MANAGEMENT

OBJECTIVES
After the discussion, the students will be able to:
■ Define the term management
■ Distinguish the Different Management Functions
■ Discuss the different Traditional Organizational Theories and Structures
■ Explain the step-by-step process of Strategic Planning
■ Determine the Standards of Nursing Practice

WHAT IS MANAGEMENT?
- The classic definition of management was Henri Fayol’s 1916 list of managerial tasks: planning,
organizing, commanding, coordinating, and controlling the work of a group of employees (Wren, 1972).
- Mintzberg (1989) argued that managers really do whatever is needed to make sure that employees do their
work and do it well.
- A manager, in contrast, is an individual employed by an organization who is responsible and accountable
for efficiently accomplishing the goals of the organization.

❖ Managers focus on coordinating and integrating resources, using the functions of planning, organizing,
supervising, staffing, evaluating, negotiating, and representing. Interpersonal skill is important, but a
manager also has authority, responsibility, accountability, and power defined by the organization.
The manager’s job is to:
● Clarify the organizational structure
● Choose the means by which to achieve goals
● Assign and coordinate tasks, developing and motivating as needed
● Evaluate outcomes and provide feedback

❖ All good managers are also good leaders—the two go hand in hand. However, one may be a good
manager of resources and not be much of a leader of people. Likewise, a person who is a good leader may
not manage well. Both roles can be learned; skills gained can enhance either role.

AONE BELIEVES THAT MANAGERS AT ALL LEVELS MUST BE COMPETENT IN THE

FOLLOWING:

COMMUNICATION AND RELATIONSHIPS-BUILDING COMPETENCIES INCLUDE:

● Effective communication
● Relationship management
● Influence of behaviors
● Ability to work with diversity
● Shared decision making
● Community involvement
● Medical staff relationships
● Academic relationships

KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT INCLUDES:

● Clinical practice knowledge
● Patient care delivery models and work design knowledge
● Health care economics knowledge
● Health care policy knowledge
● Understanding of governance
● Understanding of evidence-based practice
● Outcome measurement
● Knowledge of and dedication to patient safety
● Understanding of utilization/case management
● Knowledge of quality improvement and metrics
● Knowledge of risk management

LEADERSHIP SKILLS INCLUDE:

● Foundational thinking skills
● Personal journey disciplines
● The ability to use systems thinking
● Succession planning
● Change management

PROFESSIONALISM INCLUDES:
● Personal and professional accountability
● Career planning
● Ethics
● Evidence-based clinical and management practice
● Advocacy for the clinical enterprise and for nursing practice
● Active membership in professional organizations

BUSINESS SKILLS INCLUDE:

● Understanding of health care financing
● Human resource management and development
● Strategic management
● Marketing
● Information management and technology

DESIGNING ORGANIZATIONS

An organization is a collection of people working together under a defined structure to achieve

predetermined outcomes using financial, human, and material resources.

TRADITIONAL ORGANIZATIONAL THEORIES

Classical Theory
- The classical approach to organizations focuses almost exclusively on the structure of the formal
organization.
- The main premise is efficiency through design. People are seen as operating most productively within a
rational and well-defined task or organizational design.
- Therefore, one designs an organization by subdividing work, specifying tasks to be done, and only then
fitting people into the plan.

Classical theory is built around four elements:

1. Division and Specialization of Labor

- Dividing the work reduces the number of tasks that each employee must carry out, thereby increasing
efficiency and improving the organization’s product.
- This concept lends itself to proficiency and specialization. Therefore, division of work and specialization
are seen as economically beneficial.

2. Organizational Structure
- It describes the arrangement of the work group. It is a rational approach for designing an effective
organization.
- Classical theorists developed the concept of departmentalization as a means to maintain command,
reinforce authority, and provide a formal system for communication.
- The design of the organization is intended to foster the organization’s survival and success.

3. Chain of Command
- The chain of command is the hierarchy of authority and responsibility within the organization.
• Authority is the right or power to direct activity.
• Responsibility is the obligation to attain objectives or perform certain functions.
- Both are derived from one’s position within the organization and define accountability.
- The line of authority is such that higher levels of management delegate work to those below them in the
organization.

One type of authority is line authority, the linear hierarchy through which activity is directed. Another type
is staff authority, an advisory relationship; recommendations and advice are offered, but responsibility for
the work is assigned to others.

The relationships among the chief nurse

executive, nurse manager, and staff nurse
are examples of line authority. The
relationship between the acute care nurse
practitioner and the nurse manager
illustrates staff authority.

4. Span of Control
- It addresses the pragmatic concern of how many employees a manager can effectively supervise.

- Complex organizations usually have

numerous departments that are highly
specialized and differentiated; authority is
centralized, resulting in a tall organizational
structure with many small work groups.

