Leadership and Management

Nursing
Leadership & Management
Peter Eustaquio Capistrano, PT, RN, Theo
Peter Eustaquio Capistrano 1

Introducing Nursing Management
• Today all nurses are managers (but

not all can be leaders)
• Nurses must learn how to work
effectively & efficiently with:
 staff
 other nurses
 UAP
• Nurses must understand the health
care system and how the organization
functions.
• You need to know what external

forces affect your work.
• Be able to collaborate with others as a

leader, as a follower, a team member
• You need to know what motivates
people, &
• How you can help create an environment

that inspire and sustain the individuals
who work with you.

Forces Changing Health Care
+ Proliferation of managed care

+ greater emphasis on the business of
health care
(financial & marketing aspects)
+ shift from acute care to community &
outpatient settings
+ shift to costumer-focus
+ technology advancement

+ emerging new threats such as

terrorism, biological warfare, global
pandemics
+ addressing the ever-increasing
international nursing shortage
+ high turnover rates of staff
+ new legislations of minimum staffing
ratios

Concerns (for employers, HCW, public & policy makers):

• Costly live-saving medicines
• Robotics
• Remote care
• Innovations in imaging technologies
• Non-invasive treatments & surgical
procedures

Health Care Networks
• Integrated Care Networks
Due to the struggle to find ways in

today’s cost-conscious health society
• Common characteristics:
Deliver a whole continuum of care
Provide coverage for the buyers of
health care services; and,
Health Care Networks
• Accept the risk inherited in taking a
fixed payment in return for providing
health care for all persons.
 Variety of arrangements and affiliations

have occurred

The focal point for care:
-- primary care rather than hospital
 goal of care:
-- keep patients healthy by treating them
in the setting that incurs the lowest cost
& thereby reducing expensive hospital
txs.

• It is now the GOAL of the health
care
industry to keep
patients out of
the hospitals!!!

Demands to reduce errors

Demand to ↓ Errors
4 Systems Used to ↓ medical errors
I. Control of Medical errors:

- US reported in 1999 – 98,000 death
occurred each year from preventable
medical mistakes in hospitals
- Medical injuries found to ↑ length
of stay, patient’s costs & mortality
A. Computerization system for pharmacy
that will alert staff for possible:
 drug interactions, or
 adverse reactions
B. Computerized medication
administration records
C. Patient ID band w/ bar codes

D. Beginning fiscal year 2008, CMS-US
would no longer reimburse hospitals for
the cost related to hospital-acquired
infections or medical errors.
CDC-US, approx: 2m people suffer

from nosocomial infections w/c costs
$27.5b
(CDC, 2007)

II. Leapfrog Group
- A consortium of public & private
purchasers
- Provides benefits to more than 37m
Americans in all 50 states.
- Rewards health care organizations that
demonstrate quality outcome measures

• 3 quality indicators:
1. ↑ computer-physician order entry
system
2. Using evidence-based hospital
referrals
3. Using ICU physician intensivists
staff

Most significant impact on preventing
medical errors:
• ≥ 65,000 lives could be saved
• ≥ $41b could be saved
• ≥ 900,000 medical errors could be

avoided

III. Quality management
Preventive approach to address
problems before they become crises
Began in post-WW II Japan

• To improve the quality of manufactured
products
• Consumers’ needs should be the focus

of management
• Employees should be empowered to

evaluate and improve quality
• TQM  build tools for continuous
improvement of product & services thru
constant evaluation of how well the
consumers’ needs are met  devise
plans to perfect the process
 Done thru patient satisfaction surveys

IV. Benchmarking
• Compares an organization w/ similar
organizations (in contrast w/ TQM)
• Outcome indicators are identified to be
used to compare performances across
disciplines

Benchmarking
• Used for standard development &
performance improvement
• Once the results are known, weaknesses
can be addressed & enhance areas of
strength

Benchmarking
Questions to be asked in benchmarking:

+ “How did they do it?”
+ “What tools did they use/”
+ “What were their lessons
learned?”

• Populations & Cultural Diversity
• Generational Diversity
• Aging Patients & Aging Nurses

Immigrant Populations &
Cultural Diversity
• US Census Bureau  minority
population = 100m in 2007
• Hispanics – 44m (largest group)
• African origin – 40 m
 fastest growing minority
• Asians – 14m
 2nd fastest growing minority

Cultural Diversity
• The challenge for health care policy
makers & the public:
 to find ways to provide universal access

to care regardless of care, ethnic origin,
or socioeconomic status.

