change. Describe the
anticipated resistance and methods to manage
the resistance.
4. Identify a needed change in your health care
setting. What are the driving and restraining
forces that will enable or prevent that change?

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CHAPTER FORTEEN
PROJECT PLAN MANAGEMENT
Objectives:
At the end of this chapter, the student should be able to:


Develop a complete project plan of its interest using
all the steps of project planning.

Project Plan Management
Studies have consistently shown that planning and goal
setting can improve program performance. A total plan
provides the structure for implementing the program,
serves as a guide for effectively using human, material
and financial resources, and creates a common
understanding of program goals and objectives among
staff.

Organizing and Developing a Written Plan
A good plan should describe the type of project that you
intend to implement, the expected results, the plan of
activities for setting up and implementing the project, the
way that progress will be tracked, the reporting system,

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and the cost of carrying out the project. The plan should
contain distinct sections that clearly describe:


The existing problem or need that the project will
address and the proposed project;



The goals and objectives of the project, and the
time frame for achieving the objectives;



A general activity plan for the term of the project,
including how the activities will be carried out,
who will be responsible for each activity, and
when each major activity will be completed;



A plan for monitoring progress and evaluating
the results of the project;



A reporting plan and schedule, including how the
project will manage its finances;



A projected budget for at least the first year of
the project, land a summary budget for the life of
the project.

Explaining the Purpose of your Initiative
Each new initiative or project should be created to
respond to documented needs or problems in the
community or region your program serves. Thus, the
first part of the plan should justify the need for the
project. This part of the plan can be divided into two
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sub-sections; the problem statement and your proposed
solutions.

The Problem Statement
This is a statement of the specific problem or need to be
addressed by the project. It should include some basic
data (baseline data) that help to explain the problem,
including the following information:


A description of the extent, scope, or severity of
the problem, so that the proposed results can be
put in the perspective;



A description of the geographic area and
demographic characteristics of the population in
the area in which the problem exists;



An analysis of the causes of the problem;



The results of the previous efforts, by your
program or other programs, to solve the
problem.

An example of Problem Statement:
Within the region of Somalia there is a large per-urban
population of 250,000 that at the present time does not
have any access to family planning services. Ten
government clinics are located within and near this area
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but they offer only some other services on maternal and
child health services. At 52 births per 1,000 populations,
the birth rate in this peri-urban area is roughly two times
than in other areas within the state.

The Proposed Solution- in this section of the plan you
should explain the design of your project, emphasizing
those aspects of your approach that you think best
address

the

problem

you

have

described.

The

description of the project design should answer the
following questions:


What approach will you use, and why have you
chosen this approach over other possibilities?



What other local programs are addressing this
problem and how does your proposed approach
complement their activities?



What changes do you expect will result from this
project?



How does this project fit in your organization’s
overall strategic plan?



What sources of support are likely to be available
to you for continuing the project in the future?



In what ways is the project designed so that it
can be replicated in other areas?
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An example of a Proposed Solution:
Within the Peri-urban area of Somalia region there are
10 MCH clinics staffed by government nurses. This
initiative, “Project Expand: Somalia”, would use existing
government clinics to introduce family planning services
to these peri-urban areas. A family planning trained
physicians and nurses in each of the existing clinics
would provide Family Planning services. In addition, a
network of local promoters (TTBA and extension health
workers) would be formed to disseminate family
planning information, distribute contraceptives, and refer
clients to clinics for clinical methods. By building on the
accessibility of the existing government clinics and
linking community outreach activities with clinic services,
this project is expected to significantly decrease the birth
rate in the peri-urban area of Somalia region. It is
expected that this model will be replicable in other urban
areas in Ethiopia.

Being Specific about what the New Initiative will
Accomplish
A well-designed project should have both overall goals
and specific objectives. The goals and objectives set
forth the intended results to be achieved by the project
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and the degree to which the problem described will be
resolved. Once the objectives have been determined, a
set of activities that describe how each objective will be
achieved should be specified in the activity plan that
follows.
Goals: The overall goals should describe, in a broad
way, the long-term changes that will result from your
project's work on the problem outlined in the problem
statement. Normally one or two general statements
describing the proposed long-range benefits to the
target population are sufficient to describe the overall
project goals.
Example of an overall goal: To reduce the birth rate in
the

peri-urban

community

of

Somalia-region,

by

providing clinic-and community-based family planning
services.
Objectives: for each overall goal that you develop,
there should be several specific, measurable objectives.
These objectives relate to the problem statement and
describe anticipated results that represent changes in
knowledge, attitudes, or behavior of the project clients or
participants. Your objectives should be SMART.

