MODULE ONE

REVIEW OF MAJOR MANAGEMENT FUNCTIONS

SPECIFIC OBJECTIVES

At the end of the module four, you will be able to:1. Describe the components of effective management2. Give at least 5 principles of nursing management3. Define, planning, organizing, leading and controlling4. State the purpose and benefits of planning5. Describe the phases of planning6. Differentiate between strategic and operational planning7. Describe the steps in strategic planning8. Apply the WOTs-Up system of analyzing an organization9. Name the principles of organizing10. Define leadership11. Describe leadership styles12. Name the major elements of directing13. Name two important criteria in the delegation of responsibilities14. Name and describe at least three techniques used in controlling

THE MANAGEMENT PROCESS

Management has been defined as the process of getting work done through others. According to Fayol (in Swansburg, 1993).To manage is to forecast and plan, to organize, to command, to coordinate and to control. To foresee and provide means, examining the future and drawing up the plan of action. To organize means building up the dual plan of action. To organize means building up the dual structure, material, and human of the undertaking. To command means binding, together, unifying and harmonizing all activity and effort. To control means seeing that everything occurs in conformity with established rule and expressed demand. Fayol listed the principles of management as follows:1. Division of work.2. Authority3. Discipline4. Unity of command5. Unity of direction6. Subordination of individual interests to the general interest.7. Remuneration8. Centralization9. Scalar chain

Nursing management is the process by which nurse managers work through others to achieve nursing organizational goals. The nurse managers task is to plan, organize, direct, and control available financial, material and human resources so as to provide the most effective care possible to groups of patients and their families. Swansburg (1993) identified thirteen general principles of nursing management as follows: Nursing management is planning. Nursing management is the effective use of time. Nursing management is decision making. Meeting patients s nursing care needs is the business of the nurse manager. Nursing management is the formulation and achievement of social goals. Nursing management is organizing. Nursing management denotes a function, social position or rank, a discipline, and a field of study. Nursing management is the active organ of the division of nursing, of the organization, and of society in which it functions. Organizational cultures reflect values and beliefs. Nursing management is directing or leading. A well-managed division of nursing motivates employees to perform satisfactorily. Nursing management is efficient communication. Nursing management is controlling or evaluating.

Tappen (1996) identified the components of effective management as follows:a. Leadershipb. Planningc. Directingd. Monitoringe. Recognitionf. Developmentg. RepresentationAs a process, management has many similarities with the nursing process. The nursing management process, like the nursing process, include gathering data, making plans, executing plans, and evaluating results.

NURSING PROCESSMANAGEMENT PROCESSFigure A. The Nursing Management Process Supports the Nursing ProcessGENERAL OBJECTIVESAt the end of the course, the students will leave acquired advanced knowledge and understanding of the theories, concepts, principles, and applications of the administrative processes in nursing organizations. Specifically, the students will be able to:1. Define the four major management functions2. Explain the processes, tasks and applications of planning in nursing organizations3. Compare strategic and operational planning in relation to their use in nursing organizations4. Discuss the uses and benefits of management by objectives5. Compare the advantages and disadvantages of the different kinds of organizational structures6. Describe the methods of team building7. Explain the uses of job analysis8. Write a job description9. Give specific examples of the applications of each of the management functions10. Discuss the dynamics of conflict and conflict resolution11. Explain the tasks involved in controlling12. Analyze management situations

REQUIREMENTS:The following are the requirements to pass the course:1. Completion of assessment exercises and learning activities at the end of each unit module.2. Submission of a 25 page typewritten term paper on the analysis of any of the aspects of the four management functions.3. Submission of five annotated bibliography

NURSING ADMINISTRATION

COURSE OVERVIEW:Nursing Administration II provides the student with advanced knowledge and understanding of theories, concepts, principles and applications of administrative process in nursing organizations. Administrative process I is a prerequisite to this course. Major top are the four major management functions of planning, organizing, directing, controlling and the general and specific applications in nursing organizations. Trends, issues, problems can significantly impact on nursing administration are incorporated in the discussion of each of the management functions. This course is organized into six modules:MODULE I offers a review of the concepts and process of the four management functions of planning, organizing. Directing and controlling.MODULE IIdiscusses the administrative processes and tasks involved in planning. Strategic and operational planning are discussed and differentiated; tools and planning such as budgeting, development of standards, formulation of policies, rules, regulations, procedures and methods, the System Approach are likewise covered.MODULE III deals with the processes and tasks of organizing. Organizational structure of tables of organization, organizational charts, job evaluation, job analysis, job description, team building, group work are discussed.MODULE IV centers on organizing patient care and staffing. Topics covered are different Patient Care Delivery systems, scheduling of staff, recruitment, selecting orientation of new employees, Staff Development, the problems of absenteeism.MODULE V the processes of leading, directing, supervision, coordination, decision-making, conflict management, communication and delegating are discussed in this module. The concepts of leadership, power, change are also covered.MODULE VI this module covers the processes and tasks of controlling. This including performance evaluation, standards, quality improvement, discipline, counseling and terminating of employees.

PLANNING

Planning is a dynamic and future-oriented process, is the first element of management and is the first step in the long and oftentimes complicated process of management. It is complete involving a whole set of interrelated actions and decisions (Tappen, 1997). Planning has been defined in several ways as for example making a plan of action for a foreseeable future (Fayol, 1949, in Swansburg, 1996); or as having a specific aim or purpose and mapping out a program or method beforehand for accomplishment of the goal" (Douglas, 1988), a process beginning with objectives, followed by deciding strategies, policies, then by detailed steps on how to achieve them (Steiner, 1969). These definitions indicate it is a process whereby it is decided in advance what to do, how to do it, when to do ir, who will do it, as well as determining feedback as bases for new plans. The planning step of the management process not only consists of determining the care need of different types of patients, but also includes establishing nurses objectives, determining budgetary allotments, deciding the size and the type of staff needed, designing an organizational structure that will maximize staff effectiveness, and establishing operational policies and procedures.(Gillies, 1994). Planning is a basic function of all managers. Why plan? There are many reasons for planning. According to Douglas (in Swansburg, 1996), benefits and purpose of planning include the following:1. Planning leads to success in achieving goals and objectives.2. It gives meaning to work.3. It provides for effective use of available personnel and facilities.4. It helps in coping with crisis situations.5. It is cost-effective.6. It is based on past and future, thus helping reduce the element of change.7. It can be used to discover the need for change.8. It is needed for effective control.

Some other benefits of planning include the following:

a. Satisfactory outcomes of decisions;b. Elements of the planning process;c. Strategic or long-range planning processd. The highest of personnel

Process of Planning. The process of planning is divided into three phases:A. Developing the planB. Presenting the planC. Implementing and monitoring the plan

Process of Planning

STEPSIIIIII

Develop PlanPresent PlanImplement and Monitor Plan

Establish purpose

Analyze situations: Problem analysis Situational factors Response to change

Formulate Objectives

Generate alternative courses of action

Analyze alternatives and select course of action

Plan

Purpose

Objectives

Action

EvaluateOrganize Implementation

Sequence activities Set the target date Responsibilities Allocation of resources

Direct ImplementationMonitor Implementation

Evaluate outcomes

Revised and update plan

Figure B. Planning Model

TYPES OF PLANNINGAccording to Tomey (1992), planning can either be a long range strategic planning and short range or operational planning. Tappen (1995), on the other hand, classified planning according to the purpose it serves. For example, healthcare planning is a broad, survey approach to determine health needs of a specified population, a community, or even an entire nation. The National Health Care Plan is an example. Project Planning is the process applied to a particular project within an organization or a project carried out in cooperation with other agencies.

