MANAGEMENT IN NURSING

NSC 410

BY

OJO OPEYEMI

ESSENTIAL TOOLS OF NURSING CARE MANAGEMENT

The Nursing Process

The nursing process is a scientific method used by nurses to ensure the quality of patient care.
This approach can be broken down into five separate steps.

Assessment Phase
The first step of the nursing process is assessment. During this phase, the nurse gathers
information about a patient's psychological, physiological, sociological, and spiritual status. This
data can be collected in a variety of ways. Generally, nurses will conduct a patient interview.
Physical examinations, referencing a patient's health history, obtaining a patient's family history,
and general observation can also be used to gather assessment data. Patient interaction is
generally the heaviest during this evaluative phase.

Diagnosing Phase
The diagnosing phase involves a nurse making an educated judgment about a potential or actual
health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These
assessments not only include an actual description of the problem (e.g. sleep deprivation) but
also whether or not a patient is at risk of developing further problems. These diagnoses are also
used to determine a patient's readiness for health improvement and whether or not they may have
developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course
of treatment.

Planning Phase
Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple
diagnoses need to be addressed, the head nurse will prioritize each assessment and devote
attention to severe symptoms and high-risk factors. Each problem is assigned a clear, measurable
goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-
based Nursing Outcome Classification, which is a set of standardized terms and measurements
for tracking patient wellness. The Nursing Interventions Classification may also be used as a
resource for planning.

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Implementing Phase
The implementing phase is where the nurse follows through on the decided plan of action. This
plan is specific to each patient and focuses on achievable outcomes. Actions involved in a
nursing care plan include monitoring the patient for signs of change or improvement, directly
caring for the patient or performing necessary medical tasks, educating and instructing the
patient about further health management, and referring or contacting the patient for follow-up.
Implementation can take place over the course of hours, days, weeks, or even months.

Evaluation Phase

Once all nursing intervention actions have taken place, the nurse completes an evaluation to
determine the goals for patient wellness have been met. The possible patient outcomes are
generally described under three terms: patient's condition improved, patient's condition
stabilized, and patient's condition deteriorated, died, or discharged. In the event the condition of
the patient has shown no improvement, or if the wellness goals were not met, the nursing process
begins again from the first step.

What Is a Nursing Care Plan?

A nursing care plan is the written manifestation of the nursing process, which the American
Nurses Association defines as “the common thread uniting different types of nurses who work in
varied areas. It is the essential core of practice for the registered nurse to deliver holistic, patient-
focused care.”

The nursing process includes five key steps:

1. Assessment: Collecting and analyzing data to gain a holistic understanding of the

patient’s needs and risk factors.
2. Diagnosis: Using data, patient feedback, and clinical judgment to form the nursing
diagnoses.
3. Outcomes/Planning: Setting short-term and long-term goals based on the nurse’s
assessment and diagnosis, ideally with input from the patient. Determining nursing
interventions to meet those goals.
4. Implementation: Implementing nursing care according to the care plan, based on the
patient’s health conditions and the nursing diagnosis. Documenting care the nurse
performs.
5. Evaluation: Monitoring (and documenting) the patient’s status and progress towards
goals, and modifying the care plan as needed.

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Benefits of implementing care plans, include:

• Continuity of care: Nursing care plans ensure that nurses from different shifts or floors
have the same patient data, are aware of the patient’s nursing diagnoses, share their
observations with one another, and collaborate towards the same goals.
• Inter-professional collaboration: Nurses are the heart of the care team, but they’re not
the only members. Physicians, social workers, nursing assistants, physical therapists, and
other care providers also need to understand the patient’s health problems, goals, and
progress. A nursing care plan puts all this information in one place, providing a clear
roadmap to the desired outcomes.
• Patient-centered care: Care plans help to ensure that patients receive evidence-based,
holistic care. Nursing diagnoses are standardized to ensure quality care, but nursing
interventions are tailored to meet the physical, psychological, and social needs of the
individual patient.
• Engaged patients: Setting achievable goals for and with patients helps to guide and
measure nursing care. Goals also help motivate patients to become more involved in their
recovery, because they can understand exactly what they need to do to achieve the
desired outcomes.
• Compliance: The care plan serves as proof of receipt and helps payers determine how
much they should reimburse for care.

REVISION QUESTION

Define nursing process

List and explain 5 phases of Nursing process

List and explain 4 benefits of implementing Nursing care

CONCEPT OF QUALITY ASSESSMENT

Williamson (1962) defines quality assurance as “the measurement of the actual level of the
service provided, plus efforts to modify, when necessary, the provision of these services in the
light of the results of the measurement.”
Smith and Hibberd (1998) also describe quality assurance as the systematic process wherein
there is a data-based, judgmental appraisal of a selected element of care and subsequent
improvement. These definitions show that there is a commitment to respond positively to results
obtained from an assessment of services provided. However, assessment of services without
effort to improve it is not quality assurance activity. So in quality assurance actual practice is

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assessed against a given standards, deficiencies identified and action are then taken to remedy
and prevent them from recurring in the future.

Aims and Objectives of Quality Assessment Programme in Nursing

1. To assess the quality of performance in provision of nursing care and management of other
services within patients environment.
2. To provide nursing personnel with information on their level of performance in relation to set
standards in the organisation.
3. To serve as a tool to increase awareness on medico-legal implications of nursing practice.
4. To identify specific needs for additional in-service-training of personnel and staff
development.
5. To provide statistical data concerning the management process of organised nursing services
and utilisation of resources (human and material).

Elements of Quality Assessment

Quality assurance ensures that health care provided to patient is consistently of good quality.
However, the quality of care the patient receives in any situation is determined by certain
variables.
Four of the principal elements are:
1. The provider i.e. the people who give the care takes cognizance of the education, intelligence
and experience of health profession.
2. The standards that are maintained in the agency providing care.
3. The environment, or setting in which the care is given.
4. The recipient of care, i.e. the patient.

Components of Quality Assessment

Modern approaches to quality assurance are depicted as a triangle, quality design, quality
control, and quality improvement.

The three are essential, interrelated, and mutually reinforcing components of quality assurance.
1. Quality Design: This is a planning process within which goals are set, resources allocated and
standards of service delivery set.
2. Quality Control: This consists of monitoring, supervision and evaluation of care to ensure
that standards are met and good quality is consistently maintained. It ensures that a programme
of activities take place as designed, more importantly it may uncover, flaws in design and thus
point to changes that could improve quality.

For effective good quality control, the following must be present:

(i) Measurable indicators of quality
(ii) Timely data collection and analysis
(iii) Effective supervision.

3. Quality Improvement: This is directed at increasing quality and raising standards by

continually solving problems and improving processes.

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Types of Information Required for Quality Assessment
Structure
The attributes of settings in which care occurs (physical and organisational tools and resources).
The structure includes:
• material resources (e.g., facilities, equipment, money);
• human resources (e.g., number and qualifications of personnel); and organisational
structure (e.g., medical staff organisation, peer-review methods).

Process
What is actually done in giving and receiving care (the activities that occur between client and
provider). The process includes: patient’s activities in seeking care and carrying it out; and
practitioner’s activities in making a diagnosis, and recommending or implementing treatment.
Outcome
The effects of care of the health status of patients and populations (the changes in status
attributable to antecedent health care). Outcomes include:
• improvements in a client’s knowledge;
• changes in a client’s behavior; and
• degree of client satisfaction with care.

Steps to Quality Assessment Review

A variety of techniques have been proposed to perform the quality assurance review. Presented
here is the problem-solving model used by the American Nurses Association (ANA). Its eight
steps include the following:
1. Identify values
2. Identify standards and criteria
3. Measure degree of attainment of standards and criteria
4. Interpret strengths and weaknesses
5. Identify possible courses of action
6. Select a course of action
7. Take action
8. Re-evaluate.

Steps in Quality Assurance Review

Step 1: Identify Values

Before the implementation of the quality assurance model, there must be an examination of the
societal, professional, and individual values that guide the health care in the respective agency.
The very word quality implies that someone somewhere has determined that certain outcomes
have more value than others. As applied to nursing care, the individual nurse, nursing unit,

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hospital, and community will interact to influence the development of criteria to be used in the
review process.