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Specific - to avoid differing interpretations
Measurable - measurable, observable, or otherwise
documentable. It allows for monitoring and evaluation.
Appropriate - to the problems, goals and strategies
Realistic - achievable, challenging, and meaningful
Time bound - with a specific time period for achieving
them

Examples of specific objectives:


To select, recruit, and train a network of 60 family
planning promoters by the end of the first year of the
object.



To attract 4,000 new family planning acceptors
during the first year of operation of the project, and
an additional 9,500 during the second year of the
project.

To be serving 20,000 family planning clients by the end
of the third year of the project.

Developing Detailed project Activities
The plan of activities constitutes the core of your plan
and should describe the major activities needed to
accomplish each project objectives. To fully develop the
plan, you should list the key activities that must be
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Nursing Leadership and Management

carried out in order to achieve each objective. One or
more individuals should be assigned to each activity and
these people will be responsible for overseeing or
carrying out the activity. The plan of activities can be
divided into two sub-sections: a detailed description of
project activities and a project activity timeline.

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Nursing Leadership and Management

Sample-project Activity Timeline

Project Activity

Year-1

Year-2

Year-3

Person(s)

1234

1234

1234

Responsible

Select and recruit project personnel
5 nurses

Head

3 outreach supervisors

XX

20 promoters

XX

Nurse/

Metron

XXX
Order contraceptive supplies and IEC
materials

Project
XXX

XXX

XXX

Coordinator

Develop monitoring and reporting
forms

XX

"

Evaluate project progress and impact

XX

XX

Head
Metron

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Nurse/

Nursing Leadership and Management

Tracking the progress toward Meeting Objectives
Plans for monitoring and evaluating your project should
be included in the initial project design.
Monitoring - is the process by which project activities
and the budget are regularly reviewed. Monitoring helps
to ensure that the activities planned in the work plan are
being completed and that the costs are in line with the
budget. The monitoring plan should include at least the
following information:


A list of the project personnel who will be
involved in monitoring the project, and their
specific monitoring responsibilities



How and when project managers will monitor
activities



A plan for the development of criteria that will be
use to monitor project activities, including
measures of service quality



A plan for the development of forms that will be
used for monitoring activities

An example of a monitoring plan
The project coordinator assigned to the project will
monitor the progress of activities and the costs incurred
in carrying out these project activities. On a quarterly
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Nursing Leadership and Management

basis,

the

project

coordinator

will

compare

the

completed activities and the expenditures against
planned activities and the budget, by making site visits
to clinics and outreach worker sites. Clinic heads will be
responsible for monitoring the activities of the promoters
on a quarterly basis by making visits to selected
outreach worker sites with the supervisors assigned to
each area. The medical director will monitor the quality
of care provided by the nurses on a quarterly basis by
making site visits to the clinics and by conducting
random exit interviews with clients. Early in the first
quarter of the project, the project coordinator and the
medical director will develop specific monitoring criteria
for the project and will revise existing government
monitoring and reporting forms for use in the project.
The forms will be designed to collect basic family
planning data, to track potential discontinuers so that the
outreach workers can provide timely and effective follow
up visits, and to assess client satisfaction with clinical
and outreach services.
Evaluation - The evaluation of the project should
analyze the implementation process (that is whether the
planned activities were carried out and completed) as
well as the impact (or long-term effect) that the project
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Nursing Leadership and Management

has had on the target population. By developing this
section of the plan, you will define and let other project
personnel know in advance what aspects of the project
will be evaluated, and how and when the evaluation(s)
will be conducted.

Your evaluation plan should specify the following:


How the evaluation criteria will be developed



Who will perform the evaluation and when the
evaluation(s) will occur



How evaluation data will be collected and
submitted, including how qualitative data, such
as information on user satisfaction, will be
collected



How and when evaluation data will be analyzed
and reported



How the evaluation findings will be used

To establish the evaluation criteria, base the criteria on
specific project objectives. Because these objectives are
SMART, they are measurable and observable, and can
be easily converted into evaluation criteria.

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Nursing Leadership and Management

Example:

Evaluation criteria

Target

Actual

Target

Actual

(yr 1.)

