Nursing Leadership and Management: External Forces Influencing Health Care Delivery PDF

LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Module 1 External Forces Influencing Health Care Delivery...

LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Module 1 External Forces Influencing Health Care Delivery System Objectives: After working on this module, you should be able to: 1. Describe the paradigm shift in the health care delivery system; 2. Identify major forces affecting delivery of health service; 3. Discuss how these forces affect the role of the nurse administrator; 4. Explain the concept and basic principles of inter-local zones ; and 5. Discuss the role of the Health Care Industry Training Council in the current skill shortage of health human resources in the country. The rapid and complex changes in the health care environment demand organizational and managerial expertise of the nurse administrator. Devolution and corporatization of local hospitals; managed care schemes, new treatment technologies, continuous quality improvement agenda, globalization, and accountability, among other factors, point to the increased need for nurse administrators to operate effectively and efficiently across organizational boundaries. Paradigm Shift in Health Care Delivery System Political and socioeconomic forces have shifted the health services system from the largely reactive acute care paradigm to amore holistic and preventive paradigm emphasizing population-based wellness. There is a moving away from the episodic treatment of acute illness events to the provision of a coordinated and preventive continuum of services that aims to improve the health status of defines populations. Today there are several forms of managed care and capitated payment (examples include medical/health insurance and health maintenance organizations) which, with their budges and expenditure targets, favor health care organizations by helping health care professionals provide services at that point in the continuum of care where the greatest value (that is, where benefit most exceeds cost) is provided. In this kind of arrangement, the trust of health care organizations is to provide health promotion and preventive care services rather than the traditional cure and healing aspects, causing a fundamental shift in health care delivery. The major elements of the paradigm shift are outlined in table 1.1 below. Table 1.1 Transformation of health care Old paradigm New paradigm Emphasis on acute inpatient care Emphasis on the continuum of care Emphasis on treating illness Emphasis on maintaining and promoting wellness Responsible for individual patients Accountable for the health of defined populations All providers are essentially similar Differentiation based on ability to add value Success achieved by increasing market share of Success achieved by increasing the number of inpatient admissions covered lives and keeping people well Goal is to fill bed Goal is to provide care at the most appropriate level Hospitals, physicians and health plans are Integrated health delivery system separate Managers run an organization Managers oversee a market Managers serves as department heads Managers operate services across organizational boundaries 1|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Managers coordinate services Managers actively pursue quality and continuous Improvement Certain private local hospitals in the paradigm do not “win” by filling hospitals beds or continuing to have physicians and other health care workers. Instead, new and different ways of organizing and managing health care services are instituted. One of the most important feature is the institutionalization of quality management and continuous improvement process. For example, St Lukes’s Hospital and Medical Center in Quezon City, Makati Medica Center in Makati, and San Juan de Dios Educational (Hospital) Foundation Inc. in Pasay City (all tertiary hospitals in the Philippines) have ISO 9002 accreditation, signifying “world class” services and equipment. Two example of health care system in the USA operating in the new paradigm are the Kaiser Permanente health system and the New England population-based or denominator-based management, is positioning itself to integrate the insurance component with the delivery component in its defined geographic area. The important ingredient of Kaiser Permanente is its ability to provide its varied and numerous clienteles cost effective care under capitated or pre-established budgets. This scheme is possible with the integration of all the major components of services delivery, the establishment of effective physicians’ relationship, and development of information system that connect patients and the health care provider across the continuum of care and provide valuable information concerning its organizational performance. On the other , the New England Medical Center’s pediatric and adult oncology-hematology units and the cardiovascular unit illustrate very well the ability to manage across organizational boundaries and restructure patient care. The highlights of this approach include: 1. Assessing patient needs and expectations 2. Reorganizing patient care roles based on the assessment 3. Training nurses and physicians to provide care across the continuum from the acute phase to the MD’s Clinic or the patient’s home 4. Providing care using clinical pathways and protocols 5. Using patient outcome and patient satisfaction data to improve care 6. Developing an information system that support all the above activities In Table 1.2, can see the major economic, political, and social forces that are influencing and will continue to influence the delivery of health care services in the years to come. External force Management implication 1. Capitated payment , expenditure targets, or Need for increased efficiency and global budgets for providing care to define productivity population Redesign of patient care delivery Development of strategic alliances and add value 2. Payment Increase growth of networks and systems Information system that link financial and clinical data across of episodes of illness and “pathways of illness” 2|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Effective implementation of clinical practice guidelines Ability to demonstrate continuous improvement of all functions and processes 3. Growth of new technology emphasizing outpatient, work place and at-home treatment Expansion of the continuum of care, need for new treatment sites to accommodate new treatment modalities Increase capacity to manage care across organizational boundaries New relationship with physicians and other caregivers 4. Aging of the population Increase demand for primary care, wellness, and heath promotion services among the 65 to 75 age group Increase demand for chronic care management among the 75 plus group Challenge of managing ethical issues associated with prolongation life 5. Increase ethnic or cultural diversity of the Greater difficulty in understanding and population meeting patient expectation Challenge of managing an increasingly diverse health services workforce Table 1.2 cont’d External force Management implication 6. Changes in the supply and education of health Need for creative approaches pin meeting professionals the population’s need for greater primary care Need to compensate for shortage in someone categories of health professionals (i.e., physical therapy pharmacy, and some areas of nursing) Need to develop effective teams and caregivers across multiple treatment sites 7. Social morbidity (AIDS, drugs, homicides, “new surprises” 3|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Ability to deal with unpredictable increases in demand Need for increase social support system and chronic care management 8. Information production and , management Training the healthcare work force in new information , production, and management methodologies Increase ability to coordinate care across sites Challenge of managing an increase pace of change due to more rapid information transfer Challenge of dealing with confidentiality issues associated with new information production and management technologies 9. Globalization and creation of the world Need to manage cross-national and cross- economy cultural teritary and quaternary patient care referrals Role of the health services organization in increasing the productivity of the labor force Managing global strategic alliances particularly in the areas of biotechnology and new technology development Philippine Health Care Industry Situation For the past decades, our nurses have been prominently criticized for leaving the country(mainly for economic reasons), to work abroad. (Lately in the past five years or so, even our doctors have left their medical profession to take up nursing hopefully to work abroad as nurses). This trend continues with the increase demand for our competent nurses to work abroad in the western and some middle east countries and consequently, the situation has adversely affected our health services in the country. On the other hand, this current change that affects socio-economics life of global Filipino health workers, brings with it transformational imperatives of the practice and, therefore, qualification of current and emerging health care practitioners. The National Consultation on Technical Education in the Health Care Industry in 2002 was organized to develop and strengthen human resource requirements of the health care industry in the country. It was task to validate the findings of the Health Care Industry Study conducted by the Health Solution Corporation and to validate the occupation and jobs in the health care industry where the Technical Education and Skills Development Authority (TESDA) should intervene (Guaing in Executive Report, 2002). Significant inputs were taken from a local study on the “Philippine Health Workforce” which was a consolidation or statistics concerning the supply health workers obtained from the Professional Regulation Commission (PRC) and professional organizations (Ronquillo in Executive Report, 2002). Also includes 4|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT were findings from a series consultation and review of related literature on the state of the health workforce in the country. The initial findings of the healthcare industry study included the following findings: low priority and low allocations of resources for health, uneven distribution of the health facilities, services and products, and the impact devolution on health human resources, health services, and facilities. Study results reveal enormous and inadequacies in the training of human resources, low salaries and benefits, and for working conditions, all contributing to uneven distribution and inadequacy of health human resources. There is also a need to create public awareness on health. Local as well as overseas health services markets have expanded the range of occupations or jobs that are being demanded. This expansion has consequently emphasized the growing challenge to the government, particularly TESDA and the private sector to produce the “right kinds and numbers” of needed health care workers. After the review of the health industry study, a health industry mapping exercise followed, moderated by Dr. Jaime Galvez-Tan, a former DOH undersecretary and respected key health industry leader. This mapping