Cultural Diversity
• Current trend:
 assume trans-cultural focus
They consider:
- values
- beliefs
- lifestyle of the diverse cultures

Immigrant Populations & Cultural
Diversity
• Trans-cultural diversity affects

nursing:
- 81.8% of US nurses
 caucasians (2004 survey)
- 18.2% - from minority population
- only 5.4 nurses are male (2000 survey)

Generational Diversity
• Seeing four generations working
together side by side in today’s
workplace is common:
 traditionals
 Baby boomers  have different
 Generation X values &
 millenials expectations
in the workplace
• Baby boomers:
+ value professional & personal
growth
+ expect that their work will make a
difference

• Traditionals:
+ value loyalty
+ respect authority
+ follows bureaucracy policies

• Generation X – desire a (+) work
environment
• Want their work to have worth
• Want independence, fun
• Value independence
• Tend to focus on outcomes rather than
processes

• To have balance between work & other
important areas of their lives:
- personal relationships
- child rearing
- pleasurable pursuits

• Millenials (a.k.a. Generation Y)
• Technically savvy
• Responsible
• Competent
• Expert in connecting online
• Prepares to participate in collaborative
structures

• Challenge for managers:
- avoid stereotyping within the generations
- value unique contribution of each
generation
- encourage mutual respect for differences
- leverage differences to enhance
teamwork

• Challenge for managers:
- changes in the workplace also add
to conflicts due to the generations’
different expectations

Aging Patients, Aging Nurses
• Older generation  65 y/o & ↑
 37m in 2006 (12% in US population)
 approximately 1 in every 10 Americans
 by 2030 – more than 71m older adults

• Reasons for continuation of demand
for health care for aging patients:
- people are living longer
- advancement in technology are enabling
people to survive previously fatal
diseases & conditions
- older x often require on-going care for
chronic / acute illnesses

↑ older people are due to:
• Increase in life expectancy
• older workers retiring later
• good health practices (exercise, healthy
eating, screenings)
 These people will require episodic &

chronic care
• Nurses are growing older
• Ave. age : 46.8 (US, 2007) compared to

44.3 in 1996
• % of nurses over 54 y/o increased to

25.2% in 2004.

• Means that the current need for nurses
will continue and grow as more & more
aging nurses will retire from work
• US Dept of Labor predicts (2014) that

RN will be the second largest occupation
second to retail salesperson)

• Changes for future nurses

More Change on the Way
• Evidence-based practice
 applying the best scientific
evidence to a px’s unique diagnosis,
condition & situation to make
clinical decisions

Evidence-based practice
• The process of EBP:

- identify the clinical question
- find the evidence to answer the question
- evaluate the evidence
- apply the evidence
- evaluate the outcome

Evidence-based practice
• ΣθΤ International (honor society for nurse)
EBP: The integration of best evidence available,

nursing expertise, and the values & preference of
the individuals, families & communities who are
served. EBP will be successful when nurses &
health care decision makers have access to a
synthesis of the latest research, a consensus of
expert opinion and then exercise their judgment as
they plan & provide care that takes into account
cultural & personalPeter
values & preferences. (2004)
Eustaquio Capistrano 46
Strategies for new Nurses to promote EBP:
+ keep abreast: subscribe to journals & read widely
+ encourage use of multiple sources of evidence
+ find established sources in your specialty
+ question & challenge nursing traditions, promote
spirit of risk-taking
+ dispel myths & traditions not supported by evidence
+ Collaborate with others nurses locally & globally
+ interact with other disciplines to bring nursing
evidence to the table

Electronic Health Records
• Integrates health info from all

sources and cane be accessed from
multiple locations from authorized
providers.

• Electronic records:
- ↓ redundancies
- improve efficiency
- ↓ medical errors
- lower health care costs

• Patient’s personal health record:

- online system allowing patients to
track medications, record medical
interventions, update their own
medical information as needed.