- Less complex organizations have flat

structures; authority is decentralized, with
several managers supervising large work
groups

Humanistic Theory
- Criticism of classical theory led to the development of humanistic theory; an approach identified with the
human relations movement of the 1930s.
- A major assumption of this theory is that people desire social relationships, respond to group pressures, and
search for personal fulfillment.
- This theory was developed as the result of a series of studies conducted by the Western Electric Company at
its Hawthorne plant in Chicago.
• The first study was conducted to examine the effect of illumination on productivity. However, this
study failed to find any relationship between the two.
• In most groups, productivity varied at random, and in one study productivity actually rose as
illumination levels declined. The researchers concluded that unforeseen psychological factors were
responsible for the findings.
 • Further studies of working conditions, such as rest breaks and the length of the workweek, still
failed to reveal a relationship to productivity.
• The researchers concluded that the social setting created by the research itself—that is, the special
attention given to workers as part of the research—enhanced productivity. This tendency for people
to perform as expected because of special attention became known as the Hawthorne effect.
- Although the findings are controversial, they led organizational theorists to focus on the social aspects of
work and organizational design.
- One important assertion of this school of thought was that individuals cannot be coerced or bribed to do
things they consider unreasonable; formal authority does not work without willing participants.

Systems Theory
-Organizational theorists who maintain a systems perspective view productivity as a function of the interplay
among structure, people, technology, and environment.
- Organizational theory defines system as a set of interrelated parts arranged in a unified whole. Systems can
be closed or open.
• Closed systems are self-contained and usually can be found only in the physical sciences.
• An open system, in contrast, interacts both internally and with its environment, much like a living
organism. An organization is a complex, sociotechnical, open system.
- This theory provides a framework by which the interrelated parts of the system and their functions can be
studied.
➢ Resources, or input, such as employees, patients, materials, money, and equipment, are imported from
the environment.
➢ Within the organization, energy and resources are utilized and transformed; work, a process called
throughput, is performed to produce a product.
➢ The product, or output, is then exported to the environment.
➢ An organization, then, is a recurrent cycle of input, throughput, and output.

Contingency Theory
- Contingency theory posits that organizational performance can be enhanced by matching an organization’s
structure to its environment.
- The environment is defined as the people, objects, and ideas outside the organization that influence the
organization.
- Health care organizations are unique with respect to the kinds of products and services they offer.
- However, like all other organizations, health care organizations are shaped by external and internal forces.
These forces stem from the economic and social environment, the technologies used in patient care,
organizational size, and the abilities and limitations of the personnel involved in the delivery of health care,
including nurses, physicians, technicians, administrators, and, of course, patients.
- Given the variety of health care services and patients served today, it should come as no surprise that
organizations differ with respect to the environments they face, the levels of training and skills of their
caregivers, and the emotional and physical needs of patients.
- It is naive to think that the form of organization best for one type of patient in one type of environment is
appropriate for another type of patient in a completely different environment. Thus, the optimal form of the
organization is contingent on the circumstances faced by that organization.

Chaos Theory
- Chaos theory, which was inspired by the finding of quantum mechanics, challenges us to look at
organizations and the nature of relationships and proposes that nature’s work does not follow a straight
line.
- Chaos theory suggests that the drive to create permanent organizational structures is doomed to fail.
- The set of rules that guided the industrial notions of organizational function and integrity must be discarded,
and newer principles that ensure flexibility, fluidity, speed of adaptability, and cultural sensitivity must
emerge.
- The role of leadership in these changing organizations is to build resilience in the midst of change and to
maintain a balance between tension and order, which promotes creativity and prevents instability.
- This theory requires us to abandon our attachment to any particular model of design and to reflect instead
on creative and flexible formats that can be quickly adjusted and changed as the organization’s realities shift.

Complexity Theory
-Complexity theory originated in the computational sciences when scientists noted that random events
interfered with expectations.
- The theory is useful in health care because the environment is rife with randomness and complex tasks.
- Managing in such ambiguous circumstances requires considering every aspect of the system as it interacts
and adapts to changes.
- Complexity theory explains why health care organizations, in spite of concerted efforts, struggle with
patient safety.

TRADITIONAL ORGANIZATIONAL STRUCTURES

Functional Structure
- In functional structures, employees are grouped in departments by specialty, with similar tasks being
performed by the same group, similar groups operating out of the same department, and similar departments
reporting to the same manager.
- In this structure, all nursing tasks fall under nursing service; the same is true of other functional areas.
- Functional structures tend to centralize decision making because the functions converge at the top of the
organization.
- Functional structures have several weaknesses.
▪ Coordination across functions is poor.
▪ Decision-making responsibilities can pile up at the top and overload senior managers, who may be
uninformed regarding day-to-day operations.
▪ Responses to the external environment that require coordination across functions are slow.
▪ General management training is limited because most employees move up the organization within
functional departments.