Step 2: Identify Standards and Criteria

A standard is the desirable or achievable level or range of performance of a certain criterion, or a
framework against which performance is compared. An example of standard is “Every patient
will have an admission assessment by registered nurse ” A criterion measure is that variable
believed to be the indicator of the quality of care, for example, “The assessment form will b e
completed by the admitting nurse within 8 hours of admission.” The standards for nursing
practice are generally develop ed by clinical nursing leaders in the institution, using their
professional expertise as well as professional research and literature. The standards are made
operational by construction of the criterion elements. These criteria, which are the actual
evaluation criteria, are generally develop ed by a quality assurance committee, the nursing
practice committee, or some similar group. The actual criteria that are developed can be three
types: structure, process, and outcome.

Structure criteria describe the environmental elements, setting, and conditions within which the
nurse-patient relationship occurs. It includes the philosophy and objectives of the institution; its
fiscal resources, equipment, physical facilities, management structure, accreditation, and
licensure; and the quality and characteristics of the professional and technical employees.
Examples of structure criteria include, “Hospital beds must be 3 feet apart.” “All patients must
sign the required consent form before any invasive or surgical procedure.” “The current license
number of each registered nurse must be on file in the main nursing office.”

Process criteria describe the nature and sequence of nursing care activities. For example,
process criteria might describe the nursing plan for a patient who demands pain medication every
1½ hours, or a teaching plan for a diabetic patient.
Outcome criteria focus on the results of the processes of health care. Many experts consider
them to be the ultimate indicators of the quality of patient care. For the patient, the outcome
should be measurable in terms of change in health, knowledge, or functional status. After the
criteria have been written, they must be validated, generally b y “consensus among peers.” The
rationale for this validation step is to ensure that all criteria are correct and relevant and reflect
nursing practice at the particular institution. Usually, nurses most expert in the selected clinical
areas are chosen to do the review.
The final step in the criteria writing process is the establishment, by the quality assurance
committee and the “nurse experts,” of a specific and observable level of performance for each
criterion measure. For example, for the come criterion “Patient or significant other is able to
demonstrate proper technique in insulin administration,” at least 90 percent compliant might be
expected.

Step 3: Measure Degree of Attainment of Standards and Criteria

Multiple methods are available to collect data to assess the attainment of the standards and
criteria. The degree to which the actual practice exceeds, meets, or falls below the validated
criteria provide the data necessary to evaluate the strengths and weaknesses of the nursing care
programme. Data collection methods might include questionnaires, staff interviews, patient

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interviews, self-assessment questionnaires, performance evaluation, utilisation review, audits,
patient or staff complaints, and direct observation. Whatever the method selected, the data should
be easily accessible, and questions of efficiency and accuracy should be considered. Data
collected are tabulated, and the results indicate whether the percentage of yes/no responses
corresponds to the previously established level of performance (per cent compliance) for each
criterion. If the level of performance does not achieve expectations, the criterion element has not
been met.
Step 4: Interpret Strengths and Weaknesses: The degree to which the levels of performance
have been met serves as the basis for describing the strengths and weaknesses of the nursing care
programme. However, it is essential that certain subtle factors not be overlooked before final
judgments are made. Consider the following: One of the outcome criteria for a patient with a
pacemaker is, “The patient or significant other is able to take a pulse. ” A retrospective nursing
audit was done on patients with pacemakers to determine whether the outcome was being met.
On nursing Unit A, 95 per cent of the patients could take their pulse, whereas on nursing Unit C,
only 65 per cent of the patient data revealed that, in general, patients on Unit C were older, had
fewer significant others, and were frequently discharged to extended care facilities. Comparing
the two units on these factors provided insights into reasons for their differences that ma y have
been missed if the evaluator had not questioned these differences.
Step 5: Identify Possible Courses of Action
After identifying the strengths and weaknesses, possible courses of action to correct the
weaknesses are developed. The goal of the action plan is elimination of the weaknesses and
reinforcement of the strengths of the existing programme. Some consideration should be given to
how best to motivate the nursing staff to implement the desired changes. Generally the best
results will be obtained when those staff most affected by the quality assurance review is
involved in the planning of subsequent courses of action.

Step 6: Select a Course of Action After examination of the alternatives, the peer group selects
the course of action, based on such considerations as the identified problem, available resources,
and organisational structure. How the decision is implemented will vary among institutions. For
example, if it involves a nursing practice change, it may have to be reviewed by the director of
nursing.
Step 7: Take Action Improving the quality of nursing care implies change, and sooner or later
some action must be taken. Implementation of the selected action generally includes time frames,
persons responsible for overseeing each step of the plan, and selection of a date of reevaluation.
This action step is critical to the success of the quality assuran ce review.
Step 8: Re-evaluate After the action has been taken, the cycle begins again. If a change has been
made, it must be reassessed to determine its effectiveness in improving the quality of care.

REVISION QUESTIONS
What is quality assessment?
Mention any 4 aims and objectives of quality assessment programme in nursing
List the 8 steps in quality assurance review
Give reasons quality assessment is crucial in nursing.

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 Methods of Nursing Assessment
In addition to the problem-focused quality assurance reviews, a variety of methods have been
devised for ongoing assessment of the nursing. Some of the more frequently used methods are
described here.

Incident Reports
Whenever an untoward event occurs involving a patient, nurse, or visitor, an incident report must
be completed. Generally these are compiled by the hospital and/or the hospital insurance carrier.
Increases in certain types of incidents, such as medication errors or patient falls, would be a
signal to the quality assurance committee that a review of either of these two areas may be
indicated.

Nursing Audit
The nursing audit is a method of evaluating the quality of client care. The purpose of the nursing
audit is to examine nursing care that has been given to clients and to verify that acceptable
standards are being met. The audit is conducted during or after care has been provided and is a
method of accounting for outcomes achieved. Audits are usually based on the assumption that
when expected client outcomes are achieved, nursing process criteria are also met. The nursing
audit team compares predetermined criteria with the documentation found in the patient record.

Audit: could be defined as the systematic review and evaluation of records and other data to
determine the quality of the services or products provided in a given situation.

Nursing Audit

Nursing audit is defined as the evaluation of nursing care in retrospect through analysis of
nursing records. It is a systemic format and written appraisal by nurses of the quality of content
and the process of nursing service from the nursing records of the discharged patient.

Other definitions

A review of the patient record designed to identify, examine, or verify the performance of certain
specified aspects of nursing care by using established criteria. Often a nursing audit and a
medical audit are performed collaboratively, resulting in a joint audit

(Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier)

“Nursing audit refers to assessment of the quality of clinical nursing” Elison

“Nursing audit is an exercise to find out whether good nursing practices are followed” Goster
Walfer

The audit is a means by which nurses can define standards from their point of view and describe
the actual practice of nursing.

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BRIEF HISTORY OF NURSING AUDIT

Before 1915- very little was known about the concept.

1918- industrial concern introduced for the beginning of medical audit.

George Groword- introduced the term physician for the first time medical audit.

Ten years later Thomas R Pondon MD established a method of medical audit based on
procedures used by financial account. He evaluated the medical care by reviewing the medical
records.

1955- First report of nursing audit of the hospital published

Next 15 years, nursing audit is reported from study or record.

The program is reviewed for record nursing plan, nurses’ notes, patient condition, nursing care.

PURPOSES OF NURSING AUDIT

1. Evaluation: Evaluating the nursing care given. Achieve deserved and feasible quality
of nursing care.
2. Verification: Stimulant to better records. Focuses on care provided and not on care
provider.
3. Contributes to research. Review of professional work or in other words the quality
of nursing care i.e. we try to see how far the nurses have confirmed to the norms and
standards of nursing practice while taking care of patients.
4. It encourages followers to be actively involved in the quality control process and
better records.
5. It clearly communicates standards of care to subordinates.
6. Facilitates more efficient use of health resources.
7. Helps in designing response orientation and in-service education programme.

Method/types of Nursing Audit

There are two types of audits: retrospective and concurrent.

