POINTERS TO REVIEW _LEADERSHIP AND MANAGEMNENT

DEFINITION OF TERMS / CONCEPT

• Record _It is a permanent written communication that documents information relevant to a

client’s health care management.
▪ _It is a clinical, scientific, administrative and legal document relating to the
nursing care given to the individual family and community.
▪ are “information created, received, and maintained as evidence and information
by an organization or person, in pursuance of legal obligations or in the
transaction of business.”
• Record Management _It is a systematic and effective control of records (both paper and
electronic). It aims to ensure that records are accurate and reliable, can be retrieved speedily and
efficiently, and efficiently, and are kept for no longer than necessary. It is
crucial to all organizations.
• Information _ is “data, ideas, thoughts, or memories irrespective of medium.”
• Archives _are those records that have been selected for permanent preservation because of their
administrative, informational, legal and historical value as evidence of official business
• Documents _are any “recorded information or objects that can be treated as individual units
about Record Management
a. Systematic and effective control of records
b. It aims to ensure that records are accurate and reliable
c. Administration of digital or paper records

IMPORTANCE OF RECORD MANAGEMENT

• To provide evidence of actions and decisions

• To support accountability and transparency
• To comply with legal and regulatory obligations, including employment, contract
• and financial law as well as the data protection act and freedom of information act
• To protect the interests of staff, students and other stakeholders
• Help to address complaints or legal processes.
• To support patient choice and control over treatment and services
• To support day to day business of the health care delivery
• To support evidenced based practice
• To assist clinical and other types of audits
• To support sound administrative and managerial decision making.
• To support improvement in clinical effectiveness through research
 BENEFITS OF RECORD MANAGEMENT

• Saves time by ensuring that records can be found easily and quickly
• Save space by preventing records from being kept longer than necessary
• Saves money by reducing storage costs and maintenance costs
• Improves efficiently by ensuring records are readily accessible legally
• Improves compliance by keeping records in line with legal and regularly requirements
• Keeps records under control by preserving data and preventing accumulation control of referral
material
• Improves the quality of information, providing staff with access to accurate and reliable quality
records security
• Increases the security of confidential records continuity
• Support business continuity and risk management
• Records are managed efficiently and can be easily assessed and used
• Records are stored as cost effectively as possible and when no longer required they are disposed
of in a timely and efficient manner.
• Complies with requirements concerning records and records management practices to ensure
compliance with institution
• Records of longer-term value are identified and protected for historical and other research

CLASSIFICATION OF RECORDS

1. ACTIVE RECORD _ A record that is regularly referenced or required for current use

2. INACTIVE RECORD_ a record that is still needed by an organization but not for current

operations

3. ELECTRONIC RECORD _A record recorded or formatted only a computer can process.

4. SAMPLE OF RECORDS Administrative records of Grants/Contracts

• Bid documents

• Blueprint of facilities

• Consent forms-adult-minor

• Endowment Fund Records

 Records in the Nursing Office and Unit

Administrative records: organogram, job description, procedure manual

Personnel records: personal files, records

Patient records send to medical center chief/medical director

Leave record, duty roster, minutes of the meeting, budget etc.

Miscellaneous: circular log book, formats, etc.

Principles of Record Writing

• Nurses should develop their own method of expression and form in record writing

• Records should be written with clearly and appropriately

• Records should contain facts based on observation conversation and action

• Select relevant facts and the recording should be neat, complete and uniform

• Records should be written immediately after an interview

• Records are confidential documents.

SAFEKEEPING AND RELEASE OF RECORDS

1. Sentinel events

2. Anecdotal

3. Incident report

4. Kardex

5. Patients chart/records / 201 files

Nurses responsibility for record keeping and recording

• Keep under safe custody of nurse

• No individual sheet should be separated

• Not accessible to patient and visitors

 • Strangers is not permitted to read records

• Records are not handed over to the legal advisors without written permission of the

administration

• Handed carefully, not destroyed

• Identified with bio-data of the patients such as name, age, admission number,

diagnosis, etc.