Strategic Planning or long range planning extends to five years into the future. It begins with in-depth analysis of the organizations internal environments strengths and weaknesses and the external opportunities and threats so that realistic goals can be set for the future. Strategic planning goals are more generic and broader than those of operational planning. Historically, strategic planning became prevalent in US health care settings and literature in the 1980s in response to major changes in the health care industry which began in the 70s. these changes amount to higher cost of healthcare to the extent that it is almost unaffordable to the general public. Chief executives of health care organizations are resorting to mergers, joint ventures, networking, and other ways of cutting costs in order to survive. The main purposes of strategic planning are to clarify beliefs and values and to give direction to the organization. It answers questions like what are the organizations strengths and weaknesses?, what are the potential opportunities and threats?, where is the organization going?, and how is it going to get there?. Strategic planning has been proven to improve efficiency, to weed out poor or underused programs, to eliminate duplication of efforts by concentrating resources on important services. Strategic planning also improves communications and coordination of activities, provides a mind-expanding opportunity, allows adaptation to the changing environment, sets realistic and attainable yet challenging goals and helps ensure good achievement. Currently in health care organizations, strategic planning focuses on the future health of an organization or its component parts. It is often marketing oriented (Tappen, 1997) and may include consideration of political, social, and economic changes affecting the health care system.

The process of strategic planning cannot be implemented without the commitment of the administrators themselves. As a first step of the process, they need to be taught the importance of strategic planning. The second step is to conduct a situation audit or environmental assessment to analyze the past, present and future forces that affect the organization. A WOTS-up (weaknesses, opportunities, threats and strengths) analysis worksheet is also helpful. For example, internal strengths or weaknesses may include management development, qualifications of staff, financial situations, cash flow position, marketing efforts, market share, facilities, location, and quality services. Threats may be shortage of nurses, decrease in patient satisfaction, decrease in insured patients, increase in accounts receivable, decrease in demand for services, competitions, regulations, litigation, legislative changes, unionization, and loss of accreditation. Opportunities include nurse and phycisian recruitment, referral patterns, new programs, new markets, diversification, population growth, improve technology and new facilities. After the situation audit is done, the management team writes a purpose or mission statement, identifies organizational goals and objectives, plans strategies to accomplish the objectives, identifies required resources, determines priorities, sets time frames, and determine accountability.

APPROACHES. Planning may be reactive or proactive. Reactive planning is done in response to an existing problem, for example, an increase of incidence of post-operative infections, an increase in staff turnover, staff absenteeism, increase in patients complaints regarding services received. Proactive planning on the other hand, is done before a problem occurs. It may be done in anticipation of changing need or to promote growth and excellence. Bateman (1993) describe proactive planners as people who take it upon themselves to have an impact of the world around them.

ORGANIZING

Organizing is a thinking process that identifies the organizational needs from mission statements and objectives and from observations of work performed, and adapting the organizational design and structure to meet these needs. It is the process of designing the machine (Urwick in Swansburg, 1993). During the organizing process, activities are grouped, responsibility and authority are determined and working relationships are established to enable both the organization and the employees to realize their common objectives. The basic principles of organizing are, according to Swansburg (1994) are:

1. The Principle of Chain of Command. This principle denotes centralizedauthority and corresponding authority. This principle states that to be satisfying to members, economically effective, and successful in achieving their goals, organizations are established with hierarchical relationships within which authority flows from top to bottom. The pure line or hierarchical structure is a straightforward, direct chain-of-command pattern that emphasizes superior-subordinate relationship. In the more modem organizations however, the chain of command is flat.

2.The Principle of Unity of Command. The principle states that employee has one supervisor/leader and one plan for a group of activities with the same objective. Although an employee may interact with many different individuals in the course of his work, he should be responsible to only one supervisor, whose direction he may regard as final. In nursing, primary nursing and case management support the principle of unity of command.

3.The Principle of Span of Control.States that a person should be a supervisor of a group that he or she can effectively supervise in terms of numbers, functions, and geography. This principle is flexible because the more trained an employee is the less supervision is needed, while those still under training need more supervision to prevent mistakes.4.The Principle of Specialization states that each person; should perform a single leading function. This concept of division of labor or the differentiation among kinds of duties, springs from this principle.Other organizational principles are mentioned by GilliesIn Nursing Management: A Systems Approach, are:5. The Principle of Requisite Authority indicates that when responsibility for a particular task is delegated to a subordinate, that subordinate must be given authority over the resources needed to accomplish the task.6. The Principle of Continuing Responsibility refers to the fact that when a superior delegates responsibility for a particular function to a subordinate, in no way diminishes his own responsibility for that functions.7.The Principle of Organizational Centrality refers to the fact that the greater the number of persons with whom a given worker reacts directly the more information he receives and the more powerful he becomes in the total organizational structure.8. The Principle of Exception refers to a management practice followed in some organizations, in which subordinates are directed to report only departures from normal functioning or expected results so that managerial efforts may be limited to those events and processes that cannot be handled by routine control mechanisms.

Review of Organizational Concepts.Role. Role can be defined as the constellation of behaviors and attitudes expected of an individual by those with whom he/she interacts. A nurse may occupy several occupational roles at the same time. She may be staff nurse, a subordinate to her nurse manager, a member of a committee, an officer in a nursing association, and so forth. A particular head nurse is a subordinate to her supervisor, a supervisor to her own staff nurses, a peer to other head nurses, a committee chairperson, and so on. Because each role calls for certain expectations, these nurses need to adjust and readjust their own behavior and manner to meet these expectations. Role theory supports the chain of command and unity of command principles. Role theory indicates that when employees face inconsistent expectations and lack of information they will experience role conflict, leading to stress, dissatisfaction and ineffective performance.Power. Power is the ability to influence another persons behavior. Power is not static, it is changing. Most of the time it increase. This is because the person who has power can generating more power, possibly because of increase in the number and quality of communications with others. The reverse seems to occur. There are different types of power. Reward power is the ability to provide rewards to another. For example, a supervisor may reward an employee with additional salary, a preferred shift rotation, an opportunity to attend seminars. Expert power is the ability to convince another that one possesses a high degree of knowledge and skill in some area of specialization. Clinical specialists and educators wield this kind of power over students. Referent power is the ability to inspire such admiration in others that they identify themselves in some way with the object of their admiration. For example, a nurse specialist in the emergency room may wield a high degree of referent power over staff nurses who wish to emulate her skills in handling emergency situations. Coercive power is the ability to apply punishment to another. For example, the nurse manager may punish an employee through demotion, suspension, or firing.

Status. Status may be defined as the rank a group confers on an individual, organization, a job. The degree of status accorded a particular job is closely related to its distance from the top of the organizational hierarchy, the amount of skill called for in performing the job, the degree of special training or education required for the position, the level of responsibility and autonomy expected in job performance, and the salary accorded the position. Within an organization, various personnel have different status, depending upon their positions in the hierarchy and the salaries they receive. In nursing, the status of each nurse depends in part on the position of nursing department in the table of organization. When the nursing directors position is at the same hierarchical level as that of the medical director, her salary is likely to fall within the executive range and with that her status goes high. With her executive position and higher salary, it is easier for her to negotiate higher salaries for her staff.Authority. The concept of authority is associated with the concept of responsibility, higher positions and higher status. Authority is the organizationally sanctioned power to direct or influence the behavior of another. An important characteristic of authority is that it is never unlimited or absolute. For example, a head nurse may have the authority to discipline or punish a staff, but does not have the authority fire the latter, or she may recommend hiring nurses, but she may not be authorized to hire them.Bureaucracy. This term was coined by Max Weber to describe an organizational make up that is highly structured. The principles of chain of command, unity of command, span of control and specialization support bureaucratic structures. The characteristics of bureaucracy include formality, low autonomy, division of labor, specialization, standardized procedures, written specifications, memos and minutes, centralization, controls and emphasis on a high level of efficiency and production. These characteristics lead to complaints about red tape, and to procedural delays and general frustrations. (Swansburg, 1993)Organizational Climate. Organizational climate refers to work environment. A work environment that is conducive to worker satisfaction can be promoted by managers. Some activities identified by Swansburg (1993), as promoting positive climate are: a) considering personal goals of employees when developing organizations missions, goals, objectives; b) establishing trust and openness through communication; c) provide opportunities for growth and development; d) promote self-esteem, autonomy, and self-fulfillment for practicing nurses, including feelings that their work experiences are oh high quality; e) provide job security an environment that enables free expression of ideas and exchange of opinions without threat of recrimination.