• Retrospective View: This refers to an in-depth assessment of quality after the patient has
been discharged, and uses the patient’s chart as the source of data.
• Concurrent Review: This refers to the evaluations conducted on behalf of patients who
are still undergoing care. It includes assessment of the patient at bedside in relation to
pre-determined criteria, interviewing the staff responsible for his care and reviewing the
patient record and care plan.

The Concurrent Audit

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This has also been called the open chart audit, because it occurs while a client is receiving care in
a health care facility. A concurrent audit is a critical examination of the patient’s progress toward
a desired health status (outcome) and patient care management activities (processes) while the
care is in progress. The purpose of the concurrent audit is to assess the past and present care
given to a client. This type of audit can provide information to care givers that may alter a
particular client’s care plan. Patient questionnaires, interviews, and observation and review of the
patient record are possible sources of data for a concurrent review. Concurrent review has the
advantage of providing opportunities for making changes in the ongoing care programme.

Retrospective Audits
A retrospective audit is a critical examination of nursing actions, with a view toward
improvement in practice. A retrospective review is done after the patient has been discharged.
The reviewer has the advantage of using data from the patient’s entire stay, from admission to
discharge, and of evaluating the results for a large series of comparable patients. The
retrospective is also called a closed chart audit. It occurs after client care has been completed,
that is, after discharge or termination of the relationship with the health care facility.
Retrospective audits are less costly than concurrent audits and usually requires less time to
complete because records are used as the data base. Usually, its purpose is to assess how well the
group provided care to a particular type of client.
One advantage of retrospective audit is that practitioners gain impressions from single cases in
which they are personally involved. The care of clients whose charts are audited is not influenced
by the outcome of a retrospective audit. However, other clients may be helped, since group
members can improve the quality of care given based on the results of the audit. When a record
is unclear, the retrospective auditor must assume that the criteria have not been met, while the
concurrent auditor can seek more information.

Nursing Audit Team

The Nursing Audit is often conducted by a nurse or a team of nurses not directly involved with
the care of the patient being examined. This is done in order to give objectivity to the process.
The membership strength should not be less than 5 and could be between twelve and fifteen, and
should include a representative of all categories of nurses in the hospital. It is important that in
selecting members, each Nursing Unit is also represented.
A typical audit committee should consist of:
1. Head of Nursing Research Unit or Continuing Education Unit – Chairman.
2. Representatives from all cadres of nurses – members.
3. A representative of the professional Nursing Association – member.
4. Representatives of other hospital professionals e.g. Medical Record Officers/Librarian –
Consultants.
5. Director of Nursing Services

This is important because as experienced professional nurses in a particular specialty they are in
a better position to write the outcome criteria to evaluate performance in their specialty area. The
team must have a proven integrity bordering on honesty, dedication and truth. They should be
objective in their thinking, skilful, knowledgeable, and experienced and exhibit competencies in
nursing practice.

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Nursing audit must be mounted regularly by nursing. This programme are planned to maintain
quality nursing care while also controlling the cost to the patient. These concepts can be equated
with industry’s “efficiency” and effectiveness‟.
Note - A nursing department is efficient if it observes cost containment, and wise use of
resources, it is effective if it can at the same time deliver quality patient care, which is its
reason for existence.

ESSENTIAL CHARACTERISTICS OF NURSING AUDIT

There should be:

1. Written standards of care against which to evaluate nursing care

2. Evidence that actual practice was measured against such standards, sharing a percent
conformance rate.
3. Examination & analysis of findings.
4. Evidence of corrective action being taken.
5. Evidence of effectiveness of corrective action.
6. Appropriate reporting of the audit programme.

PROCESS OF NURSING AUDIT

1. Set the key criteria (item): It should be measurable against identified values, set
standard & in terms of desired patient outcome.

Methods to develop criteria are:

• Define patient population.

• Identify a time framework for measuring outcomes of care.
• Identify commonly recurring problems presented by the defined patient
population.
• State patient outcome criteria.
• State acceptable degree of goal achievement.
• Specify the source of information

2. Prepare Audit Protocol keeping in mind Audit Objectives, Target groups, Method of
information gathering (by asking, observing, checking records), Criterion you are
measuring, identify the time framework for measuring outcome of care, identify
commonly recurring nursing problems, State acceptable of goal achievement.
3. Design the type of tool: Quality assurance must be a priority. Those responsible must
implement a program not only a tool. A co-coordinator should develop and evaluate
quality assurance activities. Roles and responsibilities must be delivered. Nurses must be
informed about the process and the results of the program. Data must be reliable.
Adequate orientation of data collection is essential. Quality data should be analyzed and
used by nursing personnel at all levels.

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 4. Plan and implement the tool: What is to be evaluated? Who is going to collect the
information? How many sample in the target group? Time period
5. Recording/Analysis, Concluding: Record the information, Analyze the information,
Make a summary, Compare with set standard, Conclusion.
6. Using results : The results aid to modify nursing care plans & the nursing care process,
including discharge planning, for selected patient outcome, implementing a program for
improving documentation of nursing care through improved charting policies,
methodologies & forms, focusing of nursing rounds & team conferences. Focusing
supervisory attention upon areas of weakness identified, such as one particular nursing
unit or specific employees. Designing responsive orientation & in-service education
programs. Gaining administrative support for making changes in resources, including
personnel.

AUDIT AS A TOOL FOR QUALITY CARE

The audits most frequently used in quality control include outcome process and structure audits.

Outcome Audit

Outcomes are the end results of care; the changes in the patient’s health status and can be
attributed to the delivery of health care services. Outcome audits determine what results if any
occurred as result of specific nursing intervention for the clients.

Examples of outcomes traditionally used to measure quality of hospital care include mortality, its
morbidity, and length to hospital stay.

Process Audit

Process audits are used to measure the process of care or how the care was carried out. Process
audit it task oriented and focuses on whether or not practice standards are being fulfilled. These
audits assume that a relationship exists between the quality of the nurse and quality of care
provided.

Structure Audit

Monitors the structure or setting in which patient care occurs, such as the finances, nursing
service, medical records and environment,. This audit assumes that a relationship exists between
quality care and appropriate structure. These above audits can occur retrospectively, concurrently
and prospectively

PREREQUISITES OF NURSING AUDIT

• Audit Committee: Before carrying out an audit, an audit committee should be formed
which consists of fair and impartial members including senior nurses as members to do
nursing audit. This committee should comprise of minimum five members who are

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 interested in quality assurance, are clinically competent and able to work together in a
group.
• It is recommended that each member should review not more than 10 patients each month
and that the auditor should have the ability to carry out an audit in about 15 minutes.

If there are less than 50 discharges per month, all the records may be audited. If there are large
numbers of records to be audited, an auditor may select 10 per cent of discharges. The impetus
must come from the nursing staff themselves, realizing the benefits to the patients and
themselves. A good system of nursing record keeping

ADVANTAGES OF NURSING AUDIT

1. Can be used as a method of measurement in all areas of nursing.

2. Seven functions are easily understood.
3. Scoring system is fairly simple.
4. Results easily understood.
5. Assesses the work of all those involved in recording care.
6. May be a useful tool as part of a quality assurance programmed in areas where accurate
records of care are kept.
7. Enables the professional group to highlight the deficiencies and how good they are in
giving care.
8. Better planning can be done.
9. Helps in re-allocation of resources.
10. Administrators are also sure that patients are getting quality care

DISADVANTAGES OF NURSING AUDIT

1. Appraises the outcomes of the nursing process, so it is not so useful in areas where the
nursing process has not been implemented.
2. Many of the components overlap making analysis difficult.
3. It time consuming.
4. Requires a team of trained auditors.
5. Only evaluates record keeping.
6. It only serves to improve documentation, not nursing care.\ Medical legal importance.
The professionals feel that they will be used in court of law as any document can be
called for in court of law.
7. Deals with a large amount of information.

ROLES AND FUNCTIONS OF NURSE MANAGER FOR EFFECTIVE QUALITY CARE

ROLES

1. Encourages followers to be actively involved in the quality control process.

2. Clearly communicates standards of care to subordinates.
3. Encourages the setting of high standards to maximize quality instead of setting minimum
safety standards.