Robotics & Remote Care
• Use of robots to transfer supplies and to
deliver remote care
• Systems & supplies can be ordered now
electronically & filled by laser-guided
robots
• Robots deliver the requested supplies to
nursing units

Robotics & Remote Care
• Physicians in remote locations can
access pxs using wireless video
connections in robots at the bedside
• Some robots offer electronic
stethoscopes & other diagnostic devices
• Can follow-up lab results between cases
instead of after the day’s procedures

Terrorism & Disaster
Preparedness
• Extensive staff training is required
• Assess nurses’ concerns & provide
accessible info, support & opportunities
for debriefing
 Natural disaster, attack of terrorism,

epidemic are examples

Challenges Facing Nurses
Nurse mangers are challenged to:
 manage with decrease resources
 To supervise teams of professionals &
non-professionals from a variety of
cultures
 Must a coach, teacher & facilitator
because they are responsible for others’
work

• Must be a leader to motivate &
inspire
• Must address the interests of both
admin & employees
• Works thru others to meet the goals
of individuals, the unit, & of the
organization

• Organizations
And
organizational theories

Organizational Theories
• Organization – a collection of
people working together under a
defined structure to achieve pre-
determined outcomes using
financial, human and material
resources.

Organizational Theories
• Types:
+ classical Theory
+ Humanistic Theory
+ Systems Theory
+ Contingency Theory
+ Chaos Theory
+ Complexity Theort\y

Organization
• The lifecycle of the org is dependent on
its adaptability & response to changes in
its environment
• When org tends to grow, it tends to

stabilize & develop more formal
standards.

Organization
• When the org becomes large, it tends to
lose its adaptability & its
responsiveness to its environment.

Classical Theory
Focuses solely on the structure of the
formal organization
 main premise: efficiency thru design
 people are operating within a rational &

well-defined task

4 elements of Classical Theory
• Division & Specialization of Labor

• Chain of Command
• Organizational Structure
• Span of Control

Division & Specialization of Labor
• Division of work  reduces the

tasks that each employee must carry
out  ↑ efficiency  proficiency &
specialization
• Managers can standardize the work

to be done
Chain of Command
 hierarchy of authority & responsibility
w/n the organization
Authority – as the right or power to direct

activity
Responsibility – as obligation to attain
objectives or perform certain functions

Chain of Command
• The line of authority – higher levels of
management delegate work to those
below them in the organization.
• Line of authority – linear hierarchy
• Staff authority – advisory relationship;
recommends & advices

Chain of Command
Chief Nurse executive Acute Care Nurse Practitioner
N urse Ma n ag er N urse Man a ger
Staff Nurse Staff Nurse Staff Nurse Staff Nurse

Organizational Structure
• describes the arrangement of the
interrelated work group
• The design of the organization is

intended to foster the organization’s
survival & success

Span of Control
• Addresses the pragmatic concern of

how many employees a manager
can handle effectively

Span of Control
• Complex organizations – have numerous
departments that are highly specialized &
differentiated
• Authority is centralized
• a.k.a tall organizational structure

Span of Control
• Less Complex organizations – flat
structure
• Authority is decentralized
• With several managers supervising large
work groups

• Organizational
theories

Humanistic Theory
• Criticism of the Classical Theory led to
the development of the Humanistic
Theory in the 1930s.
• Major assumption:
 People desire social relationships,
respond to group pressures, & search for
personal fulfilment.

Humanistic Theory
• Hawthorne effect – if special attention is
given to workers they will work better
resulting to increased productivity.

Systems Theory
• Defined as a set of interrelated parts
arranged in a unified whole;
• Productivity is the result of interplay
among structure, people, technology &
environment

Types of Systems
• Closed System – self-contained &
usually can be found in the physical
sciences
• Open System – interacts both internally

& & with its environment (a living
organism)

• Organizations are complex, social,
open system
• Framework are interrelated by part of
the system and their functions can be
studied
• Health care org’zn
requires human,
financial & material
resources
Health Care System as Open
System
OUTPUT
INPUT
THROUGHPUT RESTORED HEALTH
MATERIALS
REHABILITATION
MONEY
HEALTH CARE DISEASE
EMPLOYEES
DELIVERY PROTECTION
PATIENTS
EDUCATION DEATH W/
EQUIPMENTS DIGNITY
RESEARCH

Contingency Theory
Contingency Theory  believe
organizational performance can be
enhance by matching an organization’s
structure to its environment.
Environment  people, objects, ideas that

influence the org.

Contingency Theory
• Environment of a  competitors
health care org’n:  regulators
 patients  suppliers
Potential patients Pharmaceuti-cals
 third-party payers

Contingency Theory
• Given the variety of health care services
and different types of patients served
today,
The organizations differ w/ respect to
the environment they face
Levels of skills & training of their
caregivers
The emotional & physical needs of
patients
Chaos Theory
• The nature of relationship we have
w/ each other & with the
organization does not follow a
straight line.