DIRECTING

Directing is a function of leadership. It involves the activite of commandind, supervising, coordinating, leading, implementing, delegating, communicating, training, motivating. (Rowland & Rowland, 1994) In nursing, directing is a physical act of nursing management, the interpersonal process by which nursing personnel accomplish the objectives of nursing. (Swansburg, 1993). It is the process of applying the management plans to accomplish nursing objectives. It is also the process by which nursing personnel are inspired or motivated to accomplish work. In nursing management, twelve activities related to the directing functon of a nurse manager have been identified by Douglas (1998). These are:1.Formulating objectives for care that are realistic for the health agency, patient, client and nursing personnel.2.Giving first priority to the needs of patients/ clients assigned to the nursing staff.3.Providing for coordination and efficiency among departments that provides support services.4.Identifying responsibility for all activities under the purview of the nursing staff.5.Providing for safe, continuous care.6.Considering the need for variety in task assignment and for development of personnel.7.Providing for the leaders availability to staff members for assistance, teaching, counsel and evaluation.8.Trusting members to follow through with their assignments.9.Interpreting protocol for responding to incidental requests.10.Explaining procedure to be followed in emergencies.11.Giving clear, concise, formal, and informal directions.12.Using a management control process that assesses the quality of care given and evaluate individual and group performance given by nursing personnel.Thirty one task had been identified as tasks of first line nurse managers/supervisors in a research done by Beaman (in Tappen, 1986). Some of these are shown in table 1. Table 1. Tasks of Nurse Managers-Supervisors1. Assist in service to prepare orientation schedule.2. Discuss the program of orientation with the new member.3. Decide when orientation is complete.4. Write counseling reports and discuss them with staff members5. Terminate after approval has been obtained.6. Submit time schedule for three shifts.7. Assign patients, teams for day shift.8. Make recommendations about budget to nursing administration.9. Calculate nursing hour used and justify them.10. Call in extra help when needed.11. Prepare reports about budget variances.12. Make daily patient rounds.13. Attend and participate in first-line nursing management meetings.14. Conduct meetings with own staff for problem solving and learning.15. Set goals for individual units.16. Participate in setting goals for the nursing department17. Discuss unit problems with physicians regularly18. Participate in all levels of quality assurance, including designing studies, collecting data, and preparing reports.

Three of the major elements of directing are leadership, communication and motivation. A brief review of the concepts and processes of these three elements follows.

Leadership. The leaders philosophical beliefs, abilities, leadership style influence greatly the way he or she directs. Does the leader subscribe to the trait theories? To the behavioral theories of authoritarian-democratic-laissez faire style? What is more important to the leader, finishing the task or maintaining good relationship? Or, is the leader subscribed more to the more contemporary management and leadership theories such as the motivational theories of Maslow, McGregors X and Y theories, Taylors Scientific Theory, Herzberg Hygienic and Motivation theory, or Druckers Management by Objective (MBO)? Figure C shows the comparison of authotitarian, democratic, and laissez fair leadership styles.

According to Tappen (1996), leadership attributes of nurse executive include administrative competence with adequate educational background, business skills, and clinical expertise combined with a global understanding of leadership principles. To be effective, she must have the leadership traits associated with leadership effectiveness, namely, intelligence, personality, abilities. The traits related to intelligence inclued judgement, decisiveness, knowledge, fluency of speech.

Personality inclued adaptability, alertness, creativity, cooperativeness, personality integrity, self-confidence, emotional balance and control, independence (non-conformity). Abilitites include ability to enlist cooperation, popularity and prestige, interpersonal skills, social participation, tact, diplomacy. Effective nurse managers practice leadership behaviors that stimulate motivation withing their constituents. These behavior include promotion of autonomy, decision-making, and participative management by professional nurses. The componenets of effective leadership include adequate knowledge self-awareness; effective communication; wise use of energy; clear, congruent, and meaningful goals; and taking action. The Leadership Effective Checklist (Figure D), in the next page is a guide to analysis of ones leadership ability. As a leader/future leader, this should help you identify the strengths you can build on or to help you identify what changes you nedd to do to become an effective leader.

Authoritarian | Democratic | Laissez-FaireDegree of Little freedom Moderate freedom Much freedom Freedom

Degree of Control High control Moderate control No controlDecision Making By the leader Leader and groupBy the group together or by no one

Leader Activity High High MinimalLevel

Assumption of Primarily the Shared Abdicated Responsibility leader

Output of the Group High quantity, Creative, high Variable, maygood quantity quality be poor quality

Efficiency Very efficient less efficient than Inefficientauthoritarian.

Figure C.Comparison of authoritarian, democratic, and laissez faire leadership styles. (fromTappen (1996).

Communication.Another major element of directing id communication. Communication is the sharing of thoughts, feelings, and ideas. It can be more specifically defined as sending, receiving, and interpreting verbal and nonverbal messages. It is an exchange of information between at least two people who coact or affect each other. The communication process, involves the six steps of Ideation, Encoding, Transmission, Receiving, Decoding and Response or Feedback. Ideation begins when someone who senses a need to communicate develops an idea or selects information to share. The purpose of the communication develops an idea, or selects information to share. The purpose of the communication may be is to inform, persuade, command, inquire, or entertain. Encoding involves putting meaning into symbolic forms such as speaking, writing, or into nonverbal behavior. Transmission of the message is disseminating it through various media of communication. Oral or face to face communication is the most common form used by managers. Telephone, e-mails, fax, bulletin board, memos, and other forms of written materials are also common. It must be remembered that transmission of the message can be affected by interference, such as garbled speech, unintelligible use of words, noise illegible handwriting. In receiving, the receivers senses of seeing and hearing are activated. In decoding the receiver defines words and interprets gestures during the transmission of speech. The response or feedback is the final step. It is important for the sender to know that the message has been received and accurately interpreted.

Using good communication techniques is one of the hallmarks of effective leadership and management. (Tappen, 1996). The nurse manager must understand that cooperational and communication in an organization go hand-in-hand. He or she should also be aware that there are barriers to effective communication. These include failure to listen with respect and understanding, lack of skill in feedback, misinterpreting the meanings of words used by the speaker. According to Marriner-Tomey (1992), faulty reasoning and poorly expressed messages are the major barriers to communication. Faulty reasoning results in poor organization of ideas and lack of coherence. Also, messages are poorly expressed when there is lack of clarity and precision resulting from inadequate vocabulary and poorly chosen words. Peoples own biases, values, attitudes, beliefs and assumption can affect ones perception of the message.

Motivation.The third element of directing is motivation. Motivating employees achieve high productivity and job satisfaction is a major concern of the manager. Questions often asked are: what makes people work? Why do some employees seek perfection in their work while others are content with mediocrity or less? What causes high turnover rates? What can a manager do to motivate employees achieve more and to make them feel satisfied? How can the manager reduce rapid turn-over rates? As many nurse managers know, job dissatisfaction contributes to high turnover rates among nurses. Frequent hiring is expensive as it takes considerable time and money to orient new nurses. Meantime, employees who stay must assume the job and responsibility of the resigned employee, in addition to their own work assignments.

Traditional management theory is based on McGregors Theory X, which is based on the belief that the ordinary person is lazy, unmotivated, irresponsible, not too intelligent, prefers to be directed, rather than act independently. The more contemporary theories believe otherwise, having proven that people can be motivated to complete their work with little or no supervision, to be creative, trustworthy, enthusiastic, fine work rewarding. According to Theory Y, the negative traits described in Theory X are due to poor leadership and management, and that they are symptoms that employees need for belonging, recognition, self-actualization are not being met. Theory Z even goes further. Theory Z has a humanistic viewpoint and focuses on developing better ways to motivate people. These ways include collective decision-making, long-term employment, slower but more predictable promotions, indirect supervision, and a holistic concern. Trust, fair treatment, commitment, loyalty, are all characteristics of Theory Y other motivational theories are Maslows Hierarchy of Needs and Herzbergs Hygiene and Motivation Factors. A manager needs to know among others, that employees become dissatisfied if the salary is inadequate, if supervision is poor, if the working condition is intolerable and unsafe. She must understand that employees feel satisfied if the work is meaningful and satisfying, if there are opportunities for advancement, if they are given appropriate responsibilities and recognition, if interpersonal relationships among co-employees are good.

Effective Leadership Checklist Very much | Somewhat | Not at all

A. Leadership1. Have you reviewed the leadershipChecklist?Are you Developing self-awareness? Acquiring adequate knowledge? Using critical thinking? Practicing good communication? Recognizing and reconciling difference in goals?Using your energy wisely?2. Do you give your attention to both the relationshipand takes aspects of your responsibilities?