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 4. Implement quality control proactively instead reactively.
5. Uses control as a method of determining why goals were not met.
6. Is positively active in communicating quality control finding.
7. Acts as a role model for followers in accepting responsibility and accountability for
nursing actions.

FUNCTIONS

1. In conjunctions with other personnel in the organization establishes clear cut, measurable
standards of care and determines the most appropriate method for measuring if those
standards have been met.
2. Selects and uses process, outcome and structure audits appropriately as quality control
tools.
3. Assesses appropriate sources of information in data gathering for quality control tools.
4. Determines discrepancies between care provided and unit standards and seeks further
information regarding why standards were not met.
5. Uses quality control findings as a measure of employee performance and rewards,
coaches, counsels, or disciplines employees accordingly.
6. Keeps abreast of current government and licensing regulations that affect quality control.

The Role of the Nurse Manager in Rendering Quality Nursing Care

The nurse has a significant role to play in rendering quality nursing care, through the following
functions:
1. Provision of Therapeutic Ward Milieu To facilitate the provision of quality nursing care, the
nurse must ensure a therapeutic ward environment. The physical, social and psychological
environment of the patient must be conducive. Both the hospital and ward environments must be
neat and the nursing staff must demonstrate kindness and understanding in rendering the care
needed by the patient/client.
2. Staffing It is the responsibility of the nurse to ensure that the hospital/ward/unit is adequately
staff with nursing staff of relevant cadre and specialty to render quality nursing service. The
nurse should be able to project into the future in respect of the hospital need for nursing staff,
hence the need to ensure enough hands to provide the quality nursing care.
3. Delegation of Responsibility Since the nurse cannot do all the work, she has to delegate
responsibilities to subordinates considering their knowledge, skill and attitudes. The nurse must
use his/her authority to delegate responsibility in such a way to enlist the full co-operations,
commitment and loyalty of the staff. The nurse takes the blame for a delegated work that is not
satisfactorily executed; hence the need to give appropriate guidelines for carrying out delegated
responsibilities.
4. Leadership Style
In order to enlist optimal performance from subordinates, the nurse needs to adopt different
leadership style depending on the knowledge, skill and attitude of the followership that will
enhance high productivity and provision of quality nursing care. The nurse needs to be dynamic
in relating with subordinators. It is assumed that lazy, dependent, irresponsible, unimaginative

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and short-sighted worker will function well with autocratic leadership style, whereas active,
independent, under a democratic leader.

5. Discipline/Control
Quality nursing care
demands that the nurse should have a good control of staff and the activities in the unit/ward/
hospital. He/she should be able to evaluate both the activities and the staff. Do the nursing
actions meet the objectives? Monitoring the staff to ensure that jobs are performed according to
specification. Thus the nurse needs to be firm, just, knowledgeable and hardworking in order to
ensure a good control of the subordinates.
6. Staff Development Knowledge update is a key to provision of quality nursing care. The nurse
should take advantage of opportunities for continuing education programme through continuing
training, reading of professional journals, financial, political and international literature. The
nurse in- charge arranges or sponsors subordinates for conferences, seminars and courses.
7. Motivation This is a process of ensuring that the best is obtained at all times from every
worker. The need to motivate subordinates for quality nursing care to patients cannot be over
emphasised. Different things motivate different workers. The nurse must be conversant with
different theories of motivation such as satisfaction theory, incentive theory, intrinsic theory,
Hertzberg’s dual-factor theory, McClelland three factor theories, Theory X and Y etc. In
addition, the nurse must be ready to give appropriate reward to ensure high productivity from his
subordinates through recognition of good performance.
8. The use of the nursing process
It is through the use of Nursing Process that nurses can render quality nursing care. It is through
this that nursing assessment can be made to identify patients need, plan and implement
appropriate nursing activities to take care of identified need, and then evaluate the nursing action
implemented to ensure the achievement of good goals earlier formulated. To provide adequate nu
rising care the nurse must ensure full implementation of nursing process in rendering care at his
unit/ward/hospital. She should use her position to cover the constraints that may militate against
the provision of logistic support.

REVISION QUESTIONS
Define is nursing audit?
Mention 4 purposes of nursing audit you know
Mention and explain two types of nursing audit you know
Mention 4 essential characteristics of nursing audit
Mention 5 advantages and 5 disadvantages of nursing audit
Mention 4 roles of nurse manager in ensuring effective quality care
List and explain any 6 roles of a Nurse manager in rendering quality nursing care

BUDGETING

As nurses, the knowledge of budgeting is very important because it is an important tool for
allocating the scarce resources available to the organization and also for controlling expenditure.

15
And more recently, with corporate governance, it is become increasingly popular as a tool to
promote accountability and effectiveness in the management of organizations.

Budgets are prepared before the start of the fiscal year, so unknown factors need to be predicted.
Budget analysts review historical trends as well as make assumptions about upcoming expenses
to try and accurately predict the organization's financial situation for the year ahead.

Definitions of Budgeting
A budget is a statement, usually expressed in financial terms of the desired performance of an
organization in the pursuit of its objectives in the short-term (one year). It is an action plan for
the immediate future representing the operational and tactical end of the corporate planning
chain.

Budgeting could be defined as a written projection of a particular organization or a department’s

financial performance, for the period under consideration

For simplicity purpose

Budgeting could be defined as the process of calculating how much money you will earn or save
during a particular period of time, and planning how you will spend it for a specific period or
time considering the different internal as well as external factors prevailing at that time.

External factors examples are inflation rate, economic downturn, unexpected competition
causing lowered sales or an inability to sustain the level of growth needed.
Internal factors are rent increases, a previously unforeseen need for overtime and financial audit
fees and fines, collective bargaining in unionized organizations can all change salary and benefits
by a significant margin. Inadequate collections and poor accounts receivable practices could also
impact revenue.

Objectives of Budgeting or Profit Planning

The following are the main objectives of budgeting or profit planning:
1. to ensure by means of an overall plan that available resources are utilized to the
maximum advantage.
2. to ensure that sufficient cash to finance the proposed scale of activity will be generated
internally or will be available from additional capital loans and overdraft.
3. to approve major items of capital expenditure specifically and to fix all other limits for
minor items.
4. to fix target for current income and expenditure. (e) to have a detailed basis for
comparing performance throughout the year with estimates.

Types of Budgets
Basically, budgets are of two broad types: Capital and Expense.

The Capital Budget

Capital spending is investment and it may provide the single most important way for an
organisation to increase both sales share of the market. The capital investment has a longer time
horizon; it can make it possible for the company to produce a new product or a better product,

16
serve customers quicker or to reduce prices. Since no company has unlimited funds, of course,
nor can it call an unlimited credit or always sell new equities at the price it would like to get, it
must therefore set or adopt some criteria or priority for new investment that must be undertaken.
In capital budgeting, the criterion for judging among projects is the rate of return on investments
over the long-term.

Expense Budget
Expense budgets allot the money to be expended for various operational activities. Some of these
amounts will be fixed while others will depend on the level of operations planned for i.e. the
amount of production, the sales effort to be expended, the amount of advertising to be done.
Budgets in this category include the cash budget.

Budgeting approaches

Top-Down Approach of Budgeting

In the top-down approach, the top management prepares the budget according to the objective of
the organization and passes it on to the managers for implementations. The suggestion and inputs
may have taken from the managers before it’s preparation, but consideration to their suggestions
for such preparation is solely on management’s desecration.
Top-down budgeting begins with the estimation of costs at a higher level. The entire budget is
divided into first-level tasks, and then below level task and then below level task.

• Management from previous trends and experiences estimates the cost and revenue while
keeping internal as well as external influences in mind, such as an increase/decrease in
salary cost, the economic condition of the country, etc.
• Experience and current market conditions are critical elements for budget preparation.
Management is expected to be in knowledge of the current affairs of the market as well as
the history of the organization.
• Management may take inputs from the managers at the initial preparation. This will help
the management to acknowledge the feelings of the lower staff and expectations at the
organization level.
• Management shall consider margin pressure, macroeconomic factors such as a change
in tax legislation, as well as internal factors such as resource allocation.