exercise was a major activity which involve different types of health care providers task to identify emerging professions/jobs/occupations needed. For the hospital-based group, the following were identified as the top priority health care technical occupations: 1. Health Aide 2. Biomedical Technician 3. Hospital waste technician 4. Hospital waste manager 5. Bereavement/death assistance counselor 6. Embalmer The community-based priority technical occupations identified included: 1. Emergency health care coordinator 2. Community ambulance driver/rescue worker 3. Medical equipment technician (preventive maintenance/repair 4. Garbage and sewer collector The concern for multi-sectoral strategies to address the current issues affecting the health care industry was stressed. Health care organizations and individual experts were identified. Strategies that were recommended include: advocacy, capability building, creation of an industry-led body, lobbying for needed executive orders, and marketing. The Health Care Industry Technical Advisory and Coordinating Council was formed with Dr. Juan Nanagas as chairperson. The body was composed of representatives from the government and private agencies, donor agencies, non-government organizations, technical and vocational institution, and the academe. The council was registered with the Securities and Exchange Commission in 2003 under the name of the Health Care Industry Training Council, Inc. and yours (Prof. De Leon) serves as the chair Training and Development Committee. Under the joint cooperation of with the Australian government and TESDA, simultaneous activity on standards development and curriculum development have been initiated and validated. Policies and program registration, implementation, financing, competency assessment, monitoring and evaluation are in the pipeline and a similarly for implementation. Nursing leaders, educators, administrators and managers have a key role to play as collaborators with the various key players in the Health Care Industry and TESDA. Efforts to upgrade health human 5|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT resources to make then competent and employable both locally and globally will require meaningful linkage and support. Inter-Local Health Zone and Inter-Local Health System The Philippine health sector, under the health sector reform agenda of the Department of Health (DOH), has organized Inter-Local Health Zones (ILHZs) to ensure vitality of the system in providing adequate, accessible, efficient, and high-quality health care services that are equitable and that maximize private participation. Specifically, ILHZs aim to address some problems and issues that arose with the implementation of the Local Government Code, other wise known as R.A.7160 of 1991 which provided for the devolution of health care services from centralized (provided by the DOH) to local (provided by the local government). The ILHZs is the nationally endorsed unit for local services. It is the district system in a devolved setting. It is the mechanism that mobilizes different stakeholders (including local health officers, local government unit and other officials, other government and non-government organizations, and private groups) to help institutionalized local health system within the context of local autonomy. With the creation of ILHZs, the responsibility for health services provision has been decentralized from national to local health authorities. The Inter-Local System (ILHZs) is composed of clusters of municipalities with a defined population within a geographical area with central or core referral hospital (usually the provincial hospital), and a few primary level facilities such as rural health units (RHUs) and barangay health station (BHSs). It is a system of health care in which individuals, communities, and all the other health care providers in a well-defined geographical area work together in providing quality, equitable and accessible health care with inter-local government unit partnership. The ILHZs meet the need to re-integrate hospital and public health services for holistic services. It also identifies areas of complementation of stakeholders in the delivery of these health services. Stakeholders include: Local Government Units (LGUs) at all levels, the DOH, Philippine Health Insurance Corporation (PHIC), communities and non-government organizations (NGOs) the private sectors, peoples’ organizations (POs), and others. There are great expectations from the ILHZs (DOH, 2002). These expectations include the following 1. Universal coverage of health insurance 2. Improve quality of hospital and Regional Health Unit (RHU) services 3. Effective referral system 4. Integrated planning 5. Appropriate health information system 6. Improve drug management system 7. Developed human resources 8. Effective leadership through inter-local government unit cooperation 9. Financially viable or self -sustaining hospitals 10. Integration of public health and curative hospital care 11. Strengthen cooperation between LGUs and the health sector The right mix of health care workers who will work with health providers in the local health zones is needed to deliver holistic and comprehensive health care services. Indeed, the system calls for nurse managers and administrators are able to work in complex organization, and who are the strong not only 6|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT technically, but also human relations negotiation, collaboration, networking, social marketing, among many other skills. How External Forces Affect Nurse Administrators Progressive nurse administrators must realize that their involvement in present-day health organization should be characterized by the following: 1. Managing a market or network of services (some authors call this concept population-based or denominator-based management) 2. Managing services across organizational boundaries 3. Actively managing quality and continuous improvement Because they are in midst of rapidly evolving health care delivery systems, nurse managers at all levels of management should make use of information of manager practices, and try application of management theories of delivery of heath care services. The center of care services is moving from hospitals to primary care. Payors are demanding to know the value received for their expenditures. Finally, the nurse executive and manager/administrator must learn to deal competently with the following major trends and transformation in health cares: 1. Cost and Revenue Management. The emphasis in health care management is both generating on revenue and managing costs. Resistance from third party payors and management care systems is forcing health care facilities, including hospitals, to operate on business principles. 2. A new emphasis on wellness and shorter hospital stays. This is a renewed emphasis on wellness, prevention, and early interventions by primary care providers, mandating the crafting of innovative ways to provide acute, post-discharge and preventive health care across a spectrum of settings-hospitals, clinics, day centers, home care and community health centers. 3. Service orientation of hospitals and health care facilities. This gives them that competitive edge in an intensely competitive marketplace in which patients and payors, rather than the physicians, select the service venue. Nurse managers and administrators must lead their staff to contribute their institution’s reputation for service and hospitality. 4. Responsiveness to consumer demands. Nurse executives must help crafts specific marketing approaches and programs to meet targeted needs within the different segments. It is observed that health care consumers have become increasingly sophisticated, assertive, and outspoken the rationale for their therapy and care. 5. Public-private partnerships. Nurse executive for government hospitals must look for sector in joint ventures that will reduce government spending. 6. The importance of systems thinking, team working relationships and professional autonomy within health care system. In successful organizations, employee at all levels understand the goals and vision of their institution, the value of teamwork and their personal roles in ensuring their organization’s success. 7. Refocusing professional education. Now, more than ever before, the nurse manager/administrator is grappling with supply and demand problems, and with many other issues that reflect the changing health care marketplace. These demand that curricula and training include state-of-the-art science, interdisciplinary health care, organizational change, team building, integration of technology and innovative ways of health care delivery such as cross-training and multi-skilling of nurses, so that they can work wherever they are needed within the health care system. 7|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Summary There is a paradigm shift in delivery of health services characterized by improve quality management and holistic services addressing the needs of aging population, and those client with social morbidity such as AIDS, violence and drugs requiring the need for increase social support and chronic care. Health insurance and capitated payment demand increased efficiency and redesign of health services delivery. Training of the health care workforce to meet the need brought about by globalization, information production and new biotechnology development is necessary. The re-integration of hospital and public health services under the interlocal system challenges the health services manager to work in complex organization marked by collaboration between local government units and the health sectors, both public and private. Activity 1-1 Discuss the nursing annotated bibliography articles that focus on trends in health service delivery system. SAQ 1-1 1. In four to five sentences, explain the paradigm shift in the current global health care system. 2. Discuss the management implications of a health industry market characterized by: a. an increasing number of senior citizen clients b. an emergence lifestyle disease including cardiovascular, diabetes, and mental-emotional disorders c. capitated payment and reimbursements by various health maintenance organizations and health insurance, including Philhealth. 3. In your own locality, describe the external forces that affect the delivery of health services. a. How have these forces affected the people in the community? b. How have various health industry players responded to these forces? SAQ 1-2 1. In two to three sentences, state the rationale of ILHZ. 2. Briefly describe the characteristics/qualities/skills of the nurse administrators/manager who can work effectively with various stakeholders in the context of the ILHZ. Justify your answer. 3. Cite two reasons why the 2002 national consultation on technical education in the health care industry is important. 4. Explain briefly your personal ideas on how to address the shortage of nurses in the country. 