B. Planning1. Do you set aside time for planning?2. Do you manage your time by Preparing for emergencies and crisis? Making the best use of your time? Helping staff members manage their time well?3. Do you plan current work and consider Priorities?Timing and Sequence?Deadlines?Organizational goals?Skill mix of the staff?Characteristics of the work?4. Do you plan for the future of your department?

C. Direction1. Do you communicate clearly to staff What is expected of them? How to do the work?2. Do you provide direction in a nonthreatening manner?3. Do you ensure that everyone has a job description?4. Do you prepare schedules that areFair and adequate to meet the needs of the staff? Developed in consideration of staff suggestions?

D. Monitoring1. Do you monitorThe care given by your staff?Individual staff members performance?The budget?Operation of the unit as a whole?2. Do you monitor in a systematic way?3. Do you use a variety of formal and informalmonitoring methods?

E. Rewards 1. Do you use a variety of both positive and negativerewards?2. Do you use rewards to reinforce only the behaviorsthat are desired and not other, less desirable behavior?

F. Development1. Do you encourage staff development byRewarding it?Making opportunities available?Supporting implementation what is learned?

2. Have you furthered your own professional growthand development?

G. Representation1. In representing staff members and the unit as whole,do you function asAn advocate?A coordinator?A promoter?2. Do you support Administrations actions andRepresent them fairly to your staff?3. Do you enforce administrations policy?4. When administrations action or policy is ineffectiveIn some way, do you work to change it?5. When differences between your staff and the administration occur, do you negotiate an acceptable settlement?

Figure D. Effective Leadership Checklist, (Tappen, page 72-73)

Controlling is the leadership function in which performance is measured and corrective action is taken to ensure the accomplishment of organizational goals. According to Rowland & Rowland (1994), it is also the policing operation in management. It is verifying whether everything occurs in conformity with the plan adopted, the instructions issued, and principles established (Swansburg, 1993) and has foor its object to point out weakness and error in order to rectify them and prevent recurrence. According to Donovan (1975), controlling includes coordination of numerous activities, decision-making related to planning and organizing activities, and information from directing and evaluating of each workers performance. Urwick (in Swansburg, 1993), controlling is evaluating. He identified three principles of controlling, namely:

The Principle of Uniformity ensures that controls are related to the organizational structure. The Principle of Comparison ensures that controls are stated in terms of the standards of performance required. The Principle of Exception provides summaries that identify exceptions to the standards.

The basic control process involves three phases, namely:

Establishing Standards. He controlling process establishes standards in terms of expected and measurable outcomes. These are the yardsticks by which achievement of objectives are measured. Measuring Performance. The standards are applied by collecting data and measuring the activities of nursing department, comparing standards with actual care. Correcting Deviation. Any improvements deemed necessary from the feedback are made.

The process can be expressed as a formula:

Ss + Sa + F + C I

Where Ss refers to Standards set and Sa means Standards applied, C is correction, means Yield, and I is Improvement.

The characteristics of effective control process include ((Rowland & Rowland, 1996)

a) timelinessb) economyc) comprehensivenessd) specificity and appropriatenesse) objectivityf) responsibilityg) understandability

Swansburg (1993) described a good control system as one that:

a) reflects the nature of the activityb) reports error promptyc) is forward-lookingd) points our exceptions at critical pointse) is flexiblef) is objectiveg) reflects organizational patternh) is economicali) is understandablej) indicates correctivek) indicates corrective action

In nursing, controlling or evaluating is an ongoing function. Controls include nursing policies, rules, procedures, discipline, rounds, reports, audits, evaluation devices, tasks analysis, quality control. Nursing standards are set and these serve as yardsticks for evaluation of the quality of care and the performance of the unit and of the individual nurse. Nurse managers, in collaboration with clinical nurse, develop clinical nursing criteria against which to measure patient outcomes and the nursing process. Controlling processes in nursing include planned evaluation, planned nursing rounds, the Standards of Nursing Practice as well as the Accreditation Manual, Nursing Policy Manual. The tools and techniques in controlling are:

a) Standards, which are descriptive statements of the desired levels of performance against which to evaluate the quality, structure, process or outcome.b) Performance Appraisals, where employees behavior is compared to a set of standards which describe what the employee is expected to perform.c) Formal Review by Peersd) Disciplining of Personnele) Budgetingf) Quality Improvement Techniques

LEARNING ACTIVITIES

Answer the following and submit your typewritten answers/reactions to your professor.

1. Discuss the similarities between the nursing process and the nursing management process.

2. Describe at least three components of effective management.

3. Give one example each of a strategic and an operational planning that you have made or is making in relation to your

a) Professional lifeb) Personal life

4. Analyze your organization by using the WOTs-Up technique.5. Enumerate at least 6 organizational principles.6. Observe a nurse manager. Of the 18 tasks of nurse managers/supervisors listed on Table 1, name the ten most often performed. What are the least or not performed at all? Why are they not performed?7. Which of the leadership attributed of nurse executives mentioned by Tappen do you think is/are lacking in the nurse executives in your workplace? Explain.8. Explain the following control process equation:Ss + Sa + F + C I

MODULE TWO

TOOLS IN PLANNING

SPECIFIC OBJECTIVES

At the end of the module four, you will be able to:1. Discuss the philosophy behind Management by Objectives (MBO)2. State purpose of MBO3. Name two uses of MBO in planning4. Discuss the effects of MBO5. Describe the system approach6. Discuss how the system approach is used in planning7. Discuss the importance of budgeting in the planning function8. Discuss the purposes of nursing care standards

MANAGEMENT BY OBJECTIVES

Management by Objectives (MBO) is both a managerial philosophy and a managerial system. Peter Drucker(1978) introduced the concept of MBO in industry in the 1950s in an effect to improve worker motivation and productivity. In its simplest form, MBO is a system whereby employees at different organizational levels are assisted by their supervisors to set their own short-term goals, direct their activities toward those goals, and measure their own achievement with reference to those goals. MBO, when adopted, makes goal setting routine among worker at different levels in the organizational hierarchy and enables= them to make risk-taking decision objectively. In MBO, decisions are made by: Gathering information to predict the outcomes of various actions Systematically choosing the most desirable of several possible objectives. Identifying the most effective of several methods for realizing each objective Measuring the actual results of using the chosen methods

MBO is used in nursing to wide participation in day-to-day decisionsthat are required for quality control. With MBI, more nurses are made more aware of their individual responsibility for monitoring and controlling the quality of their own and their co-workers performance. MBO is also a mean of focusing the attention of both staff nurses and nurse managers on work results. MBO is then a tool not only in planning but in controlling.

MBO generates more effective planning at all levels of the organizational hierarchy. The collaborative goal setting by each superior-subordinate pair links the effort of each worker more directly to the overall objectives of the organization. Negotiations between superior and subordinate over work goals and specification of goals in behavioral terms clarify both the reporting relationship among staff members and the scope of responsibility and authority and authority of upper-middle- and lower-level managers. Managers who use MBO becomes increasingly willing to delegate responsibilities to subordinates, with the result that subordinates acquire management skills and a sense of personal responsibility for institutional success. According to Gillies, 1994, there are several advantages in using MBO. Positive effects mentioned are:

1. Work methods are more effectively tailored to the goals that all levels of management serve.2. Work output at each hierarchical level provides more suitable input for employee in the next higher and lower levels of the organization.3. Institutional progress is facilitated and the welfare and morale of each individual employee is improved.4. Since each worker develops her own performance objectives in collaboration with her supervisor and since adjustments can be made in her assignment and work situation to ensure maximum self-fulfillment and occupational advancement, MBO enhances the workers self-esteem and facilitates self-actualization.5. MBO eases the assimilation of new employees into a complex organization and, by encouraging self-direction and skill building, improves employees chances for promotion. Employees who are managed by objectives mature more rapidly that employees in more autocratic organizations because they know exactly what is expected of them, they receive reliable feedback about the quality of their performance, and they are continuously backed up with advice and support from a supervisor-coach who identifies personally with their success.6. MBO makes sense from a logistic point of view. With MBO, both action and control reside in the same individual, because each worker regulates her own performance through goals of her own choosing. 7. MBO promotes organizational efficiency because it ensures that each workers assignment is designed by the individual who best understands that workers interest, abilities, needs, and goals- the employee herself. The supervisor acts only as a mentor or coach for subordinates, helping each to correlate her log range career plans with the realities of the work situation and the needs of the total organization. MBO is particularly effective in handling knowledge workers such as nurse practitioners, clinical nurse specialist.8. MBO is helpful in effecting organizational change.9. In MBO, the setting of goals for employee performance is a deliberative and collaborative affair. Before setting short-range goals for herself, the employee analyzes her own job description, assesses her own job description, assesses her individual strength and weaknesses, and reviews her personal plans for long-range career development. The supervisor acts as consultants or coach in the goal-setting processes, helping the employee balance her obligations to the institution with her self-appraisal, her personal goals, and the realities of the work situation.