Advantages

1. It will have an overall corporate functional approach rather than a divisional approach
since management’s concern will be the overall growth of the organization.
2. It will be in the experienced hands, and management, if required, can take the help of an
outsider.
3. It will be fast and interdepartmental issues shall be ignored.
4. It will be aggressive towards the growth of the organization.

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Disadvantage

1. Managers / Lower management will be d-motivated as they don’t have ownership over
the budget and tends to feel that management has set practically impossible targets.
2. Top management may not have close information about the organization, and that may
impact its budget.
3. Interdepartmental communication will take a hit as they will have no idea how the
management set targets for each of them.
4. Management’s considerable time will go into this and may lose from the path of strategy.
5. It is feared as less accurate as the top-level management cannot have the idea of unit wise
expenditures.

Bottom-up Approach of Budgeting

In the bottom-up approach, the managers shall prepare the department wise/business unit wise
budget according to the information and past experiences and present the same to the
management for their inputs and approval.

The bottom-up approach begins by identifying the different operations and tasks performed by
the organization. Each unit of the organization shall disclose the resources and funds required by
them in their budgets. The finance department then consolidates the funding requirement of the
entire organization, and the HR department shall consolidate the resources needed. The
combined budget shall be put up to the management for the approval.

• Managers from their past experiences and their involvement in the day to day business
shall prepare a budget for the forthcoming period. The management has asked them to set
their targets concerning revenue as well as cost.
• Managers are expected to take into account market conditions and margin pressures and
help them to make it more realistic.
• Managers are expected to go beyond the internal environment and consider the external
influencers as well.
• Managers then put the budget to the management for their review and approval. It shall
have an explanation for every item, and if there is a significant variance from the
previous period budget, that should be highlighted to the management with the
explanation.
• Post their review and query resolution, it shall be finalized and implemented in every
business unit.

Advantages

1. The managers shall be motivated as the ownership of the budget is in their hands.
2. It will be more realistic as managers will have a better knowledge of the operations of the
organization.
3. Managers will be more committed to the organization and targets set by them as they are
the owners of the same.

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 4. Senior management will now only have to concentrate on the overall business strategy
rather than a business unit wise.
5. It can be quite accurate for the individual task, which leads to overall accuracy over the
total budget.

Disadvantage

1. The budget may not be at par with the overall objective of the organization as it has been
prepared by the managers on the business unit level.
2. It may be slow, and disputes between inter-department may arise.
3. Management may lose control over the organization’s forecasting.
4. Managers may set targets that are easy to achieve to reduce pressure from them.

Budgeting Methods/Techniques

Incremental/traditional Budgeting Method

Incremental budgeting is a method where the executives prepare the current year’s budget by
making changes in the past year’s budget. The changes are in the form of addition or reduction of
expenses to last year’s budget. In Incremental budgeting, the starting point for preparing a budget
is the prior period’s budget. The budgeting technique gives no priority to the vital activities of a
business. We simply adjust last year’s budget, considering the inflation factor. This is a quick
and easy method of preparing budgets.

Activity or programme Based Budgeting Method

This type of budget is prepared with the intention to identify the operations which generate cost
to the business and how can be the said cost reduced from the current level.
Activity-based budgeting is a method where the output or the budget targets or activity is
decided first. In other words, here, the management adopts a top-down approach. After defining
and determining the activities, what all cost drivers required to complete that activity, target, or
output is analyzed. And then a budget is prepared after considering all those cost drivers.

It does not take into account last year’s budget or expenses. This method does an in-depth
analysis of all the activities that incur the cost. The outcome of the research determines the
allocation of resources to an activity. This method aligns business activities with business goals.
It helps in increasing the efficiency and profitability of a business.

Performance Budgeting
Performance Budgeting (PB) is a system where the managers are provided with the flexibility to
utilise department or organisation’s resources as required, in return for their commitment to
achieve certain performance results. It is a system of planning, budgeting and evaluation that
emphasizes the relationship between money budgeted and result expected. The primary
disadvantage associated with a PB is the emphasis on quality, not quality of the activity being
monitored.

Zero-Based Budgeting Method

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Zero-based budgeting method is commonly in use by many organizations. In ZBB, the current
year’s budget preparation begins from scratch, without considering the budget of the previous
year. For every financial period, a new budget is prepared to take the base as zero, and resources
allocated to each department is justified according to the expenses of that particular period. The
ranking for allocation of resources is on the basis of the priority of all the activities of the
business. Though this method is time-consuming, it gives accurate results.

Zero Based Budgeting Advantages

1. Accuracy: Against the regular methods of budgeting that involve just making some
arbitrary changes to the previous year’s budget, zero-based budgeting makes every
department relook each and every item of the cash flow and compute their operation
costs. This to some extent helps in cost reduction as it gives a clear picture of costs
against the desired performance.
2. Efficiency: This helps in efficient allocation of resources (department-wise) as it does not
look at the historical numbers but looks at the actual numbers
3. Reduction in redundant activities: It leads to the identification of opportunities and
more cost-effective ways of doing things by removing all the unproductive or redundant
activities.
4. Budget inflation: Since every line item is to be justified, zero-based budget overcomes
the weakness of incremental budgeting of budget inflation.
5. Coordination and Communication: It also improves coordination and communication
within the department and motivates employees by involving them in decision-making.
6. Elimination of obsolete, non-relevant decision packages.
7. Increased or decreased levels of funding for some decision packages and addition of new
packages.
8. ZBB encourages budget participation at the operating level. As a result, managers and
employees become focused.
9. Useful for service department where the output is difficult to identify.
10. Managers and employees learn more about the organization activities and problems.

Zero Based Budgeting Disadvantages

1. Time-Consuming: Zero-based budgeting is a very time-intensive exercise for a company
or a government-funded entities to do every year as against incremental budgeting, which
is a far easier method.
2. High Manpower Requirement: Making an entire budget from the scratch may require
the involvement of a large number of employees. Many departments may not have an
adequate time and human resource for the same.
3. Lack of Expertise: Explaining every line item and every cost is a difficult task and
requires training the managers.
4. It forces the managers to justify everything related to expenditure. Sometimes, certain
departments like R&D may be threatened while production department would benefit.
5. In the first year, cost of training, paper work and implementation of ZBB may go up
because without its proper understanding, it cannot be successfully implemented.
6. Organisation may face some resistance from the employees and their unions.

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 7. Difficult to administer and communicate the budgeting because more managers are
involved in the process. Since ZBB threatens certain position of the managers and
executive they may play games and politics.
REVISION QUESTIONS
Explain what you understand by budgeting.
Why the need for budgeting in an organisation?
Name two types of budgeting approaches you know
Identify the various budgeting techniques you know.
Explain fully the Zero Based Budgeting techniques
State 5 advantages and 5 disadvantages of Zero based budgeting technique.
Explain Incremental budgeting method

Definitions and Meaning of Control

Control is a management function that is vital for the success of all organisations in attaining the
goals of the firm.

McFarland has defined control as “that function of a system which provides direction in
conformance to the plan” and or “the maintenance of variations from system objectives within
available limits” Control is determining what is being accomplished, i.e. performance,
evaluating the performance and if necessary, applying corrective measures so that
performance takes place according to the plan.

According to Henri Fayol, control is seen as follows: “in an undertaking, control consists of
verifying whether everything occurs in conformity with plan adopted, the instructions
issued and principles established. It points out weaknesses and errors in order to rectify them
and prevent their re-occurrence. It operates on everything and on every action”. Control is a
managerial or supervisory function, and it is a sort of follow up which helps to ascertain that
what is desired and planned is achieved, and various corrective measures are taken when
required.

There is a general consensus that planning and control go hand in hand - without planning, there
could not be control. Control cannot take place in a vacuum, for effective control, there should
be targets set, which can only be done through planning.