• Never sent outside the hospital without the written administrative permission

Nursing Administrator’s Responsibility

• Safeguarding its concerns

• Protection from loss

• Completeness

• Responsibility for nurse notes

• Admission record

• Scientific value of the nurse notes

• Record of order carried out

Individual Staff Record _ A separate set of record is needed for staff, giving details of their

sickness and absences.

Characteristic of a Good Record and Reporting

Accuracy

Consciousness

Thoroughness

Up to date

Organization
Confidentiality

Objectivity

Purposes of Record

• Supply data that are essential for program planning and evaluation

• Provide the practitioner with data required for the application of professional services for the

improvement of family health

• Used as tools of communication between health workers the family and other development

personnel

• Shows the health problem in the family and other factors that affect health

• Indicates plan for future

• Provides baseline data to estimate the long term changes related to services

COLLABORATION

defined as a joint communication and decision-making process with the goal of satisfying the

health care needs of a target population. NNCCS, (2012).

Current educational and clinical environments can be less than supportive of interpersonal

learning interaction. Urges the nurse educator community to work with peers in other profession

to provide students with learning opportunities that acknowledge a profoundly changed health

care environment.

The roots of the word collaboration, namely co-, and elaborate, combine in Latin to mean “work

to together.”

An effective collaboration is characterized by building and sustaining “win win-win” relationship.

EFFECTS OF COLLABORATION

improved patient outcomes

 Reduced length of stay

 Cost savings

 Increased nursing job

satisfaction and retention

 Improved teamwork

TYPE OF COLLABORATION

1. Interdisciplinary
Is the term used to indicate the combining of two or more disciplined,

professions, department, integrated for one plan formulation usually inregard to practice,

research education, and/or theory.

2. Multidisciplinary
Refers to independent work and decision making, such as when

disciplines work side-by-side on a problem.

3. Tran disciplinary
Efforts involve multiple disciplines sharing together their knowledge and

skills across traditional disciplinary boundaries in accomplishing tasks or goals.

4. Inter professional collaboration

Interactions of two or more disciplines involving professionals who work

together, with intention, mutual respect, and commitments for the sake of a more adequate

response to ahuman problem.

STAFFING

- process of determining and providing the acceptable number and mix of nursing personnel to produce a

desired level of care to meet patient’s demand.

PATIENT CARE CLASSIFICATION SYSTEM

Is primary developed to determine workloads requirements and staffing needs. It is categorizing patients

on the basis of certain needs that can be clinically observe by the nurse.

ORGANIZING

is the process of establishing formal authority. It involves setting up the organizational structure through

identification of groupings, roles and relationships, determining staffing patterns and distributing in the

various area as needed.

ELEMENTS OF ORGANIZING

The elements of organizing include setting up the organizational structure, staffing, scheduling, and

developing job descriptions.

TYPES OF ORGANIZATION CLASSIFIED BY NATURE OF AUTHORITY

1. Line Organization

 the simplest and most direct type of organization in which position has general authority over

the lower positions in the hierarchy.

Informal Organization (Flat/ Horizontal)

 refers to horizontal relationships rather than vertical. This is composed of small groups of

workers with similar interest.

 Staff Organization

 is purely advisory to the structure with no authority to put recommendations into action.

ORGANIZATION
 consists of the structure and process which allow the agency to enact its philosophy and utilize its
conceptual framework to achieve its goals. It refers to a body or persons, methods, policies and
procedures arranged in a systematic process through the delegation of function and responsibilities.

Functional Organization
 is one where unit is responsible for a given part of the organization with workload.

ORGANIZATIONAL CHART
is a line drawing that shows how the parts of an organization are linked. It
depicts the formal organizational relationships,
areas of responsibility, persons to whom one is accountable and channels of communications.

Nursing care hours per patient per day according to classification of patients

CASES/PATIENTS NCH/PATIENT/DAY PROF.TO NON PROF. RATIO

1. General Medicine 3.5 60:40

2. Medical 3.4 60:40

3. Surgical 3.4 60:40

4. Obstetrics 3.0 60:40

5. Pediatrics 4.6 70:30

6. Pathologic Nursery 2.8 55:45

7. ER/ICU/RR 6.0 70:30

RESEARCH

helps nurses determine effective best practices and improve patient care.