8|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT 9|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT MODULE 2 ETHICO-LEGAL FRAMEWORKS OF NURSING ADMINISTRATION Objectives: After working on this module, you should be able to: 1. Explain the ethical basis for the nurse administrator’s professional performance: a. Decisions b. Process 2. Describe the policy process; 3. Given an example of a policy that supports the mutual goals of the public and the nursing profession; and 4. Discuss the legal aspect of nursing administration in relation to nursing practice, patient’s rights and labor management relations There are others forces shaping health care delivery system that nurse administrators must know about to run their organizations competently. In contemporary health care settings, there is a general movement from a focus on how to control and direct others, to how to lead and collaborate with others. Nurse manager realize that nursing services are part and parcel of more complex, ever-changing, and unstable health care delivery system that requires them to better prepared to work in organization and to manage care within them. Nurses are increasingly becoming active in political arena where they are involved in shaping the nursing profession and practice, as well as the policies that affects how health care is rendered, allocated, and paid for. How ethics and the law interface in nursing practice and administration must be clearly understood by nurse managers and administrators. Ethical Framework for Nursing Administration Nurse administrators must be realize the ethical mandate that “nursing, like other profession, is responsible for nursing that its members act in the public interest -in the course of providing the unique service society has entrusted to them.” What then are the ethical frameworks and nursing understand that will best help nurse administrators to act in the best interest in the public. Nurse are patient care administrators are best guided by Hall’s (1996) ides showing the interrelationship of law and ethics: 1. Good nursing practice is legal and ethical. 2. The shared values (ethics) of the people are the basis of their law. 3. Law is the minimum standard of morality. 4. The ethics incorporated into good nursing practice are more important than knowledge of the law; practicing ethically saves individuals the effort of trying to know all the laws. 5. Nurses who follow specific legal but not right (and eventually, not even legal). 6. Good practice reflects reflect ethical behavior that results in the action that is legal. 7. A legal duty does not exist without a higher ethical duty, but there may exist an ethical duty without a lower legal duty. 1 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT 8. The minimum behavior required by law is not the same as the maximum ethical behavior. Four moral principles serve a s basis for ethical decisions in nursing (Martin in Doheny et Al., 1997). 1. Belief and the worth and dignity of the individual-involves client rights, informed consent, and right to self-determination. 2. Health care should yield general and social good and may involve risks to advance health. 3. Commitment, integrity, and faithfulness to the profession. 4. Belief in the value and validity of scientific truth and scientific method. Scope and Standards for Nurse Administrators (1995) published by the American Nurses Association focuses both standards of professional performance. The nurse administrator’s decisions and actions are based on ethical principles. Under these standards, the nurse administrator: 1. Advocates on behalf of recipients of services and personnel 2. Maintains privacy, confidentiality, and security of patient, client, staff, and organization data 3. Advocates organizational adherence to the code for Nurses (e.g., American nursing Association, Philippine Nursing Association) 4. Fosters a non-discriminatory atmosphere in which care is delivered in a manner sensitive to sociocultural diversity 5. Supports the system to address ethical issues within nursing and the organization Many individual health care facilities province ethical guidelines for health care professionals, in addition to guidelines set by profession. Medical centers and biomedical facilities and have ethics committees. Many nurses acting as advocates, are often members of research committees that reviews proposed research studie6to determines the level of acceptable risk to clients and guard against the violation of their rights. There are certain ethical dilemmas in clinical nursing when the nurse act as client advocate in assisting the patient with decision making. Nurse managers and administrators are quite influential in client decision making. Nurse managers and administrators are quite influential in client decision making and must be aware of these own values to avoid misuse of this power over clients. It is important to engage in collaborative decision making wherein all health professionals involved in the care of the client discuss ethical concern to reach decision that may be more objective and less subject to bias. From the above, we can appreciate that the effective nurse administrator considers the use of an ethical framework that guides decisions based on moral principles, and which also influences the organization to serve its members well. By example or role modeling of moral reasoning in problem solving, especially in personnel matters, nurse administrators demonstrate the rewards of ethical practice to their staff burses. The latter, because they have experienced it themselves as inherent part of the nursing service department, are better prepared and supported in their ability to respond to ethical dilemmas in their own areas of practice. Finally, keeping the effects of globalization in mind, it is good for nurse administrators to integrate insights form multicultural and global perspectives into their administrative practices, as well. 2 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Nursing Administration and the Health Policy Process A basic understanding of the health policy process is important for nurse administrators since policy creates the context for practice that allows and facilitates the delivery of nursing services to the public. To put in simply, policy decisions regulate behavior and determine the distribution of cost and benefits. Policy questions are moral questions as well as economic issues reflecting varying views about equity-touching on equal treatment, equal access, or equal outcomes for values populations and groups. In our country, as in most democracies, we hold public debates and arrive at a consensus for policy development. As a group, Filipino nurses, whether from the government or private sector or non-government organization, have long supported Philippine government’s efforts to create health care system that assures access, quality and affordable services. Examples of the more current policies on health initiated by the Department of Health are “Health Insurance for all” (Philhealth) and the Inter-Local Health Zones. How then, is a policy made? Dienemannn (1998) discusses the policy process-the series of stages by which an issue is defined and placed on the agenda; options for this resolution are considered; and a policy is adopted, later implemented, and still later evaluated. A triggering event that grabs public attention may precipitate the policy process. Assumed casual relationships and effects that should follow from implementation of the policy are used to develop policies. Research relevant to the policy at issue, test there relationships, either before the enacment of the policy or during the evaluation of a policy that has been in place for a while. Other authors describe the policy process in terms of learning, particularly within the context of an advocacy coalition from public and private organization, including researchers and journalist who are actively concerned with a policy problem. Learning occurs through dialogue and involves improve one’s understanding of a position on the policy problem. Other people are informed through research that supports the policy proposals. In the new paradigm of the transformed health care delivery system, nurse administrators are challenged to act in partnership and coalitions with other health professionals and answer questions about how nurses as a workforce should be constituted and used. These questions are raised in the area of nursing services with patients, their families, and communities while at the same time keeping in mind and alignment of nursing values with societal values and goals of government concerning health and the delivery of health services. Legal Aspects of Nursing Administration and Law There are three major areas of the law affecting the profession of nursing that nurse administrators must be alert to: nursing practice, patients’ rights, and labor-management relations, especially regarding professional workers. At this point, we will discuss the issues and current practices in each of these areas that are important to the nurse administrator. Nursing practice 3 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT The practice of health professionals is regulated through the Professional Regulation Commission (PRC) to protect the public from untrained or incompetent practitioners. The Nursing Law establishes minimum qualifications, competencies and standards of practice for nurses. As in other countries, new configurations of nursing personnel have created concerns about the liability of nurse managers for selection, assignment, delegation, and supervision of personnel. Assignment is defined as the transfer of task and accountability for the outcome. It is important that the nurse administrator knows what tasks are within the scope of practice of the different categories of nurses [in the United States of America, these would be the assistant practical nurses (APNs), registered nurses (RNs), and licensed practical nurses (LPNs) vis- à-vis the registered nurses and caregivers of our own country] and the competency in the task of the assigned. If the nurse administrator breaches the standard of care for either of those duties, she may be held to be liable if harm results from acts of the subordinate staff nurses. Delegation is the transfer of task without transferring accountability. The RN can never delegate total patient care to a subordinate who is unlicensed. He or she remains responsible for assessment, nursing diagnosis, planning, and evaluation of the patient’s response to care and may be held liable if he or she was negligent in delegating the task or did not properly supervise the individual to whom the task was delegated. The doctrine of "holding self out” provides that one can do something that in reality one is not qualified to do. If a nurse without the authority of a standardized procedure performs acts that result in injury to a patient, a presumption of negligence may result against the nurse through the application of the holding self out doctrine. This doctrine also applies when nursing students perform nursing services that are customarily performed only by registered nurses; they are held against the standard of care of the RN and considered liable. It is important then that nurse administrators realize that if nursing students are inadequately prepared for a particular assignment or duty or need additional supervision, they must be given further information and supervision. The nursing faculty are legally liable for the nursing students’ assignments and for their reasonable and prudent supervision. The hospital/agency has the corporate liability and must have a contractual agreement with the school of nursing. In the performance of their jobs as administrators and managers, nurses gain additional responsibilities that expose them to the risk of liability. Together with their employing agency, they may be held liable, under the doctrine of corporate liability or as an individual, for professional mal- practice or criminal acts. Under the doctrine of respondeat superior (vicarious liability), the employer is held legally responsible for the wrongful acts of employees. The doctrine holds that when the employee is performing within the scope and course of his/her employment and performs a negligent act, the employer is held responsible for payment of damages. However, the agency is not liable if the nurse acts beyond his/her scope of practice. The employer is held responsible for payment of damages if the nurse performs a criminal act. Nurse administrators and managers must be familiar with the legal aspects of malpractice because of the unique fiduciary duty (based on trust) in the nurse-patient relationship. Malpractice is defined as any professional misconduct, unreasonable lack of skill or fidelity in professional or fiduciary duties, or illegal or immoral conduct. The more common mal- practice actions nurses are held liable for usually involve negligence, as- sault and battery, invasion of privacy, and false imprisonment. 