What Do We Control?
Any activities concerning the following areas could be controlled:
i. Quality
ii. Quantity
iii. Time
iv. Cost
v. Profit

Elements of Effective Control

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For effective control, the following steps are necessary:
(a) Fixing of the target
(b) Measuring the performance
(c) Comparing the performance with set targets
(d) Taking corrective measures where there are deviations

Requirements for Effective Control

For effective control to take place the following requirements must be in place

1. Control Should Focus on the Results or Targets Set in the Plan

2. Control Must Reflect the Nature and Needs of Activity - The mechanism of control
should be directly linked to the activity to be controlled.
3. Control Should Report Deviations Promptly - The management should know the
activity and performance in the organization. This is essential for comparison with fixed
targets which will show deviations if any for corrective measures to be taken in time.
4. Control should be Understandable to Everyone in the organization - Especially to
those whose actions, activities and progress are being controlled
5. Control should be Objective - It should not be based on sentiments and should be
difficult to manipulate.
6. Control should be Clear, Determinable and Flexible
7. Control should reflect the Organizational Pattern - Control in a democratic or open
organization must reflect same, and should not be otherwise.
8. Control should be Economical - The amount spent on control should be justifiable.
9. Control should Lead to Corrective Measures - Control should be able to show
corrective actions to be taken.
10. Control must be Acceptable by all Members of the Organization

Control Techniques
A variety of tools and techniques have been used over the years to help managers control the
activities of organisations. Some of the techniques are identified below.

Budgets
A budget is a planning and a control tool. Budgeting has been exhaustively discussed in a
previous unit.
Financial Control
This is a very good instrument for the control of resources. It entails the use of quantifiable
measures to monitor deviations.

Inventory Control - Inventory management or control is a form of administrative control that is

particularly essential in all manufacturing, wholesale and retail establishment. The essence of all
inventor y control is to have the right quantity at the right time and place. The topic has been
fully discussed.
Auditing is a Very Important Control System - The auditor examines records and statements
and expresses an opinion regarding their fairness and accuracy.
Break Even Point Analysis (BEP) The break-even point analysis is another control technique
that is often used in some organisation. Every profit-making organisation is anxious to know at

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what level of operation the volume of total revenue will be greater than total costs. The break-
even point is that level of volume at which the total revenue equals total expenses. At this point,
the company makes no profit and suffers no loss.
Traditional Non-Budgetary Control Devices - There are many traditional control devices not
connected with budget, although some may be related to, and used with budgetary controls.
Among the most important ones are the use of statistical data of many aspects of the operation,
special reports and analyses of specific areas and personal observation such as managing by
walking around.
Time-Event Network Analysis - Another Planning and control technique is a time-event
network analysis called the program evaluation and review techniques (PERT)

Wining Acceptance for Control

Control is not an easy task as it seems, but a tedious one for management. This is because
nobody wants to be controlled in the organisation no matter their status.
It is therefore the duty of the management to ensure acceptance of control by the subordinates in
the organisation. For this to be achieved, the following steps are necessary:

1. The management should have an awareness of the personnel needs and pressure.
2. Develop mutual interest in achieving the objectives of the organisation.
3. Explain controlling mechanism to the workers.
4. Needed changes should be automatic in the control.
5. Controlling policies should be kept constant.
6. Adequate authority should be given to the person in charge of control.
7. There must be wholehearted cooperation from the top management for control.
8. For best results, comparison and controlling should be on a continuous basis

REVISION QUESTIONS
• Define control in your own words
• State 4 things that could be controlled in an organization
• State 4 elements of effective control
• Specify 8 requirements for control you know
• List and explain 6 control techniques you know
• Discuss the elements of effective control in organizations
• It is obvious that nobody wants to be controlled in an organization no matter their
status. It is therefore the duty of the management to ensure the acceptance of control by
the subordinates in the organisation. For this to be achieved as a Nurse manager,
explain at least 6 measures that are necessary to be taken by you?

Meanings of Motivation
One of the challenges of management in the process of managing organizations is to ensure that
the employees contribute their maximum effort towards the attainment of the organization’s
objectives. It is therefore of paramount importance for management to determine the needs that
drive their employees towards certain goals achievement. This drive is known as motivation.

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This is done by managers, through building into every possible aspect of the organization’s
climate, those things which will cause people to act in the desired ways.

Definition
Motivation can be defined as an individual needs, desires and concepts that cause people to act in
a particular manner. Motivation has been linked with urges, instinct, purposes, goals, and desires
involving the physiological and social aspects of human beings. It is that energizing force that
induces or compels and maintains behaviour.

Characteristics of Motivation
Motivation as an internal psychological process whose process is inferred from observed
performance has three basic characteristics:
I. It is sustained - it is maintain for a long time until satisfied.
II. It is goal directed - it seeks to achieve an objective.
III. It results from a felt need - it is an urge directed towards a need.

The Motivation Process

A need creates a tension in the individual who moves in a certain direction in order to achieve
the desired objective which reduces tension. A satisfied need does not motivate, conversely, an
unsatisfied need motivates.

Types of Motivation
There are two basic types of motivation, viz:
a. intrinsic
b. extrinsic
Intrinsic Motivation This is the motivation that is within the individual i.e. internal and not
manipulatable (controllable) by anyone apart from the individual e.g. hunger, sleep etc.
Extrinsic Motivation This is the motivation that is external. It is not within the individual to
control. It is therefore controllable. Example is incentives. It relates to the work environment,
therefore it can be influenced or changed.

Theories in Motivation For adequate understanding of motivation and workers, we shall

examine a number of theories of motivation as propounded by the following people:
1. Abraham H. Maslow
2. Douglas McGregor
3. Frederick Hertzberg
4. V.H Vroom
5. Chris Argyris

You have been familiar with Abraham Maslow , therefore read it up

Douglas Mcgregor - Theory X and Theory Y

Mc Gregor’s Theory X and Theory Y are essentially sets of assumptions about behaviour. In his
publication “the Human Side of the Enterprise”, he refers to the theoretical assumption of
management that underlies its behaviour. He sees two different sets of assumptions made by
managers about their employees.

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Theory X
Theory X regards employees as being inherently lazy, requiring coercion and control, avoiding
responsibility and only seeking security.

Theory Y
Here, the assumptions see man in a more favourable light. Employees are seen as liking work,
which is as natural as rest or play, they do not have to be controlled or coerced, when committed
to organisation’s objectives. Under proper conditions they will not only accept but also seek
responsibility, more rather than less people are able to exercise imagination and ingenuity at
work.

Fredrick Hertzberg Two-Factor Theory

Fredrick Hertzberg’s studies centred on satisfaction at work. In the initial research, some two
hundred engineers and accountants were asked to recall when they had experienced satisfactory
and unsatisfactory feelings about their jobs. Following the interviews, Hertzberg’s team came to
the conclusion that certain factors tended to lead to job satisfaction, while others led frequently to
dissatisfaction. The factors giving rise to satisfaction were called motivation, while those giving
rise to dissatisfaction were called hygiene factors. These studies were later extended to other
groups.

The following were most important motivators:

1. Achievement
2. Recognition
3. Work itself
4. Responsibility
5. Advancement These factors were intimately related to the content of work.

The hygiene factors were as follows:

1. Company’s policy and administration
2. Supervision – the technical aspect
3. Salary
4. Interpersonal relations
5. Working conditions

There are certain distinctions between motivators and hygiene factors. While motivators brought
about positive satisfaction, the hygiene served to prevent dissatisfaction. If motivators are absent
from the job, the employee will experience real dissatisfaction. However, even if the hygiene
factors are provided for, they will not in themselves bring about job satisfaction. Medically put,
hygiene, in other words does not positively promote good health, but can act to prevent ill-health.
This work has led to the job enrichment movement (adding motivators to jobs) and more recently
to the quality of working life movement.

Chris Argyris Theory

Professor Argyris research was on the relation between people’s needs and the needs of the
organization. He suggests that the reason for so much employee apathy is not because of
laziness, but rather, because people are being treated like children. This led to his so-called

25
immaturity-maturity theory which suggests that the human personality develops from immaturity
to maturity in a continuum, in which a number of key changes take place. These are as follows:

Immaturity Maturity
Passivity Activity
Dependence Relatively independent
Behave in few ways Behave in many ways
Erratic, shallow interest Deeper interest
Short-time position Equal or superior position
Lack of Awareness Awareness and control of self

From the above theory, Argyris sets the features of the typical classical organisations, task
specialisation, chain of command, unity of direction and span of control. The effect on the
individual is that they are expected to be passive, dependent and subordinate i.e. individuals are
expected to behave immaturely.