Hybrid Structure
- When an organization grows, it typically organizes both self-contained units and functional units; the result
is a hybrid organization.
- The hybrid structure can provide simultaneous coordination within product divisions, can improve
alignment between corporate and service or product goals, and foster adaptation to the environment while
still maintaining efficiency.
- The weakness of hybrid structures is conflict between top administration and managers. Managers often
resent administrators’ intrusions into what they see as their own area of responsibility.

Matrix Structure
- The matrix structure is unique and complex; it integrates both product and functional structures into
one overlapping structure.
- In a matrix structure, different managers are responsible for function and product. (For example, the nurse
manager for the oncology clinic may report to the vice president for nursing as well as the vice president for
outpatient services).
- The matrix is appropriate in a highly uncertain environment that changes frequently but also requires
organizational expertise.
- Matrix Structure have several weaknesses:
▪ A major weakness of the matrix structure is its dual authority, which can be frustrating and confusing
for departmental managers and employees. Excellent interpersonal skills are required from the
managers involved.
 ▪ It is time-consuming because frequent meetings are required to resolve problems and conflicts; the
structure will not work unless participants can see beyond their own functional area to the big
organizational picture.
▪ If one side of the matrix is more closely aligned with organizational objectives, that side may become
dominant.

Parallel Structure
- Parallel structure is a structure unique to health care.
- It is the result of complex relationships that exist between the formal authority of the health care
organization and the authority of its medical staff.
- In a parallel structure, the medical staff is separate and autonomous from the organization.
➢ The result is an organizational dilemma: two lines of authority. One line extends from the governing
body to the chief executive officer and then to the managerial structure; the other line extends from
the governing body to the medical staff. These two intersect in departments such as nursing because
decision making involves both managerial and clinical elements.
- Parallel structures are found in health care institutions with a functional structure and separate medical
governance structure.

Service-Line Structures
- More common in health care organizations today are service-line structures (Nugent et al., 2008).
- Service-line structures are also called product-line or service-integrated structures.
- In a service-line structure, clinical services are organized around patients with specific conditions.

STRENGTHS:
▪ Potential for rapid change in a changing
environment.
▪ Client satisfaction is high because each
division is specialized and its outputs can be
tailored to the situation. Coordination across
function (nursing, dietary, pharmacy, and so
on) occurs easily
▪ Work partners identify with their own service
and can compromise or collaborate with other
service functions to meet service goals and
reduce conflict.

WEAKNESSES:
▪ Possible duplication of resources (such as ads for new positions)
▪ Lack of in-depth technical training and specialization
▪ Coordination across service categories (oncology, cardiology, and the burn unit, for example) is difficult
▪ Services operate independently and often compete.
▪ Each service category, which is independent and autonomous, has separate and often duplicate staff and
competes with other service areas for resources.
▪ Some service lines (e. g., pediatrics, obstetrics, bariatric surgery, and transplant centers) present special
challenges due to low usage or the need for specialized personnel (Page, 2010).

Shared Governance
- Shared governance is a process for empowering nurses in the practice setting.
- It is based on a philosophy that nursing practice is best determined by nurses.
- Participative decision making is the hallmark of shared governance and a standard for Magnet certification.
- Interdependence and accountability are the basis for constructing a network of making nursing practice
decisions in a decentralized environment.
- The ultimate outcome of shared governance is that nurses participate in an accountable forum to control
their own practice within the health care organization.
✓ The assumption is that nursing staffs, like medical staffs, will predetermine the clinical skills of staff
nurses and monitor the work of each through peer review while deciding on other practice issues
through accountable forums or councils.
- It allows staff nurses significant control over major decisions about nursing practice.

As shown in the example in Figure 2-4,

nurses participate in unit-based councils that
interface with divisional councils, specialty
councils, and a leadership council, consisting of
nurse managers and administrators. Decisions are
made by consensus, rather than by the manager’s
order or majority rule, a process that allows staff
nurses an active voice in the decision.

- In this Figure, unit councils make decisions that directly affect the unit, divisional councils address issues
that affect more than one unit, and a hospital-wide council determines overall issues.
- The hospital-wide council consists of specific councils that address particular issues. The practice council,
for example, is responsible for patient care standards. The professional development council maintains
educational standards and competency assessments. The quality council monitors patient care quality. The
research council assists in implementing evidence-based practice.