4 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT When we speak of standard of care, we are referring to the legal requirements for nurses to exercise the same degree of care and skill that a reasonably prudent nurse with similar training and experience performing nursing duties would exercise under similar circumstances. Scope and Standards for Nurse Administrators (1995) lists assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation as some of the categories included in the standards of care. Under the standards of professional performance, the following categories are covered: quality of care and administrative practice, performance appraisal, education, collegiality, ethics, collaboration, research, and research utilization. In the event that the nurse is accused of malpractice, the patient/health consumer under the doctrine of res ipsa loquitur (the thing speaks for itself), through an expert, must show three conditions: (1) that in the ordinary course of affairs, the accident would not have occurred if reasonable care had been used; (2) that the thing that caused the accident was under the exclusive control of the nurse; and (3) that the patient did not contribute to the occurrence of the accident. There are five conditions all nurse administrators and managers must be familiar with to establish that the staff has been negligent. These conditions are: (1) failure to do something that a reasonable nurse would have done; (2) doing something that a prudent and reasonable nurse would not do; or (3) failure to exercise ordinary care under the circumstances; (4) conduct that a reasonably prudent nurse should realize involved an unreasonable risk of invading a patient’s interest; and (5) failure to do an act that is necessary for the protection or assistance of the patient. Still on the issue of negligence, it is very important that nursing management/administration come up with and implement policies for training staff in violence control (e.g., in the case of hostile patients), maintaining records of violence, and initiating a process of communication to warn others of danger. In the same light, implementation of the policy that assures protection from harm from medical devices and other hospital equipment used in the care of patients must be in place. Equally important is the responsibility to train and supervise the staff in proper use and storage, verifying functions, documenting status, repair, and replacement of (defective) instruments and equipment used in the care of patients. There is also the managerial responsibility to observe policies requiring a signed authorization for release of information before responding to inquiries. Instances when patients cannot pay their bills and are prevented from leaving the hospital, or when a patient who is not a danger to self or others is detained, can result in the tort of false imprisonment. Likewise, lack of informed consent to medical care and treatment may put the caregiver in a position of being accused of assault and/or battery. You be familiar with the terms but it is good to define them again: assault is the unjustifiable attempt to touch another person, or the threat to do so in such circumstances as to cause the other person reasonably to believe that it will be carried out; and battery involves an intentional act that is harmful or the offensive touching of another person without his or her consent. There are several important points to remember about medical records. After all, they are legal documents and are recognized as evidence to impugn a health care provider’s professional activity. First, they must be timely and accurate. Nurse managers and administrators in some health care facilities have instituted checklists and clinical pathway flowsheets as substitutes for narrative charting. It is necessary that staff are properly familiarized with the system. No alteration of the medical record is allowed; nursing management or administration must make sure that an erroneous chart entry is never to be erased, obliterated, or 5 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT destroyed. Before correct information is to be entered, the erroneous entry must be crossed through, labeled as erroneous, signed by the individual correcting the error with date and time, and kept in the record. Nurse administrators and managers need to establish and monitor chain of command procedures that will help the staff nurse report the problem of erroneous orders by medical doctors through a supervisor to the appropriate medical superior. Erroneous orders are legally defined as physician’s orders that are illegible, incomplete, ambiguous, incorrect, or violating standards of care or agency policy. In the case of telephone orders, it is safe practice for there to be two nurses taking down the order simultaneously and for the doctor to countersign the order within the time frame indicated by regulation and/or agency policy. Patients’ rights In the area of informed consent and/or refusal of treatment, we can see that it is important that patients, when mentally competent, should be given by the attending physician sufficient information regarding the risks and benefits of the treatment and alternatives to treatment to enable patients to make an informed choice. Generally, the nursing responsibility is to verify that the appropriate consent form is present and to notify the doctor when the patient has questions about or objections to the treatment. Even if they have initially signed a consent form, patients may withdraw consent for treatment at any time. This is legally anchored on the right to privacy, which includes the right to control one’s body and to consent to treatment. A release form must be signed to document the patient’s refusal of treatment. If he or she refuses to sign a release form, this must also be documented in the hospital record. Health care staff must be clear about the patient’s right to privacy and confidentiality regarding the exposure and revelation of his/her body or depictions thereof to unauthorized persons. They must likewise be conversant with privileged communication where the physician is forbidden to disclose information learned in the course of treating a patient unless the patient permits it. However, all the above conditions are waived in criminal cases. In the USA, the Patient Self-Determination Health Act of 1990 requires all health facilities, as a condition to participation in Medicare and Medicaid programs, to inform patients, families, and employees of their legal rights under state law to direct their medical and nursing care, including the right to refuse treatment. Parallel to this is the mandate for health care administrators and managers to educate the staff and the community on issues concerning advanced directives that include power of attorney and living wills. Although it is not yet fully appreciated in the Philippines, in most states in the USA the patient (or his/her representative) has the right to inspect the record while still a patient, and copy the record after discharge. To refuse the patient or his/her legal representative access to his/her hospital record can make the agency and the staff liable for damages. Laws and regulations on labor management Traditionally, human resource departments manage employee-employer issues. However, nurse managers and administrators should be knowledgeable about relevant laws and how they govern employees in health care agencies. It is important to know and understand the type of employment of everyone delivering health services. Health workers may be hired in traditional positions at will by individual contract in salaried 6 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT positions, or work in the agency through an outsourcing contract and be an employee of another firm. It is wise to consult the human resource department on issues of leaves, compensations, discipline, and termination. In some large hospitals and health care organizations, health care workers may band themselves together in a labor union/organization and become the collective bargaining unit. To become the collective bargaining unit representing a group of health care workers under Philippine laws, (Presidential Decree No. 442 and Republic Acts Nos. 6715, 6725, 6727, 7610, 7641 7655, 7658, 7700, 7730, 7796, 7877, and 8042), through the Department of Labor and Employment, essentially, a labor organization must: 1. Solicit interest through organizing efforts 2. Submit a petition demonstrating a showing of interest by at least 20% of the employees to ultimately be in the bargaining unit 3. Submit the names of its officers and their addresses, the principal ad- dress of the labor organization, the minutes of the organizational meetings, and the list of workers who participated in those meetings 4. Be a certified legitimate bargaining unit by payment of Php50.00 registration fee It would be helpful for nurse managers and administrators to realize that once a labor union is recognized, management must bargain in good faith with that organization to establish a labor contract. Both management and the labor union for the first contracts are bound (1) to meet at reasonable times to negotiate wages, working hours, and other terms and conditions of employment in good faith, namely, with an intent to reach an agreement; and (2) to put into writing and execute a contract stipulating agreements when they are reached. The term unfair labor practices include all activities carried out directly or indirectly, by either the employer or by the labor organization, that violates labor relations. Unfair labor practices violate the constitutional right of workers and employees to self-organization, are inimical to the legitimate interests of both labor and management, including their right to bargain collectively and otherwise deal with each other in an atmosphere of freedom and mutual respect, disrupt industrial peace, and hinder the promotion of healthy and stable labor-management relations. Nurse managers must recognize the importance of discipline; moreover, they must be trained to administer discipline by the appropriate procedures under the contract. In cases where the employee or the labor organization makes formal written complaints or grievances, failure to follow guidelines may result in the finding of an unfair labor practice. While labor-management problems in the Philippines focus almost always on issues affecting wages and employment conditions, the case in the USA and more affluent societies is more complex and unsettled. It is timely to mention at this point some emerging legal issues of interest to nurse managers and administrators: 1. On the issue of work design, the debate centers around the control of standards for cost-effectiveness and quality of health care by clinician employees or managers or owners (Poole, 1996). Work design has implications for nurse practice acts in these places and their regulation regarding merger and acquisition activity, and labor law regarding collective bargaining. 