 Helps nursing respond to changes and challenges in the healthcare environment, individual, family,

patient and group populations and government regulations.

NURSING RESEARCH

systematic inquiry designed to develop knowledge about issues of importance to nurses,

including nursing practice, nursing education, and nursing administration.

NURSING LEADERSHIP and MANAGEMENT

NURSING MNGT
_a guide for nurses who wants to learn the concepts behind, used to organizing, staffing,
scheduling directing and controlling, it also deals with the application of the concepts,
principles, theories and methods of developing nursing leaders and managers in the hospital or
any settings.
_Management is an old French term its means “the directing”.
THREE-FOLD CONCEPT TO EMPHASIZE THE BROADER SCOPE OF MANAGEMENT
1. Economic source
2. System of authority
3. Class and status system
THEORIES OF MANAGEMENT
 Frederick W. Taylor, the “father of scientific management’. Four Principles of Scientific
Management:
• Frank and Lilian Gilbreth – “The First Lady of Management”
• Henry Gantt – Disciple of Frederick Taylor
• Classical Organization Theories
• Henry Fayol (1925) identified management functions of planning, organization,
command, coordination, and control
• Fayol’s 14 principle of management
• Luther Gulick (1937) expanded on Fayol’s’
management functions he mentioned that they are “seven activities in management”
staffing, directing. Coordinating. Reporting, and budgeting-POSDCORB. Often times
Managers considered this as the process of management. He also believes that
management should be taught in school.

ROLE OF MANAGER
INTERPERSONAL
INFORMATIONAL
DECISIONAL

MANAGEMENT PROCESS
Planning
Organizing
Staffing
Directing
Controlling
MAX WEBBER
• is the “Father of Organizational Management”
TYPES OF MANAGERS IN MANAGERIAL GRID
• Impoverish Manager - Low Production and Low People
 • Middle-Of-The-Road Leadership - Medium Production and Medium People
• Produce or Perish Leadership- High Production and Low People
• Country Club Style Leadership - High People and Low Production
• Team Manager - High Production and High People

CONTEMPORARY MANAGEMENT
Levels of Management
• Top Level Manager – look at the overall operation of the organization.
• Middle Level Manager – coordinates activities of different department
• First Level Manager – directly responsible for the actual production of services
SKILLS OF A MANAGER
Technical
Human
Conceptual
Management
is a process by which a cooperative group directs actions towards common goals, it
involves technique by which a distinguished group of people coordinates the services of people.
It also includes moral and ethical standards in the selection of right ends toward which managers
should strive. (Venson)
-It is a universal process
-use in business, practice of one’s profession
and even day to day personal affairs
-The process of coordinating and supervising
personnel and resources to accomplish organizational goals

LEADERSHIP
is the act of influencing group to follow a certain course of action.
• A process of influence in which the leader influences others toward goal
achievement.
• Is about creating change. It involves establishing a direction, aligning people
through empowerment , motivating and inspiring them toward producing useful change and
achieving the mission.
NURSING LEADERSHIP
process whereby nurse influences one or more persons to achieve a specific goal in the
provision of quality nursing care.
COMPARISON BETWEEN LEADER AND MANAGER
MANAGER
Are assigned a position by the organization.
Have a legitimate source of power due to delegated authority that accompanies their position
Have a specific duties and responsibilities they are expected to carry out.
Manipulate people, the environment, money, time, and other resources to achieve the goals
of the
organization.
Have a greater format responsibility and accountability for rationality and control than
leaders.
Direct willing and unwilling subordinates.
LEADER
Often do not have delegated authority but obtain power through other means, such as
influence.
Have a wider variety of roles than managers.
Focus on group process, information gathering, feedback, and empowering others.
May or may not be part of the formal hierarchy of the organization.
Emphasize interpersonal relationship
Direct willing followers, MOTIVATES
Have goals that may or may not reflect those of the organization.
Great Man theory: (1900-1940)
Trait Theory
Charismatic Theory
Situational Theory
Contingency Theory
Path goal Theory
Situational Leadership Theory (Paul Hersey & Kenneth Blanchard)
LEADERSHIP STYLES BY HERSEY & BLANCHARD
DIRECTING STYLE
COACHING STYLE
SUPPORTING STYLE
DELEGATING STYLE
LEADERSHIP STYLES
1. AUTHORITARIAN
2. DEMOCRATIC
3. LAISSEZ- FAIR