The Process of Management by objectives. Once the nurse executive decides to manage the nursing department through the Management by Objectives system, the following steps are followed (Gillies,1994):

a. The rationale for the decision to shift from the conventional system of management to the MBO system is discussed to the entire staff;b. The philosophy, purpose, and the methods by which employees will establish their own work goals are explained;c. The nursing administrator and the supervisors will prepare a brief, clear statement of the purpose, objectives, and performance standards for the entire nursing department. This will be discussed and clarified in each nursing unit, division, departmental meetings to ensure that all employees thoroughly understand the departments mission, resources, and constraints;d. The employee of the whole nursing department agrees on where they are at a given point in time. They determine at what level of performance and stage of development the department is functioning at the time of transition to MBO.e. Long range goals are set. After long range goals of the nursing department have been agreed upon the nurse managers make a list of those issues and activities that require additional emphasis if long-long goals are to be met. This list of key issues and activities are analyzed by the nursing management group through exploration of the following questions concerning each.

1. Does current practice in regard to this issue permit room for improvement?2. Does need for improvement in this matter derive principally from organizational weakness or from employee incompetence?3. What are the space, materials, and personal resources that affect nursing performance in this matter?4. Have there been or are there likely to be changes in client demand that relate to this issue>5. How does the current level of nursing performance in this matter compare with the level of performance of other health professionals?6. Are there research findings that indicate desirable directions for change in this area?7. Can change be made in the external environment (community, the healthy industry, the nursing profession) that would improve performance in this area?

f. Key issues are then analyzed by the nurse managers and the list of issues and problems are distributed to all staff members, with suggestion that they address these issues in constructing their annual performance objectives. Further, the nurse managers analyze the departmental and divisional functioning to identify the internal and external factors that affect nursing performance positively and negatively. g. The nurse managers provide the staff a full set of up-to-date description of all positions in the department. Since each employee must construct a set of individual employment objectives that represents an amalgam of institutional needs, administrative expectations, and personal goals, should be given a detailed job description that reveals the way in which that position contributes to the total organization effort.

Thus, from the organizational goals and from up-dated-job descriptions,departmental and individual objectives are derived and formulated. These same objectives will serve as benchmark against which to judge achievement after the MBO system has been instituted. In preparing her performance objectives, the employee should discuss here personal statement of job duties with her supervisor in order to explore and clarify areas of disagreement and misunderstanding. The employee should select target dates for achievement of objectives and draw up specific action plans that define the exact steps to be taken in reaching each goals. The following are guidelines for formulating objectives:

1. Each objective should address itself to observable behavior and should be clearly and concisely expressed in written form.2. Each objective should be sufficiently difficult to challenge the employees efforts and ingenuity, but fully capable of attainment within the constraints of institutional reality.3. Each objective should be measurable and, whenever possible, specifically quantified.4. A target date should be set for achievement of each objectives. 5. The final statement of each objective should be accepted without reservation by both employee and supervisor.6. Criteria should be established for judging whether or not the objective has been realized.7. The objective should support objectives of other agency employees for the same time period.

Following is a sample of some objectives which might be established for a staff development nursing instructor:

By December, 1999, I will have:

1. Completed testing fifty staff nurses on the correct use of the new blood sugar monitor2. Given two telemetry classes to the nurses assigned in the Medical units.3. Completed certifying three nurses in each unit on the Basic Life Support.4. Reviewed 30 nurses notes as to accuracy and form of documentation.5. Written a pre-discharge patient education tool for each of the following diagnostic category: Diabetes mellitus Leg amputation Radical mastectomy Patient who will be discharged with central lines.6. Plan and present 1 nursing seminar on each of the following topic: Nursing Care of an HIV-Positive Patient Advanced Nursing Assessment Techniques Trends and Issues in Nursing Education

While an employee is given the responsibility to write her annual performance objectives, she still needs to meet with her supervisor so they can review, refine and agree upon the goal statement. During this meeting, the supervisor assist the employee to draw up an action plan for each objective. In designing an action plan for each objective, the employee and her supervisor delineates the activities that must be carried out to meet the objective and arrange them according to priority. Then, they clarify whose responsibility it is to perform each action (if it is not the employees sole responsibility) and assign each task to the appropriate employee. Finally, they calculate the personnel and material needed to reach each objective. At the time the employees objectives are approved in final form and the action plans to achieve each goal are developed, the supervisor sets a date for the two to meet to assess the employees progress toward the goals. The frequency of meeting depends upon many factors. A new employee may need more meetings with her supervisor. If an employee is making little progress, the two can decide whether the lack of success is a result of misdirection, inadequate effort, or lack of support. Corrective actions are then taken so the objectives can still be met by the final target date. In many organizations each employee sets annual goals for herself at the beginning of the year, and she and her supervisor do not meet to assess goal achievement until the end of the year. It is recommended however, that a midyear analysis and assessment be done to enable the supervisor to applaud a good performance by her subordinate, thereby reinforcing desirable behavior.

ObjectiveActivities arranged according to importanceWho is responsibleResources financial materials, personnelTarget date

Figure A. The Process of Designing an Action Plan for each Objective

Disadvantages of Management by Objectives. While MBO has been found to have many advantages, there are also certain disadvantages. Among those mentioned are:

a. There is a possibility that, rather than expanding a managers abilities, it may actually hamper her development by limiting her attention to those problems, tasks or projects that can be foreseen weeks or months in advance. b. If the technique is applied too rigidly, Management by Objectives can disrupt the smooth functioning of nursing department. It may also lead to neglect of the routine and repetitive aspects of management, so that insufficient attention is paid to monitoring budgetary expenditures, updating policies, formulating rules, writing procedures, posting assignments and other housekeeping tasksc. Since more attention is given on results rather than on means, little effort is spent in searching for the least time-consuming, least difficult, least expensive method of realizing the goals. d. With this method, the employee is narrowly focused on a few specific goals to be realized within a specifies time interval that she may be reluctant to react spontaneously to unforeseen opportunities, to volunteer for unassigned duties, or to create new structures or methods, thus may destroy employees individuality.

SYSTEM APPROACH

The system approach, like the MBO, is an important tool in both planning and control functions. A system can be simply defined as a set of objects or elements in interaction to achieve a specific goal (Ryan,1973). It is not just a logical and orderly arrangement of parts but an ongoing process or state of change that consist of interconnected and interrelated subsystems, each of which has its own objective that contributes positively toward the goals of a larger system. A system can be identified by the fact that it is capable of maintaining some degree of organization in the face of disturbing influences from within and without. Its function is to convert or process information, energy, or materials into a planned outcome or product for use within the system, outside the system or both. Thus, the nursing process is a system, the function of which is to convert the knowledge and skills of the nurse, the patient, the patients family into supportive and therapeutic interventions against illness, debility, and loss (Gillies,1994.) because a system is also defined by differences in their constituent parts, the manager must be familiar with the nature and function of the classic system. The parameters, factors or elements of any system are goal, input, process or throughput, output, feedback, control and environment (Figure B).