7 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT 2. Parallel to the mergers of health care agencies and expansion of integrated care, is the expansion of information technology to provide information about client-patients across a continuum of care. The protection of client patient privacy and confidentiality in this environment is still an unresolved issue (Fiesta, 1996). 3. Situations regarding limiting of access to private information and data bases such as from the health care provider to health insurer; lengthy system downtime, which may delay timely provision of care; detecting the altering or destroying of records and possible cover-ups through manipulation of record systems, are instances of legal challenges which nurse managers and administrators must be aware of. 4. There is a civil rights challenge to the use of drug testing by many hospitals both prior to and “for cause” during employment. The nurse manager/administrator must be updated on the drug testing law and his/her agency’s compliance (Simmons, 1994). 5. Issues of concern related to the Human Immuno-deficiency Virus (HIV) include anti-discrimination, privacy, confidentiality, and workplace safety. Nurse managers and administrators must consider the rights of both clients/patients and staff. Decisions are on a case-to-case basis (Zachary, 1995). 6. Legal questions arise when health care consumers call for increased regulation regarding access to care in response to incentives to re- duce care from capitated payment or global payment to providers. In many cases a liability decision will be influenced by a determination of whether the need for treatment was urgent, and the denial decision was concurrent or retrospective (Guanowsky, 1995). 7. Lastly, in the area of insurance regulation, where many health insurers are becoming national and even international purchasers of care, there is an increasing demand for a federal “bill of rights” for health care targeting managed care. Cultural Diversity in the Workplace This part of the module is intended to assist nurse managers working in multicultural environments. We hope to provide information and discuss relevant concepts to increase cultural sensitivity and suggest ways for developing skills in working effectively in workplaces with cultural diversity. Indeed there are many challenges in making health care relevant to a multicultural population. Differing cultural beliefs, values, and practices can cause problems of noncompliance and disagreements with treatment programs designed by mainstream health professionals (Boyle and Andrews, et al., 1995). In like manner, there is potential for conflict and unnecessary disagreements in delivering health services, and in the areas of restructuring and downsizing. There are reported racial slurs and prejudicial behaviors on the part of health consumers and patients when the persons giving care belong to other racial or ethnic groups. Professional and nonprofessional health workers who hold different values may interpret managerial decisions differently. There are cases when managerial decisions may be interpreted as favoritism for one race over another, and can result in underlying tensions between the groups, from outright anger and verbal exchanges to silent resentment and lowered productivity. From the above discussion, we can see that the challenge for nurse managers and administrators is twofold: that is, to ensure culturally relevant care for clients and to capitalize on the strengths of the workforce while minimizing the potential for destructive conflict. There are some authors who conclude that when diversity can be channeled to creative endeavors, a multicultural environment can be rewarding for employees and 8 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT the organization, and at the same time ensure productivity and efficiency (Loden and Resener, 1994; Jamieson and O’Mara, 1991). Different cultures have marked differences in locus of control orientations. Some tend to have a more internal locus of control, to believe that they themselves are the primary cause of events in their lives. Fatalism, which includes a belief in the predetermination of events and/or the con- trol of events by God, on the other hand, is more common among Asians and Latinos (Cox, 1994). Furthermore, Cox observes that members of a racial/ethnic minority may have a more external locus of control than the majority group members because they are aware of how prejudice and discrimination reduce personal control. According to Cox, because of the perceived discriminatory attitudes or behaviors felt by minority groups in U.S. health care organizations, these people feel that they have no chance of any reward under that system and thus experience lower work motivation. This results in low morale and productivity of the staff and contributes to unsatisfactory health care services. Many foreign health care workers may not be aware that while they comfortable using their own language, they are offending and excluding others, thus inciting hostility and dissension. Hence, to reduce feelings of exclusion, some employers have required all employees to speak only English while at work. But this action has not really altogether decreased tension. It is worth mentioning that in one court case, a hospital in the U.S. restricted Filipino nurses in the evening shift from speaking Tagalog be- cause the non-Filipinos contended that the behavior was disruptive and rude and left them out of conversations. The case was decided in favor of the hospital (Dimaranan vs. Pomona Valley Hospital, 1991). Other authors note that regardless of the legal permission to uphold the English- only rule, court cases are not only expensive but also divisive, and recommend that such policies should be used only as a last resort. It Is possible that while working with culturally diversified groups, nurse managers and administrators will encounter problems related to stereotyping, prejudice, and discrimination. Stereotyping is characterized by having fixed and distorted generalizations about all members of a particular group. This may come about when there is very minimal contact between groups. Stereotyping can either be positive or negative: either way, it sets preconceived behaviors that make the minority feel isolated and worse, ostracized. Another reality encountered in culturally diversified workplace is the problem of prejudice and discrimination. Prejudice involves judgments about specific cultural groups that reinforce a superiority/inferiority belief system. Stereotyping compounds the problem by reinforcing these counter- productive behaviors. Prejudice and discrimination may take several forms, including lower expectations in performance, and may hinder career promotion. It is important to manage cultural diversity effectively to create a climate that supports and uses it for positive outcomes. From the upper levels of management, the direction of valuing cultural diversity must be supported. Nurse administrators and managers can champion the serious efforts to generate adequate resources for programs and educational materials that improve cultural communication and lead to dialogues and experimentation with varying ideas to promote peace and productivity in the work- place. To help ensure culturally sensitive client care services, it may be useful to hold focus group discussions around cultural sensitivity issues and identify resource people within the organization who can help to reduce tension and come up with fresh approaches. While there may be strong resistance behaviors that cannot be turned around, there are things that can be done to create a favorable workplace, including clear 9 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT expectations in the job description, orientation, and disciplinary procedures that will prompt those who are unwilling to work productively to quit their jobs. Indeed, management must understand workforce differences due to cultural diversity and must move beyond the “one size fits all” model of management (Jamieson and O’Mara, 1991). However, it is important that the total organization must change to provide a climate that values difference. Moreover, nurse managers and administrators must look for opportunities for staff to receive recognition. Recognizing what the minority staff do best, and providing growth opportunities can be great come-ons, increasing feelings of organizational caring, and reducing if not eliminating potential conflict situations. Certainly, valuing staff also brings the best rewards to the organization. Summary Nurse managers and administrators are champions of their staff and clients. They are responsible for ensuring that their staff act in the best interest of the publics that they serve. To resolve ethical dilemmas in their professional practice, collaborative decision making with other professional members of the health team can be done to arrive at better and objective decisions affecting patient care. The nurse manager/administrator must not only be conversant in the areas of the law affecting nursing practice, patients’ rights and labor-management relations but must also be role models in observing and implementing these. Activity 2-1 Examine the policies in your place of work. Discuss which policies are favorable/unfavorable to you as a nurse manager/health worker. Justify an item that you would like to be developed as a policy. SAQ 2-1 1. Describe an ethical problem/issue that you face in your work. 2. Explain how the above problem/issue is being addressed or was resolved. SAQ 2-2 Before going to the next section, try answering these questions. 1. Define “malpractice”. 2. Define “informed consent”. 3. Cite an example of an unfair labor practice. Describe work related issues (if there are any) in your work situation. As a nurse manager/administrator, what do you plan to do about them? SAQ 2-3 1. What legal doctrines or statutes protect the nurse in the practice of his/her profession? 2. What legal doctrines or statutes protect the patient from mal- practice and negligence of professional staff? 3. How can health professionals actively lobby for fair labor practices? 4. What do you think of the bill on “malpractice law” being put to the Philippine Congress? 10 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT SAQ 2-4 1. What cultural diversity issue/s have you encountered in your own setting? 2. How did you address the issue/s? 3. Find out about Leininger’s proposal of Transcultural Nursing as an answer to cultural diversity. 