No. %

(yr 2)

No. %

. Number of
family planning

2,000

7,000

60

60

acceptors
served by the
clinics
. Number of
family planning
promoters
oriented and
trained

Reporting Your Achievements
You

should

have

forms

for

reporting

on

both

programmatic achievements and financial activities. If
you do not already have reporting forms, you will need
to develop new forms, or modify existing forms used by
your program or other similar programs.
Programmatic reporting provides detailed information
on the activities under taken in the project. The
narrative reports should refer to the stated objectives,
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Nursing Leadership and Management

activity plan, and evaluation criteria to be used in
analyzing project progress.
Financial Reporting - shows how much money has
been expended during a specific reporting period and
for what purpose, and whether the money that was
spent was in line with the budget.

Sample project proposal outline
I. Project summary
II. Why this new Initiative?
A. Problem statement
B. Proposed solution
III. Organizational Qualifications
A. Organizational Experience
B. Key personnel
IV. Goals and objectives
A. Goals
B. Objectives
V. Detailed Activities
A. Project Activities
B. Project Activity timeline
VI. Project Sustainability
VII. Tracking Progress
A. Monitoring
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Nursing Leadership and Management

B. Evaluation
VIII. Reporting
A. Financial
B. Programmatic
IX. Budget
A. Detailed project Budget (year I)
B. Project Budget Summary

Learning Activity
Develop a complete project plan of your interest
using all the steps of project planning.

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Nursing Leadership and Management

CHAPTER FIFTEEN
QUALITY
ASSURANCE/IMPROVEMENT
Objectives
At the end of this chapter, the student should be able to:
ƒ

Define,

and

elaborate

down

the

quality

assurance process
ƒ

Discuss the methods used in monitoring the
nursing care for the quality assurance

ƒ

Identify clinical indicators of quality care

ƒ

Discuss

on

the

concepts

of

total

quality

management.

History of Quality Assurance
The process of systematic evaluation of heath care is
not new; quality assurance activities date back to
Florence Nightingale. She urged that all nursing care
being rendered be evaluated. During the Crimean War,
Nightingale reported statistics on the mortality of British
soldiers in comparison to civilians before and after some
of her innovative nursing practices. She reported that
the patient outcome mortality rate decreases by 2
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Nursing Leadership and Management

percent in a six-month period at one military hospital
(Nutting and Dock, 1907). She communicated her
findings and received public support. The government
interest in health care accountability resulted in the
regular evaluation of hospital care; these efforts
eventually contributed to similar health care being
delivered to soldiers and civilians.
In the late 1940s and early 1950s, the general public
became more aware of organizing, planning, and
evaluating methods of health care services. In 1952, the
Joint Commission on Accreditation of Hospitals was
founded. It provides standards for accreditation. The
American Nurses Association (ANA) in 1959 published
its Functions, standards and Qualifications for Practice,
and the National League for Nursing published What
people can Expect of a Modern Nursing Service. All of
these efforts helped to form professional and public
expectations about adequate care.

Definitions
In

order

to

improvement

understand
guidelines

the
that

quality
are

assurance/

distributed

by

legislative, voluntary, and professional bodies, the nurse

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Nursing Leadership and Management

manager should be familiar with the following definitions
(Gillies, 1994).
Accountability is the obligation to provide an estimate
for one’s actions to the persons who delegated authority
for

that

action.

The

conscious

nurse

exhibits

accountability toward her/his employer, the patient, and
government agency that pays for the patient health care.
A nursing care Outcome is the end result of a nursing
intervention, a measurable change in the state of a
patient’s health that is as a circumstance by nursing
action.
A criterion is the value free name of a variable that is
known to be a reliable indicator of quality. Example,
nurses educational preparation affect the quality of
patient care decisions.
A standard is the desired quantity, quality, or level of
performance that is established as a criterion against
which worker performance will be measured. A nursing
department might establish a standard that requires 100
percent of nurse managers to earn a bachelor’s by a
target date.
A norm is current level of performance of a selected
work group with reference to a given criterion. Example,

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Nursing Leadership and Management

a norm for writing nursing diagnosis in the ward for each
patient within 12 hours of admission is 50 percent.
An Objective is a goal toward which effort is directed.
To be effective, an objective should be expressed in
observable, measurable terms and should include target
date for fulfillment. For example, “By January, 1995, all
head nurses will be certified trainers of cardiopulmonary
resuscitation.”
A Critical clinical indicator is a quantitative measure
that can be used as a guide to monitor and evaluate the
quality of important patient care activities.
The effectiveness of a particular nursing intervention is
the extent to which desired outcomes are attained
through the use of the intervention. The efficiency of a
particular

nursing

intervention

is

determined

by

computing the intervention’s cost benefit ratio, or the
relationship between monetary value of resources
expended and monetary value of results achieved.
Quality Assurance describes all activities related to
establishing; maintaining and assuring high quality care
for patients.