Feedback Loop

Input Throughput Output

Figure B. CLASSIC SYSTEM ELEMETS

Each system is defined in relation to its environment at the same time that the systems environment can be defined only in reference to the system itself. A systems environment is defined as a set of objects, events, or conditions within certain specific limits that be conceived by the system boundary, which is established by the system analyst. Input is the operating material of the system. It may consist of information, money, energy, time, individual effort, or raw material of some sort. Inputs for health organization system may be technical, social, financial, or human. Throughput is the process by which the system converts energy input from the environment into products and services that are usable either by the system itself or by the environment. The process of throughput can be modified in response to feedback about system performance. Output is the outcome or result of system throughput, the product or service that results from the systems processing of technical, social, financial, and human input. Feedback is information about some aspect of data or energy processing that can be used to monitor and evaluate the system and guide it to more effective performance.Historically, the General System Theory was introduced in1963 by Ludwig Von Bertalanffy, a biologist. Bertalanffy theorized that there are principles or laws that apply to an systems, regardless of their specific elements and goals. After more than half a century, the nurse manager finds the General Systems Theory as still significantly useful in her job as one who works within, among and upon a variety of systems of all types. The hospital is a structure system, the nursing department is a functional system, the management process is a power system, the nursing process is an information and service system, the work group she leads is a social system, and so on.

The advantages of the System Approach include:1. The system concept is a particularly useful device for studying organizational functioning.2. A systems approach to management information (such as unit census, patients length of hospital stay, budget allotments, personnel or payroll, recruitment and turnover statistics, nursing audit results, and quality assurance findings) will help to ensure unity and direction in the nursing management process. Through receipt of periodic systematically organized data about current expenditures and actual nursing performance, the nurse manager is able to judge progress toward established targets and can continually redirect the staffs efforts so as to maximize nursing effectiveness and decrease costs.3. Systems analysis, which is both a planning and a control, provides the nurse managers with valuable information for decision making and problem solving. The systems approach helps in problem solving because, according to system theory, the analyst is free to define a system in any way she likes. 4. A systems approach is helpful in increasing the efficiency of work flow. Following are illustrations of how the Systems Method is used in various nursing systems (Gillies, 1994):

INPUTPROCESSOUTPUT

DATA PERSONNELPATIENT CARE

EQUIPMENT

suppliesDATA GATHERINGInformation- about agency clients employees resourcesPLANNINGObjectives SystemsStandards Policies ProcedureBudget

ORGANIZINGTable of organizationJob descriptionGroup work and team buildingSTAFFINGPatient classificationDetermining staff needRecruitmentSelectionOrientationSchedulingAssigningMinimizingAbsenteeismDecreasing turnoverStaff DevelopmentLEADINGUsing powerProblem solvingDecision makingEffecting changeHandling conflict-communication and transactional analysisCONTROLQuality AssurancePatient Audit Performance appraisalDisciplineLabor relationsComputer information system

ELEMENT OF NURSING MANAGEMENT SYSTEM: CLIENT DATA SYSTEM

INPUTTHROUGHPUTOUTPUT

From:Annual reports:Monthly statistical reportsPeriodical staff reportNursing audit reportsPatient case studiesPatient chartsPatient interviewsProcessing employee data byReadingDiscussing Computing Comparing statistics with national and regional statisticsOutcomes of processing data:Daily patient censusPortion of total patient composed of patients in each clinical or diagnostic groupAverage length of stayIncidence of various complicationsTreatment compliance rates

ELEMENT OF NURSING MANAGEMENT SYSTEM:GATHERING DATA: NURSING PERSONNEL

INPUTTHROUGHPUTOUTPUT

From:Personnel filesEmployee interviewsPerformance evaluationsCounseling recordsDisciplinary recordsPersonnel profilesAttendance and turnover ratesOccupational recordsInterview Processing employee data byReadingInterviewingDiscussions with patientsObservation at workConsultation with coworkersComparison with regional or national statisticsOutcomes of processing data:Knowledge of Seniority ratesEducational backgroundExperiential backgroundProfessional interestsAttendance recordsTurnover ratesSkill levelProfessional aspirationsSocial abilitiesSensitivity to Values, fears, resentments, strength, weaknessesCuriosity regardingMotivation factorsGroup dynamics effectsEducational methodsWork hazards and difficulties.

Table 1. System Framework for Analyzing Environmental VariablesFUNCTION: What is our purpose?OUTPUT: What is our product?INPUT: What is needed to produce the purpose?SEQUENCE: In what order are the inputs needed?ENVIRONMENT: What is the effect of the context on our functioning?PHYSICAL CATALYST: What additional things do or would make the work easier, faster and of higher quality?HUMAN CATALYSTS: What additional people do or would make the work easier, faster and of higher qualityINTERRELATIONSHIP: How should the various parts of together to provide an integrated functional system of operation?

BUDGETING

Budgeting can be defined as the allocation of scarce resources or assets on the basis of forecasted needs, for proposed programs or activities, over a specified period of time (Gillies, 1994). It is an essential aspect of financial management and is a tool for both the planning and control functions of the management process. Budgeting is a management responsibility of only a small number of people. In a more decentralized organizations, all managers within the organization are involved in the preparation and monitoring of the budget. The managers, on the other hand, seek inputs from their staffs. Decentralization empowers the nurse manager to plan and make decisions about controlling the budget. The chief executive officer, however, has the general responsibility for the over-all budget.

The budget itself is just a document, a collection of pieces of paper with figure distributed according to a series of decision made by certain people with the organization. (Tappen, 1997). It is a numerical expression of expected income and planned expenditures for an organization for a specified period of time. When completed, the budget frequently has a great deal of power associated with it (Dillon, in Tappen, 1997). Many times the budget is used as an excuse for unpopular decisions as for example, when staffing is poor or when broken and antiquated hospital equipment are not changed.

Types of Budgets. According to Tappen, there are two different approaches to preparing the budget: a. incremental, and b. zero-base budgeting. Incremental, or historical is the traditional process in which budgets, are prepared every year on the basis of what was spent the year before. The two most basic components of the budget are income (contributions, private payment, insurance) and expenses (salaries, benefits equipment, supplies, overhead, staff education, and so forth). Zero-base budgeting on the other hand, is an approach that is based on the idea that no expense should be assumed to be absolutely necessary. The result is that every cost must be analyzed and justified as essential to the function of the organization. The zero-based budget begins with a blank slate every year, that is, no expense from the last year can simply be repeated for the next year without giving reasons why it is necessary.

The use of the decision package is the core of the zero-base budgeting process. The decision package consist of several basic elements: a. a listing of all current and proposed objectives or activities of a given time; B. nursing audit, or department; c. alternative ways of carrying out these activities; d. the different costs for each alternative; e. the advantages of continuing the activity; and f. the consequences of discontinuing the activity.

Definition of terms use in the process of Budgeting.Revenue this is the income from sale of products and services. Nursing revenue is usually included with room charges. Revenue can include accounts receivable and income-producing endowments

Revenue Budgeting is the process by which a hospital determines revenues required to cover anticipated costs and to establish prices sufficient to generate that revenue.

Expenses are the costs of providing services to patients. They are frequently called overhead and include wages and salaries, benefits, supplies, utilities, office and medical supplies, equipment and so forth.

Expense Budgeting is the process of forecasting , recording, and monitoring the manpower, materials, and supply, and monetary needs of an organization in such a manner that the operation of the various components of the organization can be controlled. The components of expense budgeting are cost centers. The purpose of expense budgeting are:

Prediction of the labor hours, material and supplies, and cash flow, flow needs for future time periods.establishing procedures for making comparative studies Providing a mechanism for determining when changes in procedures need to be made providing gross information on the kinds of changes needed, and providing evidence that control has been established and reestablished.

Patient days are statistics used to project revenues. They are commonly used as units of service to compute staffing. Patient-day statistics are usually derived from census reports that are done daily and summarized monthly, for year to date, and annually. Fiscal year is the budgetary on financial year. It may be the calendar year in some organizations, beginning on January 1 to December 31. Many organizations use July 1 to June 30.

Year to date (YTD) is the term used to describe that accumulated for a specific number of days and divided by the number of days.

Average Daily Census (ADC) is the census summarized for a specific number of days and divided by the number of days.

Unit of Service is a measure for output of hospital service consumed by the patient. In the operating units and recovery room, it will be minutes or hours; and in the nursing unit, it will be category of acuity of patients and hours per day. Measures include procedures, patient days, patient visit and cases. Cost/ Benefit Analysis is a planning technique of comparing the costs of pursuing an objective, a goal, or a program with the benefits they produce.

The Process of Budgeting. The process of budgeting begins with analyzing the expenses and revenues. According to Tomey (1993), there are three stages of the development of the nursing budget. These are:

a. The formulation stage,b. The review and enactment stage,c. The execution stage.