CONTEMPORARY LEADERSHIP
TRANSFORMATIONAL THEORY
POWER
Patient care delivery system
Process of organizing patient care:
The head nurse or the nurse in charge should carry out their duties and responsibilities
1. PLANNING
2. ASSIGNING
3. LEADING
4. EVALUATING
5. REPORTING
Nursing care delivery models
Is the method used to provide care to patients
Nurse Manager’s role
Must be sensitive to the quality of patient care delivered and the institution’s budgetary
constraints.
• Achieving patient outcomes.
• By using effective management and leadership skills, can improve the staff’s perception of
their lack of independence.
Direct care nurse’s role
Nurses are educated to care for the patient holistically, and providing only a fragment of
care to the patient.
• Do the tasks that are usually assigned by the charge nurse.
Team Nursing
Developed in the 1950s in an effort to decrease the problems associated with the
Functional organization of patient care.
• Developed that reduced the fragmented care that accompanied functional nursing.
Nurse manager’s role
Teaching, and coordinating patient activities.
• Responsible for more than one unit.
• Determine which nurse are competent and interested in becoming a charge nurse or a team
leader
• Provide an adequate staff mix.
• Orient team members to the team nursing system.
• Providing continuing education
MODULAR NURSING
A mini-team (2-3 members approach).
• Members are sometimes called “care pairs”.
• A small team requires less communication, allowing members better use of their time for
direct patient care activities.
Primary nursing
The INTEGRATED MODEL OF CARE
1-Practice partnership
2-CASE MANAGEMENT
3-Critical pathway
4-Differentiated practice

Evidence-Based-Practices-in-Nursing-Management

National Nursing Care Competency Standards (NNCCS)

◦Developed for Nsg Practice in 2001, through the initiative of the Professional Regulation
Commission - Board of Nursing (PRC-BON) which created a National Task Force for Core
Competency Standards Development.
◦The project was completed in 2005 after a series of workshops, consultations and discussions
among representatives of nursing practice, nursing education and Community Health Nursing.
11 Core Competencies Nursing
1. safe and quality nursing care
2. Communication
3. collaboration and teamwork
4. health education
5. legal responsibility
6. ethico-moral responsibility
7. personal and professional development
8. quality improvement
9. research
10. management of resources and environment
11. record management
PATIENT CARE SAFETY STANDARDS
SAFETY
It is one aspects of quality where quality includes not only avoiding, preventable harm, but also
making appropriate care available providing effective services to those who could benefit from
them and not providing ineffective or harmful services.
Aim of Safety in healthcare organization
◦to prevent harm to patients, their families and friends, healthcare professionals, contract of
service workers, volunteers, and the many other individuals whose activities bring them into an
environment.
Standards of Practice
◦ The Standards of Practice describe a competent level of nursing care as demonstrated by the
critical thinking model known as the nursing process.
◦ The nursing process includes the components of assessment, diagnosis, outcomes
identification, planning, implementation, and evaluation.
Accordingly, the nursing process encompasses significant actions taken by registered nurses and
forms the foundation of the nurse’s decision making.

Ethico – Legal and Moral Consideration in Nursing Practice

Philippine Health Agenda
RA 9173-CODE OF ETHICS FOR REGISTERED NURSES (BOARD OF NURSING)
ORGANIZATIONAL COMMUNICATION
Models and Theories of Communication
Transmission Model of Communication
Interaction Model of Communication
Transactional Model of Communication
Peplau’s Theory of Interpersonal Relations
Orientation Phase
Identification phase
Exploitation Phase
Resolution Phase
Barriers to Communication Among Health-Care Providers and Health- Care Recipients
Low Health Literacy
 Cultural Diversity
Cultural Competence
Interprofessional Communication Education of Healthcare Providers
Written Communication within the Organization
Memo Writing
Minutes of the Meeting
Reports in Nursing
Telephone Reports
Transfer Reports