Chaos Theory
 challenges traditional thinking
regarding the design of organizations.
 organizations are living, self-

organizing systems that are complex and
ever-changing.

Chaos Theory
• Chaos theory suggests that the drive

to create a permanent organizational
structure is doomed to fail.

Chaos Theory
• Organizations, to succeed, must
ensure:
+ flexibility
+ fluidity,
+ speed of adaptability, &
+ cultural sensitivity

Chaos Theory
• The role of leadership in Chaos Theory
(changing organizations) :
+ build resilience in the midst of change
+ to maintain balance between tension &
order
+ promote creativity, &
+ prevent instability

Chaos Theory
• Challenges of Chaos Theory:
 to reflect on creative and flexible
formats that can be quickly adjusted and
changes as organizations shift.
 abandon our attachments to any

particular model of design

Complexity Theory
• Organization is a mixture of all the
theories that consider it as a total system.
reasons:
 random events interfere with
expectations
 Patient’s condition change in an instant

Complexity Theory
necessary staff are not available or is
not equipped
 failure of equipments to function
well
 tasks are sometimes contradicting
with the values of the pxs, nurses &
physicians

Complexity Theory
• Health care continues to focus on px
care providers rather than the
system as a whole.
• Using high reliability teams has

been effective in preventing serious
errors.

Complexity Theory
• Hierarchy is less important in

complexity theory.
• Every encounter between a px & a

caregiver offers information about
possible solutions to problems

Complexity Theory
• Manager’s task:
Encourage the flow of info between
and among all team members,
leaders & followers, whether top-
down, bottom-up, or sideways.

Traditional Organizational
Structures
• When structure is not aligned with
organizational needs, the organizational
response to environmental change:
 diminishes
 decisions are delayed, poor, overlooked
 conflicts result
 performance deteriorates

Traditional Organizational
Structures
• Types:
+ Functional Structure
+ Service-line Structure
+ Hybrid Structure
+ Matrix Structure
+ Parallel Structure

Functional Structure
• Employees are grouped in departments
by specialty with similar tasks
• Reports to the same manager
• Tends to centralize decision-making (top

organization)

• Weaknesses:
+ coordination across functions is
poor
+ decision-making responsibilities
can pile up at the top
+ overloaded senior managers

+ Coordination across functions are
slow
+ General management training is
limited
+ top managers may be uninformed
of day-to-day operations

Service-line Structure
• a.k.a. Product-line structure, service-
integrated structure
• All functions needed to produce a

product or service are grouped
together in self-contained units

CEO
Executive secretary
Cardiology Oncology Burn Unit

• Strengths:
+ have potential for rapid change in an
unstable environment
+ high client satisfaction due to
specialization
+ coordination occurs easily
+ service is priority because employees
sees it as the purpose why the org exists

• Weaknesses:
+ possible duplication of resources
+ lack of in-depth technical training &
specialization
+ services operate independently & often
compete
+ units (w/c is autonomous) have duplicate staff &
competes for resources

Hybrid Structure
During growth of organizations,

both self-contained units &
functional units converge

Hybrid Structure
• Strengths:
+ provides simultaneous coordination w/n
product divisions while maintaining the
quality of each function
+ improves the alignment between corporate
& service or product goals
+ fosters better adaptation to the environment
while still maintaining efficiency

Hybrid Structure
• weaknesses:
+ conflict between top admin & managers
+ managers often recent admin’s intrusions
into what they see as their own area of
responsibility
+ over time, organizations tend to accumulate
large corporate staff to oversee divisions

Hybrid Structure
CEO
NURS STORE DIETAR ADMITT PHARM BILLIN

ING ROOM Y ING A CY G

Matrix Structure
• Integrates both product & functional
structures into one overlapping structure.
• Different managers are responsible for

function & product
• (e.g. Nurse manager for oncology clinic may report to the vp for nursing
as well as to the vp for outpatient services)

Matrix Structure
• Weakness:
+ dual authority
+ excellent interpersonal skills are
needed from managers involved
+ time consuming due to frequent
meetings to resolve conflicts &
problems

Matrix Structure
• Weakness:
+ one side of the organization may
become dominate over the other

Matrix Structure
Vice-President, Outpatient Services
Oncology Pediatrics Family medicine
Vice-President for
Nursing Services Nurse Manager
Nurse Manager
Nurse Manager