The formulation stage is usually a set number of months (6-7 months) before the beginning of the fiscal year in which the budget will be executed. During this period procedures are used to obtain an estimate of the funds needed, funds available, expenses, and revenue. These procedures are communicated by the budget officer to the nursing administrators and unit/cost center manager who, then analyze the financial reports of expenses and revenues of their departments. Among the cost center reports that will assist the nurse administrators and managers are:

Daily staffing reports; Monthly staffing reports; Payroll summaries; Daily list of financial categories of patients; Reports of occupancy Monthly financial summaries of revenues and expenses.

Review and Enactment stage are processes of budget development that put all the pieces together for approval of a final budget. After the cost center managers presents their budgets to the hospital budget council, the chief nurse executive consolidates the nursing budget. In preparing the nursing budget she sees to it that objectives are clearly stated, the cost accurate, the revenues defensible. In other words, the nurse executive should present a well-prepared budget. Approval is made by the chief executive officer and the governing board of the organization. During this entire process of review and enactment there are conferences at which budget adjustment are made.

Execution Stage. Both the formulation and the review and enactment stages of the budget are planning activities. Execution of the budget involves directing and evaluating activities. The budget is executed by the nurse administrators and managers who planned it. The procedures for monitoring, evaluating revision of the budget are planned.

Operating or Cash Budgets.The cash budget is the actual operating budget in detail, excluding the capital budget. It is day-to-day- budget and represents money coming in an going out. A cash budget requirement is cash flow that must be adequate to meet debt obligations, including replacement and expansion of facilities, unanticipated requirements, the payroll, payment for supplies and services, and a prudent investment programs. Examples of cash receipts are those coming from the third party payers, tuition, endowment fund earnings, gifts and services. A negative cash flow most often result from the time lag between delivery of services and collection of Operating budget information supplied to the chief nurse, executive, department head include a large worksheet and an adjustment explanation worksheet.

The budget worksheet shows information by the cost center account number and sub code as follows:

SubcodeDescriptionPrior Year ExpenseOriginal BudgetAnnualized ExpenseBudget DetailBudget Pool

The Budget Worksheet Heading

The worksheet list prior year expense, the original budget, the annualized expense. The columns for the Budget Details and Budget Pool are left blank so the cost center manager can fill in the budget expenses for the projected fiscal year.

An adjustment explanation worksheet is used to justify any increase from the original budget.

Personnel Budget. In the budgeting process, personnel account for the largest portion of the nursing budget. The nursing administrator prepares budgets for personnel assigned in the different nursing department such as the emergency units, clinics recovery rooms. Operating rooms, delivery rooms and all the other nursing department. Nursing personnel budgets are prepared using quantitative workload measurements, which is usually a patient acuity system. It is usually a computer program that produces staffing requirements by shift and by day. The system produces an acuity index for each patient, and the formula indicates needed staff by category (nurses, nursing assistant, midwife) and by shift. It can also compare actual staffing with that required and can be summarized month and year. Each day at a given time, a registered nurse enters each patients acuity rating into a computer terminal. Shows a nursing budget that is based on a patient acuity rating system. The average daily census (ADC) is obtained the admission office. It is the result of dividing the total patient days for a unit for one year by 365 days. Census reports are prepared according to daily, monthly, and annual basis. Acuity is the result of the sum of all acuities for one year divided by 365 days. This figure is also computer generated daily, monthly, and annually. The nursing hours are generated from an acuity standard. In planning the personnel budget, the nurse has quantified information related to staffing and can accurately predict the number of full time equivalents (FTEs) needed for patient care. Things to consider in planning personnel budget are like, will there be a pay increase next year? Will fringe benefits increase? Will a new program require more personnel?

Staffing Formula:

The staffing formula is: Average Census x Nursing Hours x 1.4 x 1.147.5

Example: Medical FloorAverage daily census= 31.8Nursing hours= 4 (per 24 hours)1.4 is a constant representing 7 days in a week with full time worker 5 days in a week7-5=1.41.14 is a constant representing an allowance of 0.14 FTE for vacation, illness, etc. for each 1.0 FTE7.5 represents 1 work day

31.8x4x1.4 x 1.14 = 27 FTEs7.5

Supplies and Equipment Budget. This is part of the operating budget. It includes all supplies and equipment used in provision of services. Examples of supplies to be budgeted includes office supplies, medical/surgical supplies, pharmacy supplies, and others. Capital Budget, is separated from the operating budget. Each item in the budget is defined in terms of dollar value. If it is an equipment, it is usually used and reused over a period of time. The budget provides for depreciation for each capital budget items.

Within the frame of the standards written by authorized groups, institutions modify and develop locally applicable nursing standards. The locally developed set of standards includes:

a. Statement of institutional philosophy and objectives to assist establishing priorities.b. Adoption of a nursing theory to facilitate decision making andc. Identification of basic issues and problem for which standards should be developed. In organizing the staff to construct practice standards, the director of nursing appoints a task force to spearhead the project. The task force includes a nursing administrator who is thoroughly familiar with the institutions purpose, philosophy, long range goals, financial constraints, and personnel resources; a clinical nurse specialist, a nursing supervisor, who is well-versed in staffing strategies, a head nurse, and a staff nurse with working experience in more than one clinical specialty. After the task force members have developed the first draft of a set of process or outcome standard, it is submitted to a sample of nurses for review, analysis, and evaluation. Each standards is reviewed as to applicability, suitability, clarity, measurability, as to whether they are achievable. An example of nursing standards written for prevention and management of skin breakdown and decubiti follows (Gillies, 1994 page 105).

NURSING STANDARDS FOR PREVENTION AND MANAGEMENT OF SKIN BREAKDOWN

Disease and/or Related ConditionsCritical Preventive and Response Management

1. Immobility2. Dehydration 3. Poor nutritional status4. Chronic illness with multiple system diseasePrevention 1. Note patients tolerance of caloric intake daily by mouth, feeding tube, or intravenous fluids2. Summarize intake and output q8h3. Notify MD if intake less than 1000cc/24hr unless on fluid restriction4. Turn q2h while bedridden5. Provide daily back care6. Note condition of the skin daily7. if extremity paralyzed, provide full range of motion exercise q8h (once per shift)

Responsive Management8. notify MD of any break in skin integrity9. continue turning patient q2h while on bedrest10. cleanse open area 3x/day, dry carefully, and keep open to air.11. Apply tincture of benzoin around the area of breakdown12. Apply further local therapy per MD order.

Nursing Service Policies. Policies, procedure, rules, and regulations are the standing plans of nursing organizations. (Swansburg,1993). They are conceptual plans that are translated into physical entities, usually called manuals.A policy is a mechanism that establishes constraints or boundaries for administrative action and sets a course to be followed. Policies are formal or informal, covert or written. Formal policies are those that apply to:a. Organizations as a wholeb. A functional entity such as a division or departmentc. A basic unit such as a ward, floor, special care unit, clinic

Implementation of nursing standards implies that policies will be developed for carrying them out. Generally policies fall into three main categories:a) Those that apply to patient b) Those that apply ton personnelc) Those that apply to the environmentA fourth category could be that f relationship with other disciplines or department.

Policies are usually developed by a policy committee. At the nursing division level the committee is made up of representatives from different nursing specialist and nursing top nursing management. The policy development process includes the following steps. (Swansburg, p168) :

1. Determination that a policy is needed.2. Assignment of the development of each policy to a committee member or members3. Development of policy from appropriate sources of information by using published sources, computer search, and other sources.4. Review of the draft policy by committee5. Circulation of the draft to appropriate clinical committee of physicians who will write orders and nurses who will carry them out. A no code policy, for example would go to these groups, other policies would go to other appropriate groups6. Review of returned comments7. Referral to the organizations attorney for approval when indicated (such as no code policy)8. Final approval by committee and signature of the organizations chief executive officer9. Distribute with appropriate communication. In the case of no code policy all personnel who would respond to a cardiac arrest need to be a informed.

Nursing Service Procedure.in addition to policies, a written and current procedure manual should be available to all nursing personnel. The manual contains detailed plans for nursing skills (procedures) that include steps in proper sequence. Procedures outline a standard technique or method for performing duties and serve as guide for action.