11 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT MODULE 3 MANAGEMENT PERSPECTIVES IN NURSING ORGANIZATION Objectives After working on this module, you should be able to: 1. Explain the network of health services organizations; 2. Describe the primary organizational components of the health care system; 3. Discuss major management perspectives on health services organizations; and 4. Derive implications of the different management thoughts and theories for nursing management and administration. Components of the health care system include health care services clients (including patients, national and local governments, hospitals, clinics, infirmaries, rehabilitation centers, nursing homes, schools, business establishments, offices, religious and socio-civic organizations, etc.), insurers and payers (including Philhealth, health maintenance organizations), regulators (including Department of Health and other government licensing agencies, local and international accreditation bodies such as the Philippine Council for the Accreditation of Health Organizations (PCAHO) and its international counterpart, the Joint Commission International (JCI), and professional and trade associations. We also include suppliers of pharmaceuticals and bio equipment, funders, investors, and finally, research and educational institutions. Included under the latter category are medical and nursing schools, other professional schools, research organizations and private foundations. The Network of health Care Organizations It is very important for nurse managers and administrators to know the wide network of organizations that constitutes the health care delivery system. To be able to manage effectively and efficiently whatever organization he or she is connected with, the nurse manager should be able to maximize, as well as utilize resources at least cost, by networking and lobbying for worthy industry causes. The figure below shows the many varied organizations engaged in the process by which health care services are ultimately delivered to clients. Components of the Health Care System 1|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Components of the health care system include health care clients (including patients), insurers, and providers such as hospitals, ambulatory care services, long term care facilities, physicians, nurses, pharmacists, allied health personnel, providers of pharmaceuticals and equipment, and government health services. The redesign of health care systems to ensure continuity of care requires continuity of information, a decrease in paper work, and protection and confidentiality of client information. Thus, more health care workers are now computer literate to ensure that systems meet their information needs. Nurses must likewise be clear about their role and function as nurses and about what nursing has to offer to client welfare, if they are to contribute effectively to the health team. In more progressive health care organizations, nursing service organizational structures are being redesigned to give nurses more responsibility, authority, and accountability. Not only over nursing but also over coordination of nursing with services of other health professions, as mentioned earlier. Multidisciplinary teamwork at the operational level is emphasized. Nurses are in an ideal position to facilitate interdisciplinary cooperation in the interest of achieving integration because of their longer contact with clients across the life span compared to other health care professionals. Also, nurses are the usual coordinators of health care services. Major Management Perspectives on Health Services Organizations A number of major perspectives on how organizations work has evolved: the classical theories, scientific management school of thought, classic organization theory, human relations school, behavioral sciences school, and contingency model theory. The nurse administrator can benefit greatly from exposure to these theories. 1. Classical theories have five characteristics consistent with the closed system approach to organizations: a. the organization has well-defined policies and procedures for governing activities; b. officers of the organization perform delineated activities; c. there is a hierarchical arrangement of positions; d. technical competence is the primary consideration in the selection of the worker; and e. officials carry out their functions and duties in an impersonal manner. Many health services organizations are traditionally bureaucratic in nature. This is evident in the Department of Health setup and in many private organizations as well. However, contemporary literature points out that other forms of organization are better at dealing with rapidly changing environments and increased demand for innovation and creativity. 2. The Scientific Management School is focused on the best way to do a task and emphasizes span of control, unity of command, delegation of authority, departmentalization, and the use of work methods to improve efficiency. The scientific management school approach consists of: a. programming the job; b. choosing the right person to match the job; and 2|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT c. training the right person to do the job. Application of this theory is best appreciated in the area of work methods improvement and operations research approaches. Several people are associated with the scientific management school. First in the list is Frederick W. Taylor, generally recognized as the father of scientific management. Taylor conducted time and motion studies, analyzed workers’ movements and set work standards, thereby developing a systematic approach to determine the most efficient means of production. Frank and Lillian Gilbreth emphasized the benefits of job simplification and the establishment of work standards. They also did time and motion studies and studied the effects of incentive wage plans and fatigue on work performance. Lillian Gilbreth is known as the first lady of management; she contributed significantly to understanding the human factors in industry. The Gantt chart, used to depict the relationship of work planned or completed on one axis to the amount of time needed or used on the other, was introduced by Henry Gantt, a disciple of Taylor. Gantt also championed a more humanitarian approach, placing emphasis on service rather than the profit objective, thereby recognizing the importance of job security and staff development Classic organization theory views the organization as a whole. It does not focus solely on production. Management activities are categorized as planning, organizing, and controlling. Henri Fayol, known as the father of the administrative school, studied the functions of managers and believed in the division of work. He posited that specialization increases efficiency. Fayol introduced the concept of scalar chain or levels of authority, responsibility accompanied by authority, unity of command and direction so that each employee receives orders from only one superior. Fayol encouraged group harmony through equal treatment and stability of tenure of person- colleges. Nel. He also advocated the teaching of 14 principles of management in colleges. Max Weber is known as the father of organization theory. He brought forth the concept of bureaucracy, emphasized the importance of rules instead of individuals, and identified competence as the most efficient basis for organization. It was Weber who conceptualized the structure of authority that would facilitate the accomplishment of organizational goals. He advanced the idea that all personnel are selected for competence; that the division of labor, authority and responsibility is clearly defined; and that positions are organized into a hierarchy. 4. The Human Relations School adheres to the belief that satisfying the individual needs of the individual worker is a worthy goal in itself, and is not merely a means of achieving the goals of the organization. This approach emphasizes the importance of the social environment, participatory decision making that involves the individual in the organization, and the role of the intrinsic self, actualizing aspects of work. The human relations school focuses on the individual, group process, interpersonal relations, leadership, and communication. Management is responsible for encouraging their workers to develop their potential and help them meet their needs for recognition, accomplishment, and sense of belonging. Chester Barnard maintained that the manager’s responsibility is to define objectives, acquire resources, and coordinate activities within the organization. He also stressed the importance of cooperation between 3|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT management and labor, noting that the degree of cooperation depends on non-financial inducements which informal organization can help provide. Barnard believed that authority depends on acceptance by the followers, even as he stressed the role of informal organizations in helping facilitate communication, maintaining individual worker’s needs, and maintaining cohesiveness of the work group. Mary Parker Follet advocated the importance of coordinating the psy chological and sociological aspects of management. On the assumption that the organization is a social system and that management is a social process, Follet stressed that legitimate power is produced by a circular behavior whereby superiors and subordinates mutually influence one another. Follet advanced the idea that managers study the total situation to achieve unity. Furthermore, she believed that control would be obtained through the integration of all of the elements: people and materials and such factors as politics, economics and biology. The Hawthorne Studies done under Elton Mayo investigated the effects of changes in illumination on productivity. The researchers concluded that lighting had little effect on production. It was theorized however that the feeling that the workers were being watched and given importance by the researchers made the former more productive. The Hawthorne studies gave impetus to the human relations movement. Kurt Lewin advocated the importance of group dynamics and democratic supervision. Lewin maintained that groups have personalities of their own and that groups can overcome individual interests. His contribution to the human relations school indicated that democratic groups, where members/participants solve their own problems and have the opportunity to consult with the leader, are most effective. Jacob Moreno later developed sociometry to analyze group behavior. By pairing and ranking peoples’ preferences for others, Moreno was able to demonstrate which workers were capable of harmonious interpersonal relationships. He also contributed to psychodrama (individual therapy), sociodrama (related to social and cultural roles), and role playing techniques for the analysis of interpersonal relations. 