STRATEGIC PLANNING

Successful organizations know that they must focus their resources on their unique strengths, and health
care is no exception. Organizations that focus on a few strategic initiatives, do so after an intensive
planning process. The competitive health care environment and limited resources require organizations to
respond to public demands for safe, accessible quality health care.
A well-thought-out strategic plan guides the organization toward its goals, helps all the staff stay directed,
and prevents the organization from responding to inappropriate requests.
A strategic plan projects the organization’s goals and activities into the future, usually two to five
years ahead (Schaffner, 2009). Based on the organization’s philosophy and leaders’ assessment of their
organization and the environment, strategic planning guides the direction the organization is to take.

o Vision
- Vision statement describes the goal to which the organization aspires.
- It is designed to inspire and motivate employees to achieve a desired state of affairs.
o Philosophy
- It is a written statement that reflects the organizational values, vision, and mission (Conway-Morana,
2009).
- Values are the beliefs or attitudes one has about people, ideas, objects, or actions that form a basis for
behavior. Organizations use value statements to identify those beliefs or attitudes esteemed by the
organizational leaders.
o Mission
- Mission of an organization is a broad, general statement of the organization’s reason for existence.
- Developing the mission is the necessary first step to designing a strategic plan.
o Goals
- These are specific statements of what outcome is to be achieved.
- Goals describe outcomes that are measurable and precise.
 - Goals apply to the entire organization, whereas objectives are specific to an individual unit.

The strategic plan is based on the organization’s philosophy, vision, and mission.

The first steps in strategic planning are:

● Appoint a strategic planning committee
- People who are enthusiastic, experienced, and committed to the organization are the best representatives to
serve on the planning committee.
● Interview key stakeholders
- Stakeholders include physicians, administrators, nurses, ancillary and support staff, and community
representatives. They will have differing opinions about what the organization can and should do and provide
valuable information unavailable elsewhere.
● Conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis.
- The SWOT analysis includes assessment of the external and internal environment (Kalisch & Curley,
2008). Data is collected from multiple sources, including stakeholder information.
● Develop the plan
- To develop the plan:
✓ Determine goals, objectives and strategies
✓ Assess the projected costs
✓ Assign responsible units or individuals
✓ Identify outcome measures and expected dates of completion
● Communicate the plan

Other categories in a strategic plan include identifying the personnel responsible for each activity,
determining the projected cost, establishing criteria to recognize that the goal has been met, and deciding
the expected date of completion.
Strategic planning is an ongoing process, not an end in itself. It requires meticulous attention to how the
organization is meeting its goals and, if goals are not met, what the reasons are for the variance. Continual
evaluation will help the organization target its resources best.

STANDARDS OF NURSING PRACTICE

SCOPE OF NURSING PRACTICE

Definition of Nursing

“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and
injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, groups, communities, and populations.”
- This definition serves as the foundation for the following expanded descriptions of the Scope of Nursing
Practice and the Standards of Professional Nursing Practice.

Professional Nursing’s Scope and Standards of Practice

- A professional organization has a responsibility to its members and to the public it serves to develop the
scope and standards of practice for its profession.
- The American Nurses Association (ANA), the professional organization for all registered nurses, has long
assumed the responsibility for developing and maintaining the scope of practice statement and standards that
apply to the practice of all professional nurses and also serve as a template for evaluation of nursing specialty
practice.

Description of the Scope of Nursing Practice

- The Scope of Nursing Practice describes the “who,” “what,” “where,” “when,” “why,” and “how” of
nursing practice.
- Each of these questions must be answered to provide a complete picture of the dynamic and complex
practice of nursing and its evolving boundaries and membership.
✓ The definition of nursing provides a concise characterization of the “what” of nursing.
✓ Registered nurses and advanced practice registered nurses comprise the “who” constituency and have
been educated, titled, and maintain active licensure to practice nursing.
✓ Nursing occurs “when”ever there is a need for nursing knowledge, wisdom, caring, leadership,
practice, or education, anytime, anywhere.
✓ Nursing occurs in any environment “where” there is a healthcare consumer in need of care,
information, or advocacy.
✓ The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use
to practice professionally.
✓ The “why” is characterized as nursing’s response to the changing needs of society to achieve positive
healthcare consumer outcomes in keeping with nursing’s social contract with an obligation to society.
- The depth and breadth in which individual registered nurses and advanced practice registered nurses engage
in the total scope of nursing practice is dependent on their education, experience, role, and the population
served.