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Nursing Leadership and Management

Quality Assurance Process
Quality assurance process is the systematic process of
evaluating the quality of care given in a particular unit or
institution. It involves setting standards, determining
criteria to meet those standards, data collection,
evaluating how well the criteria have been met, making
plans for change based on the evaluation, and following
up on implementation for change.
Setting Standards- The nursing profession should have
to design standards of nursing practice that are specific
to the patient population served (for example, the
American Nurses Association has set up a Standards of
Nursing Practice based on nursing process).

These

standards could serve as the foundation upon which all
other measures of quality assurance are based. An
example of a standard is: Every patient will have a
written care plan.
Determining Criteria- After standards of performance
are established, criteria must be determined that will
indicate if the standards are being met and to what
degree they are met. Just as with standards of care,
criteria must be general as well as specific to the
individual unit. One criterion to demonstrate that the
standards regarding care plans for every patient are
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Nursing Leadership and Management

being met would be: A nursing care plan is developed
and written by a nurse within 12 hours of admission.
This criterion, then, provides a measurable indicator to
evaluate performance.
Data Collection- The actual collection of data is the
third step in quality assurance. Sufficient observations
and random samples are necessary for producing
reliable and valid information. A useful rule is that 10
percent of the institutional patient population per month
should be sampled. The devised tool to collect data
should leave as little room for interpretation by the data
collector as possible. Data collectors need to be taught
the purpose of quality assurance along with the
principles of data collection.
Data collection methods include patient observations
and interviews, nurse observations and interviews, and
review of charts. Flow sheets and Kardexes are also
resources from which to assemble information about
past and present conditions.
A policy should outline guidelines of the reporting of
quality assurance data so it is clear who in the
organization

needs

to

receive

quality

assurance

information. The policy should also state at what level in
the organization the analysis of the different criteria is to
265

Nursing Leadership and Management

take

place,

to

whom

these

analyses

and

recommendations are to be reported, who is responsible
for implementing the recommendations, and who is
responsible for follow up. Unless definite policies are
established, the system may fail and changes in nursing
practice are not likely to occur (Sullivan, 1992).

Evaluating Performance
Several methods can be used to evaluate performance.
These include reviewing documented records, observing
activities as they take place, examining patients, and
interviewing patients, families, and staff. Records are the
most commonly used source for evaluation because of
the relative ease of their use, but they are not as reliable
as direct observations. It is quite possible to write in the
patient’s chart activities that were not done or not to
record those things that were done. Further, the chart
only indicates that care was provided; it does not
demonstrate the quality of that care. For example, care
plan could be checked nursing diagnosis, interventions
planned, and discharge planning.

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Nursing Leadership and Management

Monitoring Nursing Care
In addition to the individual patient care activities
described, another component of quality assurance is
the ongoing monitoring of nursing care. Several
methods are used to monitor nursing care. These
include the nursing audit, peer review, utilization review,
and patient satisfaction.
Nursing Audit can be retrospective or concurrent. A
retrospective audit is conducted after a patient’s
discharge and involves examining records of a large
number of cases. The patients’ entire course of care is
evaluated

and

comparisons

made

across

cases.

Recommendations for change can be made from the
perspective of many patients with similar care problems
and with the spectrum of care considered.
A concurrent audit is conducted during the patient’s
course of care; it examines the care being given to
achieve a desirable outcome in the patient’s health and
evaluates the nursing care activities bearing provided.
Changes can be made if they are indicated by patient
outcomes.
Peer Review- occurs when practicing nurses determine
the standards and criteria that indicate quality care and
then assess performance against these. In this case,
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Nursing Leadership and Management

nurses are the “experts” at knowing what the indicators
of quality care and when such care has been provided.
Patient Satisfaction. It is using a questionnaire and
asking the patient to fill out before leaving the institution.
Such questionnaire includes care given in a timely
fashion and other variables in the environment that
contribute

to

recovery

rather

than

standards

professional care.

Critical Indicators (Rate based) Surgical Unit


Postoperative pneumonia



Paralytic ileus



Wound infection



Haemorrhage



Urinary tract infection



Phlebitis



Fever

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K.

(1981).

Human

Behavior

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Gillies, Ann Dee (1994). Nursing Management. A
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271

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