5. The Behavioral Science School emphasized the use of scientific procedures to study the psychological, sociological, and anthropological aspects of human behavior in organizations. Behavioral scientists maintained that management is not strictly a technical process and it should not be executed through authority. The behavioral science school emphasized the necessity of maintaining a positive attitude toward people, training managers, fitting supervisory role to the situation, meeting employees’ needs, promoting employees’ sense of achievement, and obtaining commitment through participation in planning and decision-making. Abraham Maslow developed his hierarchy-of-needs theory in which he outlined a hierarchical structure for human needs classified into five categories: (1) physiologic (the most important for survival; includes need for water, food, oxygen, sleep); (2) safety (needs include freedom from danger, threat and deprivation, and freedom from physical harm, economic distress and ill health); (3) love (needs include affectionate relations with others, acceptance by one’s peers, recognition and companionship); (4) esteem (needs comprise self-respect, positive self-evaluation and regard by others); and (5) actualization (needs include self-fulfillment, and achievement of one’s full potential). In Maslow’s hierarchy of needs, physical needs must be met before other needs can be addressed, and the satisfaction of self-actualization needs is possible only after all other needs are met. As a need is met and satisfied, it decreases in priority and becomes less of a motivator in relation to other needs. Not all needs are really fully met or satisfied. 4|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Frederick Herzberg used the critical incident method in his researchers and came up with his two-factor theory. Herzberg theorized that job factors in situations associated with satisfaction were different from job factors associated with dissatisfaction. The motivators or satisfiers identified were achievement, recognition, work itself, responsibility, advancement, and the potential for growth. Hygiene factors or job- context factors are those that cannot motivate but can lower performance and cause job dissatisfaction. These hygiene factors or dissatisfiers include: supervision; company policy; working conditions; interpersonal relations with superiors, peers, and subordinates; status; job; and security. 5|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Douglas McGregor expanded on the theories of Maslow and developed them in the area of management. McGregor’s Theory X and Theory Y showed that one’s management style is dependent on one’s philosophy of people. The goal of the organization is emphasized in Theory X, which maintains that people need direction because they have little ambition and avoid responsibility. Managers who subscribe to Theory X will do most of the thinking and planning with no or minimal participation from the staff. Because people dislike work, management will supervise them closely and make them perform through coercion and threats. On the other hand, the goal of the individual worker is emphasized in Theory Y. Management believes that the individual worker is self-directed and has self-control. It is also believed that individual workers seek responsibility and are capable of creativity, prompting management to respond favorably with job enlargement, recognition, and praise. All in all, McGregor maintained that both Theory X and Theory Y are ineffective on their own and recommended that the work situation be structured in such a way that there is a fit between the individual’s personal goals and the organization’s goals and objectives. To facilitate meeting the worker’s personal goals while working toward the goals of the organization, there must be collaboration and cooperation between the manager and the worker for integration of goals. Chris Argyris complemented McGregor’s Theory Y. His researchers focused on the coexistence of personal and organizational needs. For individual workers to grow and achieve self-actualization, Argyris believes that managers can make jobs more meaningful and allow individual workers to participate in planning and problem solving. Rensis Likert is a major proponent of the participative style of management. He developed the Likert Scale, which measures several factors related to the leadership behavior process, motivation, managerial influence, communication, decision making processes, goal setting, and staff development. Likert advanced the Linking-pin concept based on studies about the differences between good and poor managers as measured by their level of productivity. He suggested that managers form groups for supportive 6|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT relationships and that those groups be linked by overlapping groups of managers. This structure facilitates three-way communication (upward, downward and sideways), allowing interaction between managers and workers, and facilitating fit between the worker’s personal goals and that of the organization. Robert Blake and Jane Mouton contributed the Managerial Grid. According to Blake and Mouton, there are two important dimensions of leadership, namely: (1) the concern for people and (2) the concern for production. The two dimensions are independent; hence, it is possible that the manager can be high on both, low on both, or high on one and low on the other. The manager’s concern for people is depicted in the vertical axis and the manager’s concern for production is depicted in the horizontal axis. The figure on the next page will show that team management is the desirable management approach. Here, management integrates its concern for both people and production. The Contingency Model of leadership effectiveness was introduced by Fred Fiedler. According to Fiedler, there are three important dimensions of a situation: (1) leader-member relations, (2) task structure, and (3) position power. Leader-member relations are based on the amount of confidence and loyalty followers have in their leader; task structure is related to the number of correct solutions to a problem; and position-power depends on the amount of organizational support available for the leader to carry out his/her mission. Peter Drucker, known as the father of modern management, introduced the concept of management by objectives (MBO). To Drucker, the way for management to justify its existence is through economic results. He identified three areas of management: managing (1) a business, (2)managers, and (3) workers. In MBO, the manager develops the framework and the staff supplies the goals, which are agreed upon by both. Managers are directed by objectives of performance rather than by top management. 7|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Objectives are developed for every level of management in the hierarchy and each unit in the organization. We can see that Drucker favors decentralization and maintains that it is more productive for workers to set their own norms and measure their own performance than for management to set minimal standards for them to comply with. Drucker believes that the most important resource of the organization is the workers and that they must be given more control over their jobs. Implications for Nursing Administration and Management We can appreciate the different contributions of the different management concepts and theories from the different schools of thought. Although so much has evolved and the focus has changed, there are universal elements that remain valid and can be used by the nurse executive or administrator. Indeed, by studying the development of management thought, nurse managers and administrators can define their management role, develop their philosophy of management, equip themselves with proven tools and techniques for carrying out their responsibilities, and gain increased appreciation and understanding of working in teams to accomplish organizational goals. The nurse manager can use Gilbreth’s time and motion studies to improve the prediction of staffing needs and study efficiency of health services. The Gantt chart can be adapted to visualize the time element of planning and controlling. The principles of Fayol's management, which include planning, organizing, directing, coordinating and controlling, are essentially the managerial tasks of every nurse manager and administrator. We can rely on Weber’s concepts of bureaucracy and authority to assist us with our organizing responsibilities. The work of the different human relations theorists-Barnard, Follet, Mayo and Lewin-stresses for the nurse administrator the importance of developing workers to their potentials and meeting their needs for recognition, achievement, and sense of unity with the organization. Managers can reflect on Lewin’s participative type of management and we can use Moreno’s sociometry to study group behaviors of our workers. We agree with the ideas of other theorists (McGregor, Argyris, Likert and Mouton) that support the benefits of positive attitudes toward people, development of workers, satisfaction of their individual and personal needs, and commitment through participation in goal setting and problem solving related to their jobs. We can appreciate Maslow’s hierarchy of needs theory not only in the delivery of health services but also in dealing with co-workers. We can firm up our commitment to the importance of accomplishment, recognition responsibility and advancement as motivators and satisfiers as formulated in Herzberg’s two- factor theory. The nurse manager and administrator can use Fiedler’s work on leadership to assess the work situation and particular circumstances to determine the most effective style or modify the work situation to fit the chosen style. Lastly, Drucker’s management by objectives can be used to gain clarity in the planning, directing, and controlling phases of the management process. 8|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Summary An explanation of both the network of health service organizations and the components of the health care system are important for the nurse manager/administrator to understand, realizing that nursing services are an integral part of a complex, competitive and demanding health care industry. The various players of the health service industry have their own unique purposes and concerns. The nurse manager/administrator is a collaborator ensuring continuity of quality care to the clients served. Major reasons for low employee motivation are lack of understanding concerning expectations, organizational impediments to performance, and lack of valued rewards for performance. It is important for nurse managers/administrators to work on inadequate performance-reward linkages through behavior modification, pay for performance, and provision of desired motivators related to achievement of growth or esteem or power needs of employees. Activity 3-1 Summarize the different proponents’ contribution to management perspective in tabular form. Proponents Purpose/Use of Theory/Model Frederick W. Taylor Frank Gilbert and Lilian Gilbert Henry Gantt Henry Fayol Max Weber Kurt Lewin Mary Parker Follet Abraham Maslow Frederick Hersberg McGregor Fred Friedler Peter Drucker Activity 3-2 Behind the success of health service organizations are cultivated attitudes and values, commitments and management processes that accrue slowly and steadily. For managers, the first step to do is to foster a work environment conducive to learning. In four to five sentences, write your comment on Peter Senge’s learning organizations as places “where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together.” SAQ 3-1 1. Have you applied any of the above theories or models in your work setting? Discuss. 