For individuals who are relatively mature, the environment is a major source of frustration at
work, which could lead to difficulties such as creating informal organization which work against
the formal hierarchy. Argyris is of the opinion that the more we understand human needs the
more it will be possible to integrate them with the needs of the organization. If the goals of both
individual and the organization can be brought together, the resulting behaviour will be
cooperative, rather than defensive and antagonistic.

V.H. Vroom Expectancy Theory

This theory attempted to study the process of motivation. It was developed by V.H. Vroom in the
United States of America in 1964. The key point to note is that an individual’s behaviour is
formed not on some sense of objective reality, but rather on his own perception of reality i.e.
how he actually sees the world around him. The perception is based on three things: efforts,
performance and reward. The strength of the attraction of particular outcomes or rewards for
an individual is termed valence”. The degree of belief that a particular act will produce a
particular outcome is termed “expectancy”. Valence and expectancy depend on the individual’s
own perception of a situation.

Motivational Techniques
There are three basic motivational techniques employed by management in motivating
employees. They are: money, behaviour modification and participation. We shall consider them
one after the other.

Money
Money plays an important factor in motivating workers. It could be in form of wages, pay rise,
granting bonuses or any other things that may be given to people for improved performance.
Managers and union leaders have tended to place money high on the scale of motivators, while
the behavioural scientists tend to place it low. Money is most important to people as it is a means
of meeting basic needs of life. Money is also a means of keeping an organisation adequately
staffed, to attract and hold employees.

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Behaviour Modification
This approach holds that individual can be motivated by properly designing the work
environment. Good performance is rewarded while poor performance is punished. Specific goal
are set with workers participation and assistance, point and regular feedback of result is made
available and performance improvement are rewarded with recognition and praise. Where the set
targets are not met by the workers, ways are found to help people and praise them for the good
thing they do.

Participation
People are more motivated through the use of participation of people in the management of an
organisation. People are more motivated by being consulted on action affecting them. As those
people in the centre of the act will have in-depth knowledge of the problem and can easily proffer a
solution which can lead to organisation’s success.
Participation is a means of recognition. It appeals to the need for affiliation and acceptance and
finally it gives people a sense of accomplishment.
Though participation does not mean that the manager should abandon their authority to their
subordinates, but rather, they should call subordinates on matters that affect them for advice, while
taking the final decision.

Revision question
What do you understand by motivation?
Mention and discuss any 2 characteristics of motivation.
Mention and explain 2 types of Motivation you know.
Explain Douglas Mcgregor - X and Y Theory
List 4 most important motivators as enumerated by Fredrick Hertzberg Two-Factor Theory
List 4 hygienic factors that leads to dissatisfaction as enumerated by Fredrick Hertzberg
Explain V.H. Vroom Expectancy Theory
Explain any 2 ways an employees could be motivated?

STAFFING

Staffing is a selection, training, motivating and retaining of competent personnel to fulfil specific
roles in an organization structure through recruitment.
Nurse staffing is a constant challenge for health care facilities. Before the selection of the
employees, one has to make analysis of the particular job, which is required in the organization,
then comes the selection of personnel.

Staffing Process

1. Preparing to Recruit – types and number of personnel

2. Attracting a Staff – formal advertisement
3. Recruiting and Selecting a Staff – interview ►induction ►orientation ►job
order ►pre-employment testing ►signing of contract

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Staffing Pattern – plan that articulates how many and what kind of staff are needed/shift or per
day in ►unit or in ►department.

Man power planning may be defined as a strategy for the acquisition, utilization, improvement
and preservation of the human resources of an organization. This involves ensuring that
organization has enough of the right kind of people at the right time and also adjusting the
requirements to the available supply.

The main objectives of man power planning

1. Ensuring maximum utilization of the personnel
2. Assessing future requirements of the organization
3. Determining the recruitment sources.
4. Anticipating from past records, i.e. resignations, simple discharge, dismissal and
retirements.
5. Determining training requirements for management’s development and organizational
development.

Steps of manpower planning:

1. Scrutiny of present personnel strength.
2. Anticipation of man power needs.
3. Investigation of turnover of personnel
4. Planning job requirements and job descriptions

Two Ways of Developing a Staffing Pattern

1. Determine the number of nursing care hours needed/patient

• Generating the full-time equivalents of an employee
2. Determine the nurse-patient ratio in providing nursing care
• FTE – measure of work committed of full-time employee
• 1.0 FTE = works 5 days/week, 8 hours/day
• 0.5 FTE = part time employee who works 5 days/2 weeks

Considerations in Staffing Pattern

1. Benchmarking

• Management tool for seeking out the best practice in one’s industry so as to
improve one’s performance.
• Process of measuring products, practices and services against best performing
organization as atool for identifying desired standards of organizational
performance.
2. Regulatory Requirements – mandated by RA
3. Skill Mix – percent or ratio of professionals to non professional

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Ex: 40 FTE (20 RN + 20 non RN) = 50% RN mix
4. Staff Support – staff support in place for the operations of the units or department.
5. Historical Information – review of any data on quality or staff perception regarding the
effectiveness of the previous staffing pattern

Patient Classification System

o Measuring tool used to articulate the nursing workload for specific patient or
group of patients over a specific time.
o Patient Acuity – measure of nursing workload that is generated for each patient.

Patient Care is Classified According to:

1. Self-care or minimal care patients are capable of carrying ADL, e.g., hygiene,
meals etc.
2. Intermediate or moderate care requires some help from the nursing staff with
special treatments or certain aspects of personal care, e.g., patients with IV fluids,
catheter, respirator, etc.
3. Total care patients are those who are bedridden and who lack strength and
mobility to do average daily living. Ex: patients on CBR, immediate post-op, with
contraptions.
4. Intensive care patients are those who are critically ill and in constant danger of
death or serious injury. Ex: comatose, bedridden etc.

Staff Scheduling

Staff scheduling could be simply defined as assigning an employee to each workplace task for a
specific period of time.

Issues to consider in scheduling staff:

1. Patient type and acuity

2. Number of patients
3. Experience of Staff
4. Support available to the staff

Shifting Variations

• Traditional Shifting Patterns

• 3 shift (8 hr shift)
• 12 hr shift
• 10 hr shift

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 • Weekend option
• Rotating work shift
• Self-scheduling – staff makes their own schedule
• Permanent work shift
• Floaters – “on-call”

What do you understand by staffing in nursing?

List 3 processes of staffing
List any 2 examples of shifting pattern you know
List 4 objectives of man power planning
List 4 steps of manpower planning
What is staff scheduling?
As a nurse manager what are 4 issues you will consider in scheduling your staff

CONTROLLING/DIRECTING

Controlling/directing could be defined as an act of issuing of orders, assignments, instructions, to

accomplish organizational goals and objectives.

• Delegation – entails responsibility

• Assignments – no responsibility

Elements of Directing
1. Communication
2. Delegation
3. Motivation
4. Coordination
5. Evaluation

DELEGATION

What is delegation?
• Act of assigning to someone else a portion of the work to be done with corresponding
authority, responsibility and accountability (ARA).
• According to ANA, it is the transfer of responsibilities for the performance of the task
from one person to another. Much of the work of manager is accomplished by
transferring the responsibilities to subordinates

Good Reasons for Delegation

What Delegation Can Do For You

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 1. It frees up time for planning and organizing.

Most managers would like to have more time to get a handle on planning and organizing other
things. Manager delegate routine task so that they are free to handle problems that are more
complex or require higher level of expertise

2. It helps to learn how to manage and develop employees.

If you aren’t certain of your own ability to develop your team, delegation is the best way to start.
If you know what you want to accomplish, learning how to delegate the process is an important
step towards becoming a better manager and having a better team.

3. It prevents managers stressing themselves too much.

Having too much on your plate is not only difficult for you, it can be disastrous for your team. If
you can’t manage your own workload, you can’t hope to manage anything else. Get a grip; work
smarter, not harder, and spread the load around.

4. It encourages open communication and trust.

If you delegate to your team members and remain open for questions, they will feel that you trust
them and that you are accessible for communication. If your employees feel that you trust them
and that they can talk to you, you will benefit immeasurably. A team built on trust and open
communication is a team poised for success.