Parallel Structure
• Unique to health care
• Complex relationship that exists

between he formal authority of the HC
org and the authority of its medical staff
(separate &a autonomous from its org.)
• two lines of authority: organizational

dilemma
Parallel Structure
CEO
Chief Nurse chief financial Officer Chief Suport Services MEDICAL dIRECTOR
executive Hr
dIRECTOR
NM NM
CHIEF OF SERVICES
BUDGET HOUSEKE MAINTENA

RN LPN
NM
UAP
EPING
IN TE RN AL mE D IC IN E
NCE
S URGE RY OB
BUDGET pERSONNEL

Leadership
And
Management

• Nurse managers need a body of
knowledge and skills distinctly different
from those needed for nursing
practice!!!
• Yet few nurses have
the education or
training necessary
to be managers!!!
• Managers depend on experiences with
former supervisors, who also learn
supervisory techniques on the job!!!
• Often a gap exists
between what managers
know and what they
need to know!!!

Leader
• Anyone who uses interpersonal
skills to influence others to
accomplish the specific goals.
• Exerts influence by using a flexible

repertoire of personal behaviors &
strategies.

Manager
• Latin: manu, agere, “to lead from the
hand”
• An individual employed by an
organization responsible &
accountable for efficiently
accomplishing the goals of the
organization.

Leader Manager
• Often do not have • Have assigned position
delegated authority but w/n the formal
obtain power thru organization
influence • Have a legitimate source
• Have a variety of roles of power due to delegated
than do managers authority
• May or may not be a part • Expected to carry out
of a formal org. specific functions, duties,
responsibilities

Leader Manager
• Focus on group • Emphasize control,
process, informal decision-making,
gathering, decision analysis &
empowering people results
• Emphasize • Manipulate the

environment, people,
interpersonal
money, time & other
relationship
resources to achieve
organizational goals
Leader Manager
• Directs willing • Have a greater formal
followers responsibilities &
accountability for
• Goals that may or may rationality & control
not reflect the those of than leaders
the organization
• Direct willing &
unwilling subordinates


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Nursing

Leadership & Management

Peter Eustaquio Capistrano, PT, RN, Theo

Peter Eustaquio Capistrano 1

• Today all nurses are managers (but

• You need to know what external

• Be able to collaborate with others as a

• How you can help create an environment

Peter Eustaquio Capistrano 4

+ Proliferation of managed care

Peter Eustaquio Capistrano 5

+ emerging new threats such as

Peter Eustaquio Capistrano 6

Concerns (for employers, HCW, public & policy makers):

Peter Eustaquio Capistrano 7

Due to the struggle to find ways in

 Variety of arrangements and affiliations

Peter Eustaquio Capistrano 9

Peter Eustaquio Capistrano 10

Peter Eustaquio Capistrano 11

Peter Eustaquio Capistrano 12

I. Control of Medical errors:

Peter Eustaquio Capistrano 14

CDC-US, approx: 2m people suffer

Peter Eustaquio Capistrano 15

Peter Eustaquio Capistrano 16

Peter Eustaquio Capistrano 17

• ≥ $41b could be saved

• ≥ 900,000 medical errors could be

Peter Eustaquio Capistrano 18

Began in post-WW II Japan

Peter Eustaquio Capistrano 19

• Consumers’ needs should be the focus

• Employees should be empowered to

Peter Eustaquio Capistrano 21

Peter Eustaquio Capistrano 22

Peter Eustaquio Capistrano 23

Questions to be asked in benchmarking:

Peter Eustaquio Capistrano 24

Peter Eustaquio Capistrano 25

Peter Eustaquio Capistrano 26

 to find ways to provide universal access

Peter Eustaquio Capistrano 27

Peter Eustaquio Capistrano 28

• Trans-cultural diversity affects

Peter Eustaquio Capistrano 29

Peter Eustaquio Capistrano 31

Peter Eustaquio Capistrano 32

Peter Eustaquio Capistrano 33

Peter Eustaquio Capistrano 34

Peter Eustaquio Capistrano 35

Peter Eustaquio Capistrano 36

Peter Eustaquio Capistrano 37

Peter Eustaquio Capistrano 38

Peter Eustaquio Capistrano 39

 These people will require episodic &

• Ave. age : 46.8 (US, 2007) compared to

• % of nurses over 54 y/o increased to

Peter Eustaquio Capistrano 41

• US Dept of Labor predicts (2014) that

Peter Eustaquio Capistrano 42

Peter Eustaquio Capistrano 43