2. What theory or model are you interested in applying in the future? Justify. 9|Page LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Module 4 Models of Nursing Administration Objectives After working on this module, you should be able to: 1. Describe the nature and functions of nursing service organizations; 2. Discuss the key concepts of general systems theory; 3. Discuss an open system model applied to nursing management and administration; and 4. Compare and contrast nursing administration models based on: a. Orem’s Self-care Deficit Theory of Nursing b. Iowa Model of Nursing Administration c. WHO International Model of Nursing Administration In this module, we will discuss various models of nursing administration. Nurse managers can use lessons learned from the merger of several disciplines-human relations, labor relations, human resource management-into a unifying force for effective management. A successful synthesis of these various disciplines would inspire individual commitment to the organization each nurse belongs to; promote increased productivity; facilitate sound labor-management relations; and manage competitiveness in health care. Nursing Administration and the Operational Functions of the Organization The nursing perspective must be clearly articulated and must contribute to the overall running of the health care organization, particularly in: 1. Providing leadership in the development of the organization’s mission and vision 2. Informing the governing body about nursing’s contribution to the enterprise 3. Determining the needs for nursing based on the characteristics of the population being served 4. Designing and planning for nursing operations, including the structuring and development of the practice of nursing within the organization in order to: a. Adopt the appropriate nursing care modality b. Specify the appropriate complement of resources, including equipment and supplies, facilities and personnel needed to operate the nursing system c. Manage the above resources to ensure the adequate availability of nursing services to all users d. Implement a program for the growth and development of the nursing staff e. Participate in research related to the development of patient care technologies Allison, McLaughlin and Walker (1991) wrote that a theory-based nursing system will reveal the following: 1. Mission, philosophy and objectives statements 2. Documentation tools or forms, the data from which to provide a nursing database 3. Standards of care and practice 4. Staff education 5. Quality assurance audits 6. Patient classification systems 7. Job descriptions 8. Policies and procedures Page 1|9 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT 9. Career development programs that attract and retain the best practitioners as they motivate by clarifying the role of the nurse 10. The support given by nursing administration’s commitment Key Concepts of General Systems Theory Nurse managers and administrators work within demanding and complex bureaucratic organizations with both a health care mission as well as business objectives to meet. Their performance depends a lot on their personal savvy and their being able to view organizations as open systems. Viewing organizations as open systems provide nurse managers and administrators with a valuable perspective, one that allows them to step back and look at the whole organization beyond their department, position, or situation. The brief discussion that follows should hopefully help you appreciate how nursing administration and management is operationalized in the larger context of a health services delivery system. The major concepts of general systems theory applied to organizations which nurse managers and administrators need to be aware of are summarized in the figure below. General systems theory is an organismic approach to the study of the general relationships of the empirical universe of an organization and human experiences. Nursing management is based on the body of know- ledge generated by practical experiences and eclectic scientific research concerning organizations. Indeed, the body of knowledge developed through theory and research is translatable into more effective organizational designs and managerial practices that the nurse manager and administrator can use. It is important to recognize that many managers, including nurses, have used and will continue to use a systems approach and contingency views intuitively and implicitly. Without much knowledge of the underlying body of organization theory, nurse managers and administrators have an “intuitive sense of the situation,” are flexible diagnosticians, and adjust their actions and decisions accordingly (Ward and Price, 1991). The general systems theory is a “midrange” concept that recognizes the complexity involved in managing health care and nursing organizations and uses patterns of relationships and configurations of subsystems in order to facilitate improved practice. As many authorities would say, “the art of management depends on a reasonable success rate for actions in a probabilistic environment.” Page 2|9 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Box 4-1 Key concepts in general systems theory Open Systems. Permeable boundaries exist between the system and its environment. Holism/Synergism/Organicism/Gestalt. The whole is greater than the sum of its parts. The four major analytical components of the transformation process are: participants, formal sociotechnical structure and processes, mission and technology or work, and information structure and processes. Components/subunits/subsystems are interconnected and Interdependent. Input-transformation/throughout-output process is goal-oriented. Feedback, inputs, and feedforward provide information for self-regulation/dynamic equilibrium/cybernetic system. Systems are resource dependent on their environment. Change/adaptation/homeostasis/steady state processes are dynamic and ongoing. There is equifinality of varying strategies to reach the same goals. Over time, systems of division of labor/internal elaboration are organized and become increasingly complex. Open systems model Open systems models derive from the concepts of general systems theory: both share a holistic view of internal processes and the same basic analytical elements. As we can see from Figure 4-1, the basic elements include: (1) inputs from the environment that cross the organizational boundaries; (2) a transformation process that changes and opens the inputs and transfers them to the environment as (3) outputs and (4) feedback, which is information on outputs and organization received through multiple channels. Desired inputs, transformation processes, and outputs are defined by the organization’s mission and stated as goals. The importance of the structure of work and people and the formal and informal interaction processes among work and people as the critical elements for understanding what happens within organizations, are emphasized in the general systems theory. The general “open” systems theory emphasizes the dependence of the organization on its environment and the necessity of immediate adaptation for survival. The interpretation of feedback leads to internal adjustments in the transformation process to adapt the outputs. Page 3|9 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Tichy and Beckhard (1982) developed an open systems model (Figure 4.2) to assist health care administrators to: 1. Establish core missions to guide strategic decisions 2. Understand and map environmental pressures 3. Develop more sophisticated planning processes 4. Set operational objectives at each level of the organization 5. Design functional structures 6. Manage consensual decision-making 7. Manage multiple tasks 8. Cope with internal conflict 9. Motivate and manage professionals 10. Manage change The open system model of Tichy and Beckhard uses the general systems theory concepts of inputs, transformation within organizational boundaries, outputs, and feedback. The model assists nurse managers and administrators by directing them to include critical factors when assessing critical problems. It is also useful because it helps recall how interconnected the key elements are with one another, and that decision and/or action directed at one element always affects all others. Other authors cited by Dienemann say that open systems models promote understanding of organizations. They simplify reality, allowing nurse managers and administrators to “focus on the mission as a whole, to recognize the interrelatedness of internal components, to value feedback, to devise strategies to proactively shape the environment, to seek multiple channels of information, and to plan systemic (organizational or departmental) change.” Health care organizations are increasingly employing organizational development (OD) consultants to help organizations develop and evaluate managerial changes and change employee behavior to accept and support innovation and marketing of health services. Work design must also include the interests and skills of providers and the demands and expectations of consumers receiving the health services. Open systems models and consultations with OD professionals can help to increase the responsiveness and adaptability of health care organizations. To summarize, the concepts of general systems theory that apply to all open systems models include: a holistic view, interdependence of internal elements or components, constancy of change, multiple ways to accomplish the same output or equifinality, periodic restructuring and increasing complexity as organizations grow. Page 4|9 LUNA GOCO COLLEGES, INC. DEPARTMENT OF NURSING NURSING LEADERSHIP AND MANAGEMENT Models of Nursing Administration There are three viewpoints or models of nursing administration presented here. The first model is based on Orem’s Self-Care Deficit Theory; the second is the Iowa Model; and the third is the International Nursing Service Administration Model. It makes sense to have a model considering the essential nature of nursing services for the health of all, and the related responsibilities and many resources affecting nurses. These three models are contemporary, generic, functional, and easy to understand for nurse managers and administrators. Model based on Orem’s self-care deficit theory Nursing administration as defined by Orem (1995) is “the body of persons who function in situational contexts to collectively manage courses of affairs enabling the provision of nursing for the population currently being served by an organized health service institution or agency for the populations to be served at future times.” In a caseload, we have individual nurse practitioners of nursing primarily concerned with providing nursing care to individuals or groups of individuals; whereas in nursing administration the concern is with designing, planning, and producing a nursing workforce for populations and subpopulations of persons requiring nursing. The Individual nurse’s object of concern is persons who seek and can benefit from nursing care because of the presence of existent or predicted health-derived or health-related self-care or dependent care deficits. Orem also says that the proper object of nursing administration is the “definable but changing population of persons for whom a legally constituted enterprise ensures the continuing availability and ac