o Healthcare consumers are the patients, persons, clients, families, groups, communities, or populations
who are the focus of attention and to whom the registered nurse is providing services as sanctioned by the
state regulatory bodies.
o Registered nurses (RNs) are individuals who are educationally prepared and licensed by a state,
commonwealth, territory, government, or regulatory body to practice as a registered nurse. “Nurse” and
“professional nurse” are synonyms for a registered nurse in this document.
o Graduate-level prepared registered nurses are registered nurses prepared at the master’s or doctoral
educational level; have advanced knowledge, skills, abilities, and judgment; function in an advanced level
as designated by elements of the nurse’s position; and are not required to have additional regulatory
oversight.
o Advanced practice registered nurses (APRNs) are registered nurses:
• Who have completed an accredited graduate-level education program preparing the nurse for one of the
four recognized APRN roles [certified registered nurse anesthetist (CRNA), certified nurse midwife
(CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP)];
• Who have passed a national certification examination that measures APRN-, role-, and population-
focused competencies and maintain continued competence as evidenced by recertification in the role and
population through the national certification program;
• Who have acquired advanced clinical knowledge and skills preparing the nurse to provide direct care to
patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a
significant component of the education and practice focuses on direct care of individuals;
• Whose practices build on the competencies of registered nurses (RNs) by demonstrating a greater depth
and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions,
and greater role autonomy;
• Who are educationally prepared to assume responsibility and accountability for health promotion
and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which
includes the use and prescription of pharmacologic and non-pharmacologic interventions;
• Who have clinical experience of sufficient depth and breadth to reflect the intended license; and
• Who have obtained a license to practice as an APRN in one of the four APRN roles: certified registered
nurse anesthetist (CRNA), certified nurse midwife (CNM), clinical nurse specialist (CNS), or certified
nurse practitioner (CNP) (APRN Joint Dialogue Group, 2008).

Development and Function of the Standards of Professional Nursing Practice

- The Scope of Practice Statement is accompanied by the Standards of Professional Nursing Practice.
 - The standards are authoritative statements of the duties that all registered nurses, regardless of role,
population, or specialty, are expected to perform competently.
- The standards published herein may serve as evidence of the standard of care, with the understanding
that application of the standards depends on context.
- The standards are subject to change with the dynamics of the nursing profession, as new patterns of
professional practice are developed and accepted by the nursing profession and the public.
- Specific conditions and clinical circumstances may also affect the application of the standards at a given
time, e.g., during a natural disaster or epidemic.
- As with the scope of practice statement, the standards are subject to formal, periodic review, and
revision.
- The Standards of Professional Nursing Practice consist of the Standards of Practice and the Standards of
Professional Performance.

Standards of Practice

- The Standards of Practice describe a competent level of nursing care as demonstrated by the critical
thinking model known as the nursing process.
- The nursing process includes the components of assessment, diagnosis, outcomes identification, planning,
implementation, and evaluation.
- Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the
foundation of the nurse’s decision-making.

Standard 1. Assessment: The registered nurse collects pertinent data and information relative to the
healthcare consumer’s health or the situation.
Standard 2. Diagnosis: The registered nurse analyzes the assessment data to determine actual or potential
diagnoses, problems, and issues.
Standard 3. Outcomes Identification: The registered nurse identifies expected outcomes for a plan
individualized to the healthcare consumer or the situation.
Standard 4. Planning: The registered nurse develops a plan that prescribes strategies to attain expected,
measurable outcomes.
Standard 5. Implementation: The registered nurse implements the identified plan.
Standard 5A. Coordination of Care: The registered nurse coordinates care delivery.
Standard 5B. Health Teaching and Health Promotion: The registered nurse employs strategies to promote
health and a safe environment.
Standard 6. Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes.

Standards of Professional Performance

- The Standards of Professional Performance describe a competent level of behavior in the professional role,
including activities related to ethics, culturally congruent practice, communication, collaboration, leadership,
education, evidence-based practice and research, quality of practice, professional practice evaluation,
resource utilization, and environmental health.
- All registered nurses are expected to engage in professional role activities, including leadership, appropriate
to their education and position.
- Registered nurses are accountable for their professional actions to themselves, their healthcare consumers,
their peers, and ultimately to society.

Standard 7. Ethics: The registered nurse practices ethically.

Standard 8. Culturally Congruent Practice: The registered nurse practices in a manner that is congruent with
cultural diversity and inclusion principles.
Standard 9. Communication: The registered nurse communicates effectively in all areas of practice.
Standard 10. Collaboration: The registered nurse collaborates with healthcare consumer and other key
stakeholders in the conduct of nursing practice.
Standard 11. Leadership: The registered nurse leads within the professional practice setting and the
profession.
Standard 12. Education: The registered nurse seeks knowledge and competence that reflects current nursing
practice and promotes futuristic thinking.
Standard 13. Evidence-based Practice and Research: The registered nurse integrates evidence and research
findings into practice.
Standard 14. Quality of Practice: The registered nurse contributes to quality nursing practice.
Standard 15. Professional Practice Evaluation: The registered nurse evaluates one’s own and others’ nursing
practice.
Standard 16. Resource Utilization: The registered nurse utilizes appropriate resources to plan, provide, and
sustain evidence-based nursing services that are safe, effective, and fiscally responsible.
Standard 17. Environmental Health: The registered nurse practices in an environmentally safe and healthy
manner.