Advantages of procedure include: Procedures conserves management effort Procedures facilitate delegation of authority Procedures lead to more efficient methods of operation Procedures permit significant economy in personnel Procedures facilitate control Procedures aid in coordination of activities.

The following are the steps in developing a new procedure.1. A task or title is stated2. A need is identified and a purpose is stated3. A draft of steps and sub steps is made4. References and experts, including manufacturers, are consulted5. The committee member responsible for development of the specific procedure drafts it in standard format, including related policies, equipment needed, line drawings, location of equipment, and ordering procedure. the draft provides step-by-step instructions in performances, brief theory statements and supporting documents.6. The draft is edited7. An index code number is assigned8. The procedure is typed and distributed as draft to reviewers with a deadline for feedback9. Returned drafts used to revise the procedure10. The revised manuscript is submitted to approval authorities11. When approved, the procedure is printed and distributed12. In-serve training on the procedure is given to the appropriate personnel.

LEARNING ACTIVITIES

Answer the following and submit your typewritten answers/reactions to your professor.

1. You as a nurse executive, decide to manage the nursing department by MBO. Explain how you go about it.2. What will you do to prevent or overcome resistance to the use of MBO?3. Explain how the systems approach can facilitate planning.4. Illustrate how the systems method is used in nursing management.5. If you are not responsible for preparing a budget, interview someone who is in your place of work. From the interview/s explain the step by step procedure of how the Department of Nursing prepared budget. Who is/are responsible for preparing the budget?6. Using the nursing staffing formula, calculate the number of FTEs for medical floor with a daily census of 33 patients7. Discuss the process of policy and procedure development in your organization8. Using the steps of procedure development, prepare a draft of steps and sub steps to follow in performing a nursing procedure of your choice, as example, Blood transfusion administration, intravenous administration, taking vital signs and so forth.9. Describe how nursing standards are developed.

MODULE THREE

ORGANIZATIONAL STRUCTURE, JOB DESCRIPTION, AND JOB EVALUATION

SPECIFIC OBJECTIVES

At the end of the module four, you will be able to:1. Differentiate between hierarchical and matrix organizational structures.2. Make a table of organization.3. Make a job description.4. Describe the processes involved in job evaluation.5. Explain each of the four (4) methods of job evaluation.6. Describe the techniques for team building.7. Discuss Bales method for analyzing group members interactions8. Describe how the principles of group dynamics are used in designing work groups.

ORGANIZATIONAL STRUCTUREForms of Organizational Structure

There are two common forms of organizational structures, hierarchical, and free-form. A mixture of both is needed in nursing. The hierarchical structure is commonly called a line structure. This is the traditional structure and is associated with the principle of chain of command, bureaucracy, vertical control and coordination, level differentiated by functions and authority, and downward communication. The line structure is still used in many nursing organizations because of its advantages such as:

It is easy to orient new employees to a line organization because of the simplicity of interpersonal relations; It is easy to function in a line organization because responsibility and accountability for each function are clearly defined; It is relatively easy to manage a line organization because of the speed with which orders can be transmitted and, generally, the acquiescence of workers to authoritative commands; It is well suited to execution of tasks that require large numbers of moderately-educated workers to perform routine operations; The emphasis in line organization on clear-cut work specialization and role separation makes line structure more effective in relatively stable organizations in which the pace of change is slow.

There are also disadvantages especially to the staff. These are:

The small, repetitive, cyclical performance of tasks produces monotony and worker alienation; Over-emphasis on specialization leads to communication difficulties among specialists; Structures inability to adjust rapidly to altered circumstances; There is a tendency of bureaucratic structure to engender passivity and dependency in staff members and to encourage autocratic behavior in managers; There is lack of coordination and integration between divisions or sections of the organization; There is the tendency for limited use of available knowledge in a bureaucratic setting due to the relative isolation of employees from other departments.

A modification of the line structure is the line and staff organization. This pattern minimizes the disadvantages of the line organization. Here, a simple line organization is altered by providing management specialists to support and strengthen the top executives.

The free-form organizational structures are called matrix organizations. When project team or task force organization is superimposed upon and built into a fully-functionalized hierarchical organization, the result is a matrix organization. In a matrix organization, the efforts of numerous specialists are coordinated both vertically and horizontally (Gillies, 1994). Vertical coordination occurs through the hierarchical chain of command, in that the efforts of several specialized department are integrated by the executive who supervises them. Horizontal coordination takes place through direct interactions among diverse members of the patient care team, who represent different departments and occupational groups. The matrix structure is different from hierarchical and the line and staff structures in that there are fewer levels of hierarchy, greater decentralization of decision making, and less rigid adherence to formal rules and procedures. The advantages of matrix nursing organization structure include (Swansburg, 1993):

1. Improved communication through vertical and horizontal control and coordination of interdisciplinary patient care teams.2. Increased organizational adaptability and fluidity to respond to environmental changes.3. Increased efficiency or resource use with fewer organizational levels and decision making closer to primary care operations.4. Improved human resource management because of increased job satisfaction with achievement and fulfillment, improved communication, improved communication, improved interpersonal skills, and improved collegial relationships.There are also disadvantages because in matrix organization, there may be:

1. Potential conflict because of dual or multiple lines of authority, responsibility, and accountability relationships.2. Role ambiguity.3. Loss of control over functional discipline due to multidisciplinary team approach.

According to Swanburg (1993), the characteristics of a matrix organization include the following:

1. Maintenance of old-line authority structures2. Specialists resources obtained from functional areas.3. Promotion of formation of new organizational units.4. Occurrence of decision-making at the organizational level of group consensus, the middle management level.5. The matrix manager exercising authority over the functional manager.6. Cooperative planning of program development and allocation of resources to accomplish program objectives.

Organizational Charts

Organizational charts, also called schemas, are graphic representations of the organizing process in an institution. These charts show reporting relationships and communication channels as well as distribution of responsibilities. Line charts show supervisor and supervised relationships from top to bottom of the nursing organization. Staff charts show the advisory relationship of specialists or experts who are extensions of the nurse supervisors.

Decentralization

Decentralization refers to the degree to which authority within an organization is delegated downward to its divisions, branches, services, and units. Decentralization of authority includes delegation of all the management components of planning, organizaing, leading, and controlling. Flat organizational structures are characteristic of decentralized management. Because of the participatory management characteristic of decentralization, many management titles and positions are either eliminated or decreased.

The Informal Organization

Every formal organization has an informal one. The informal organization can pose a problem in an institution as it can create conflicting loyalties restricted productivity, resistance to change, and management plans. On the positive side, the informal organization, meets the employees needs for relationships, friendships, for sharing interests, hobbies, experiences, and feelings. It meets their need to belong. The informal organization can also help serve the goals of the formal organization. It should not be controlled but instead, the wise manager should exercise tolerance and understanding.

Informal organization should be encouraged and nurtured especially if they:

1. Provide a sense of belonging, security, and recognition to employees.2. Provide methods for friendly and open discussions of concerns.3. Maintain feelings of personal integrity, self-respect, and independent choice.4. Provide an informal and accurate communication link.5. Provide opportunities for social interaction.6. Provide a source of practical information for managerial decision making,7. Are sources of future leaders.

Steps in Analyzing Organizational Structure

There are six steps in analyzing the organizational structure of a division of nursing. Analyzing organizational structures are used when there is a major organizational problem, such as friction among departments heads over authority, staffing problems, and so forth.

1. Compile a list of the key activities determined by the mission and objectives of patient care. It must be remembered that when there are changes in the institutions mission, philosophy, objectives, the organizational structure should be reviewed and analyzed. Once the list is completed, it is analyzed and grouped according to similarities or kinds of contribution they make, such as:

Results-producing activities related to direct patient care, such as the nursing process. Support activities, which may include audit, advice, and teaching Hygiene and housekeeping activities. Top management activities, including managing people, marketing, innovation, audits.2. Based on the work functions to be performed, decide on the units of the organization. Decide which kinds of decisions will be required and who will make them. All decisions should be placed at the lowest kevel and as close to the operational scene as possible.3. Decide which units or components will be joined and which will be separated. Join activities that make the same kind of contribution.4. Decide on the size and shape of the units or components.5. Decide on appropriate placement and relationships of different units or components .this will require relations analysis.6. Draw or diagram the