5. It can show you a better way.

Employees who take over a process or job may have a completely new approach, and sometimes
it’s a major improvement.
If you just keep doing things the way you’ve always done them and refuse to allow anyone else a
shot, there will be no opportunity for new and different ideas and approaches, process
improvements, or other potential innovations.

What Delegation Can Do For Your Team Members

6. It motivates and builds morale.

Employees find it gratifying when their managers delegate to them. For most, this is a sign that
they are valued and trusted workers, and that their manager believes them capable of greater
success. This can be more motivational than any team pizza party could ever be.

7. It encourages and stimulates creativity and initiative.

If employees feel empowered to accomplish delegated tasks in their own way, they can become
very both very creative and very driven to succeed. Their personal initiative and the desire to
reach the goal you have set before them can produce impressive results.

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 8. It develops their skills.

The leaders of the future have to come from somewhere. Developing your employees through
delegation and helping them to learn new skills not only benefits them, but furnishes your
organization with more qualified and better trained personnel.

9. It allows them to contribute significantly to team success.

Your employees will relish the prestige and recognition that comes with doing something that
makes a difference. They will experience pride and a sense of accomplishment from making a
significant contribution.

What Delegation Can Do for Your Organization

As if all that wasn’t enough:

10. Delegation will benefit your team, your department, and your organization.

It fosters trust, boosts morale, promotes high productivity and efficiency, and generates a culture
of enthusiasm, innovation, creativity, cooperation, and openness. It will reduce employee
turnover and furnish the organization with better-qualified, more skilled employees.

Managers who do not delegate

• Does not trust

• Fear of mistake
• Fear of criticism
• Fear of own ability to delegate

Common Errors in Delegation

• Under delegating – systems from the manager’s false assumptions that

delegation maybe interpreted as a lack of ability on his part to do the job correctly
and competently. Reasons are:
• Managers believe that they can do the work faster and better
• Managers believe that the responsibility may be rejected if delegated
• Over delegating – subordinates become overburdened which may lead to
dissatisfaction and low productivity. Reasons are:
• Managers who are lazy
• Manager who are overburdened and exhausted
• Improper Delegation – delegating at the wrong person, time, tasks and beyond
the capability of the subordinates.

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Steps in Effective Delegating

1. Plan ahead
2. Identify necessary skills and levels
3. Select most capable personnel
4. Communicate goal clearly
5. Empower the delegate
6. Set deadlines and monitor progress
7. Model the role and provide guidance
8. Evaluate performance
• Motivation – whatever influences our choices and creates direction, intensity, and
persistence in our behaviour.
• Supervision – guiding and directing the work to be done. It entails motivating and
encouraging the staff to participate in the activities to meet the goals and
objectives for personal development in making the work better.
• Coordination – arranging in proper order. It creates harmony in all activities to
facilitate success of work

COORDINATION

Coordination is the force that binds all the other functions of management.

Coordination can be defined as a process whereby a manager or an executive develops an

orderly pattern of group efforts among its subordinates and secures unity of actions in pursuit of
common purpose.

The important techniques of coordination are as follows:

1. Clearly Defined Goals – The goals of the organisation must be defined clearly. The objectives
of the organisation must be understood by the individuals. Well aware people will be able to
contribute in achieving organizational goals.

2. Cooperation – When the individuals of the organisation help each other voluntarily,
coordination become easier. This is known as cooperation. Cooperation takes place in the
organisation by ensuring harmonious relations among the peoples. The informal relations speed
up the activity of the cooperation. Therefore, this should be promoted in the organisation.

3. Harmonized Policies and Practices – Policies, procedure and rules serve as guidelines for
decision- making in a constant manner. Only the harmonized policies and procedure are helpful
to achieve the goals of the organisation.

4. Sound Organisational Structure – Sound organisational structure are also known as a

technique of the coordination. This is due to well defined authorities and responsibilities. Such
organisation does not create any problem and almost dispute free.

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5. Managerial Hierarchy – Managerial Hierarchy in the organisation is also responsible for
coordination. At each level superior coordinate the activities and efforts of subordinates by
means of authority.

6. Communication System – A good communication system promotes cooperation and mutual

understandings among individuals and groups. This is helpful in effective coordination because
every aspect regarding organisation clear to each and every employee.

7. Liaison officer – Liaison officers are appointed in the organisation to enhance the coordination
between different sections, units and groups. These officers iron out the barriers of smooth
coordination.

CONFLICT MANAGEMENT

Conflict – internal and external discord that results in from differences in ideas, values or
feelings between 2 or more people. It arises because of differences in economic and professional
values.
Two Main Types

1. Competitive Conflict – 2 or more group the same goal and only one group can attain
them
• Management: Set Goals
2. Disruptive Conflict – takes place in environment filled with anger, fear and stress. There
is no mutually acceptable set of rules and the goal of each party is the elimination of each
opponent.

Conflict Resolution Strategies

1. Use of dominance and Suppression

o Win lose strategy
o Loses feels angry
2. Restriction – autocratic coercive style that uses indirect and obstructive
expression of conflict.
3. Smoothing Behaviour – persuades the opponent in a diplomatic way
4. Avoidance Behaviour – 2 parties are aware of the conflict but choose not to
acknowledge or attempt to resolve it.
5. Majority rule – unanimous decision
6. Compromising – consensus strategy where each side agrees solutions
7. Interactive Problem Solving – constructive process in which the parties involve
recognized that conflict, assist and openly try to solve the problems
8. Win-Win Strategy – focuses on goals and attempts to meet the needs of both
parties.
9. Lose-Lose Strategy – neither side wins
10. Confrontation – most effective means of resolving the conflict. Resolves through
knowledge and reason brought out in an open.

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 11. Negotiation – “give and take”

REVISION QUESTION
Define Controlling/directing in relation to nursing
List 4 element of directing you need as a nurse manager
List and explain 5 importance of delegation as a nurse manager
Mention and explain any 2 common errors in delegation

Defined Coordination
List and explain 4 importance techniques of work place coordination
Define conflict
Name 2 main types of conflict
List any 6 types of conflict resolution strategies you know

RESEARCH IN NURSING

What is research?
Research is the systematic inquiry that uses disciplined method to answer questions or solve a
problem.

French Ruth said that “Research is the problem solving process, a systematic, intensive study
directed towards full , scientific knowledge of the object studied.”

What is nursing research?

Nursing research can be defined as any scientific (i.e. systematic) enquiry into the effectiveness
or value of nursing practice. It denotes any empirical evidence on which nursing care is based.
(Parahoo, 1997; Sullivan, 1998; Polit & Beck, 2004).

The Journal of Nursing Education defines nursing research as the “systematic inquiry designed
to develop knowledge about issues of importance to nurses, including nursing practice, nursing
education and nursing administration.”

Why is research usually done?

1. To answer the questions related to specific topic.
2. To solve the unsolved problems.
3. To gain in-depth and new information related to the topic.
4. For the development of scientific knowledge.
5. To satisfy curiosity.
6. To collect facts.
7. To analyse standards and guides for action.
8. To describe a state of affairs.
9. To determine cause and effect.

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 10. For the advancement of the knowledge and be familiar with newer technology.

The importance of research in nursing are;

1. To improve nursing standards.

2. To improve nursing education system.
3. To help nurses investigate more carefully related to various nursing diagnosis and other
problems.
4. To help nursing staffs to gain in-depth information related to various topic.
5. To help nurses to investigate regarding various methods of treatment in advanced form.
6. To enquiry regarding newer methods to deal with the problem.
7. To provide quality care to the patient.
8. To invent new techniques to care patient.
9. To provide cost effective patient care.
10. To save nursing profession legally.
11. To develop and improve nursing standards.
12. To update newer information.
13. To become dynamic.
14. To improve the health of community people.
15. To solve daily obstacles.
16. To update information on various field where the nurses are involved.

ASSIGNMENT
Read comprehensively about nursing research on your own

REVISION QUESTIONS
Define research?
What is nursing research?
Mention 6 reasons why research is usually done?
Mention 10 importance of research in nursing?

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