TRADITIONAL MANAGEMENT FUNCTIONS

PLANNING
- Planning is a four-stage process to:
● Establish objectives (goals)
● Evaluate the present situation and predict future trends and events
● Formulate a planning statement (means)
● Convert the plan into an action statement
- Planning is important on both an organizational and a personal level and may be an individual or group
process that addresses the questions of what, why, where, when, how, and by whom.
- Decision making and problem solving are inherent in planning.
- Planning can be contingent or strategic.
▪ CONTINGENCY PLANNING
- In Contingency Planning, the manager identifies and manages the many problems that interfere with
getting work done.
- Contingency planning may be reactive, in response to a crisis, or proactive, in anticipation of
problems or in response to opportunities.
▪ STRATEGIC PLANNING
- Strategic planning refers to the process of continual assessment, planning, and evaluation to guide the
future (Fairholm & Card, 2009).
- Its purpose is to create an image of the desired future and design ways to make those plans a reality.
ORGANIZING
- Organizing is the process of coordinating the work to be done.
- Formally, it involves identifying the work of the organization, dividing the labor, developing the chain of
command, and assigning authority.
- It is an ongoing process that systematically reviews the use of human and material resources.
- In health care, the mission, formal organizational structure, delivery systems, job descriptions, skill mix,
and staffing patterns form the basis for the organization.

STAFFING
- The goal of staffing is to provide the appropriate numbers and mix of nursing staff (nursing care hours) to
match actual or projected patient care needs (patient care hours) to provide effective and efficient nursing
care.
- To determine the number of staff needed, managers must examine workload patterns for the designated
unit, department, or clinic. For a hospital, this means determining the level of care, average daily census, and
hours of care provided 24 hours a day, seven days a week.
- Both the Joint Commission, hospitals’ accrediting body, and the American Nurses Association identify
staffing requirements. The Joint Commission (2011) requires that the right number of competent staff be
provided to meet patients’ needs based on organization-selected criteria.
- The American Nurses Association (ANA) (Manojlovich, 2009) specifies requirements for staffing systems:

PATIENT CLASSIFICATION SYSTEM

- Patient Classification Systems (PCSs), sometimes referred to as patient acuity systems, use patient needs to
objectively determine workload requirements and staffing needs.
- To be most effective, patient classification data are collected midpoint for every shift by the unit nursing
staff and analyzed before the next shift to ensure appropriate numbers and mix of nursing staff.
- Ideally, this system would accurately predict the number and skill level of nurses needed for the next shift.

SCHEDULING

Creative and Flexible Staffing

- Nurse shortages and current restrictions in salary budgets have made creative and flexible staffing patterns
necessary and probably everlasting.
- Combinations of 4-, 6-, 8-, 10-, and 12-hour shifts and schedules that have nurses working six consecutive
days of 12-hour shifts with 13 days off, and staffing strategies, such as weekend programs and split shifts, are
common.
- Flexible staffing patterns can be a major challenge and, in some cases, a mathematical challenge. However,
once a schedule is established and agreed to by the nurse manager and the staff, it can become a cyclic
schedule for an extended period of time, such as 6 to 12 months. This allows staff members to know their
work schedule many months ahead of time.

- Problems with combined staffing patterns may include:

● The perception that nurses don’t work full-time when they work several days in a row and then are off for
several days in a row
● Disruption in continuity of care if split shifts are used (7:00 to 11:00 a.m.; 11:00 a.m. to 3:00 p.m.; 3:00
p.m. to 7:00 p.m.; 7:00 p.m. to 1:00 a.m.; 1:00 a.m. to 7:00 a.m. shifts)
● Immense challenges for nurse managers to communicate with all staff in a timely manner

- Advantages of using combined staffing patterns are that it:

● Better meets patient care needs during peak workload times
● Improves staff satisfaction
● Maximizes the availability of nurses

Self-staffing and Scheduling

- Some hospitals have instituted self-staffing. This is an empowerment strategy that allows unit staff the
authority to use their backup staffing options if the patient workload increases or if unscheduled staff
absences occur.
- Likewise, staff can and must go home early if the patient workload decreases.
- Self-scheduling allows the staff to create and manage the schedule.
- Self-scheduling can be positive for the staff and for the manager, but attention must be paid to balancing
unit needs with individual requests (Bailyn, Collins, & Song, 2007).
- Whether the schedule is determined by the manager or by staff, the schedule can be transparent for all staff
by posting it online. In this way, the organization can demonstrate fairness in scheduling and leverage staff
expertise in an equitable manner.

Shared Schedule
- A new tool currently in use is a shared schedule.
- Two people share one full-time schedule by splitting the day of 12 hours into half days of 6.5 hours each,
alternating morning and afternoon shift.
- This allows nurses who might not be able to work the full 12 hours to share the shift.

Open Shift Management

- Open shift management is an innovative technique to allow an organization’s staff to self-schedule
additional shifts (Bantle, 2007).
- With the schedule posted online, staff members can select assignments and shifts that fit their expertise and
accommodate their personal schedules.
- This strategy is especially valuable to health care systems with several hospitals in which nurses from one
hospital can select assignments at any of the others.

Automated Scheduling
- Technology today makes automated scheduling feasible (Douglas, 2010).
- Matching patient demand to nurse staffing is better done by automated systems than by individuals.
- To aid in scheduling decisions, data should include patient information, nurse characteristics, and hospital
data (Frith, Anderson, & Sewell, 2010).
- Automated systems improve patient care outcomes because nurses spend more time with the patients who
need the most nursing care. In addition, using nurses’ time appropriately improves financial outcomes as well
(Barton, 2011).
- Data are often displayed on a dashboard. A dashboard is a computer display of real-time data collected from
various sources and categorized for use in decision making.

Supplementing Staff
- When there is a need for additional staff because of scheduled or unscheduled absences, increased workload
demands, or existing staff vacancies, the nurse manager or staffing person must find additional staff.
- Options include using PRN staff (staff scheduled on an as-needed basis), part-time staff, internal float
pools, or outside agency nurses.
- Supplemental staff are needed when workload increases beyond that which the existing staff can manage,
staff absences and resignations occur, and staff vacancies exist.

Internal Pools
- Acute staffing problems can be addressed by establishing internal float pools using nursing staff and
unlicensed assistive personnel (UAPs).
- Advantages:
✓ They can provide supplemental staffing at a substantially lower cost than external agency nurses.
✓ They are familiar with the organization. All staff participating in the internal float pool must be
adequately trained for the type of patient care they will be giving.
- Internal float pools can be centralized or decentralized.
• A centralized pool is the most efficient. A pool of RNs, LPNs, UAPs, and unit clerks are available for
placement anywhere in the institution. However, it may be difficult to place the person with the
correct skills for a particular unit at the needed time.
• In decentralized pools, a staff member usually works only for one nurse manager or on only one unit.
The advantages of decentralized pools include better accountability, improved staffing response, and
improved continuity of care.

External Pools
- For some institutions, agency nurses become part of the regular staff contracted to fill vacancies for a
specified period of time (e.g., a nurse on maternity leave). However, most agency nurses are used as
supplemental staff.
- All agency nurses require orientation to the facility and unit, and they must work under the supervision of
an experienced in-house nurse.
- Management must verify valid licensure, ensure that either the agency or agency nurse has current
malpractice insurance, and develop a mechanism to evaluate the agency nurse’s performance.
- Although an agency nurse may meet an urgent staffing need, continuity of care may be compromised and
there may be some staff resentment because these nurses may earn two to three times the salary of in-house
nurses.
MODALITIES OF CARE

FUNCTIONAL NURSING
- Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to a national
nursing shortage.
- The needs of a group of patients are broken down into tasks that are assigned to RNs, LPNs, or UAPs so
that the skill and licensure of each caregiver is used to his or her best advantage.
- Under this model an RN assesses patients whereas others give baths, make beds, take vital signs, administer
treatments, and so forth.
- As a result, the staff become very efficient and effective at performing their regular assigned tasks.
- Disadvantages of functional nursing include:
● Uneven continuity
● Lack of holistic understanding of the patient
● Problems with follow-up Because of these problems, functional nursing care is used infrequently in acute
care facilities and only occasionally in long-term care facilities.

TEAM NURSING
- Team nursing evolved from functional nursing and has remained popular since the middle to late 1940s.
- Under this system, a team of nursing personnel provides total patient care to a group of patients.
- In some instances, a team may be assigned a certain number of patients; in others, the assigned patients may
be grouped by diagnoses or provider services. The size of the team varies according to physical layout of the
unit, patient acuity, and nursing skill mix.
- The team is led by an RN and may include other RNs, LPNs, and UAPs. Team members provide patient
care under the direction of the team leader.
- The team, acting as a unified whole, has a holistic perspective of the needs of each patient. The team speaks
for each patient through the team leader.
- Typically, the team leader’s time is spent in indirect patient care activities, such as:
● Developing or updating nursing care plans
● Resolving problems encountered by team members
● Conducting nursing care conferences
● Communicating with physicians and other health care personnel
- With team nursing, the unit nurse manager consults with team leaders, supervises patient care teams, and
may make rounds with all physicians.
- To be effective, team nursing requires that all team members have good communication skills. A key aspect
of team nursing is the nursing care conference, where the team leader reviews with all team members each
patient’s plan of care and progress.
- Advantages of team nursing are:
● It allows the use of LPNs and UAPs to carry out some functions (e.g., making beds, transporting patients,
collecting some data) that do not require the expertise of an RN.
● It allows patient care needs requiring more than one staff member, such as patient transfers from bed to
chair, to be easily coordinated.
● The geographical boundaries of team nursing help save steps and time. Disadvantages of team nursing are:
● A great deal of time is needed for the team leader to communicate, supervise, and coordinate team
members.
● Continuity of care may suffer due to changes in team members, leaders, and patient assignments.
● No one person considers the total patient.
● There may be role confusion and resentment against the team leader, who staff may view as more focused-
on paperwork and less directed at the physical or real needs of the patient.
● Nurses have less control over their assignments due to the geographical boundaries of the unit.
● Assignments may not be equal if they are based on patient acuity or may be monotonous if nurses
continuously care for patients with similar conditions (e.g., all patients with hip replacements).
- Skills in delegating, communicating, and problem solving are essential for a team leader to be effective.
Open communication between team leaders and the nurse manager is also important to avoid duplication of
effort, overriding of delegated assignments, or competition for control or power. Problems in delegation and
communication are the most common reasons why team nursing is less effective than it theoretically could
be.

TOTAL PATIENT CARE

- The original model of nursing care delivery was total patient care, also called case method, in which a
registered nurse was responsible for all aspects of the care of one or more patients.
- In total patient care, RNs work directly with the patient, family, physician, and other health care staff in
implementing a plan of care.
- The goal of this delivery system is to have one nurse give all care to the same patient(s) for the entire shift.
- Total patient care delivery systems are typically used in areas requiring a high level of nursing expertise,
such as in critical care units or post anesthesia recovery areas.
- The advantages of a total patient care system include:
● Continuous, holistic, expert nursing care
● Total accountability for the nursing care of the assigned patient(s) for that shift
● Continuity of communication with the patient, family, physician(s), and staff from other departments
- The disadvantage of this system is that RNs spend some time doing tasks that could be done more cost-
effectively by less skilled persons. This inefficiency adds to the expense of using a total patient care delivery
system.

PRIMARY NURSING
- Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team
nursing, primary nursing was designed to place the registered nurse back at the patient’s bedside (Manthey,
1980).
- Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility
and authority for nursing care allocated to staff nurses at the bedside.
- Primary nursing recognized that nursing was a knowledge-based professional practice, not just a task-
focused activity.
- In primary nursing, the RN maintains a patient load of primary patients. A primary nurse designs,
implements, and is accountable for the nursing care of patients in the patient load for the duration of the
patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses (other RNs).
- Primary nursing advanced the professional practice of nursing significantly because it provided:
● A knowledge-based practice model
● Decentralization of nursing care decisions, authority, and responsibility to the staff nurse
● 24-hour accountability for nursing care activities by one nurse
● Improved continuity and coordination of care
● Increased nurse, patient, and physician satisfaction
- Primary nursing also has some disadvantages, including:
● It requires excellent communication between the primary nurse and associate nurses.
● Primary nurses must be able to hold associate nurses accountable for implementing the nursing care as
prescribed.
● Because of transfers to different units, critically ill patients may have several primary care nurses,
disrupting the continuity of care inherent in the model.
● Staff nurses are neither compensated nor legally responsible for patient care outside their hours of work.
● Associates may be unwilling to take direction from the primary nurse.

DIRECTING
- Directing is the process of getting the organization’s work done.
- Power, authority, and leadership styles are intimately related to a manager’s ability to direct.
- Communication abilities, motivational techniques, and delegation skills also are important.

POWER
DELEGATION
COMMUNICATION
TIME MANAGEMENT
CONFLICT MANAGEMENT

CONTROLLING
- Controlling involves comparing actual results with projected results.
- This includes establishing standards of performance, determining the means to be used in measuring
performance, evaluating performance, and providing feedback.
- The efficient manager constantly attempts to improve productivity by incorporating techniques of quality
management, evaluating outcomes and performance, and instituting change as necessary.

BUDGETING
PERFORMANCE EVALUATION / APPRAISAL
STAFF DEVELOPMENT
QUALITY IMPROVEMENT / QUALITY MANAGEMENT

Planning, organizing, directing, and controlling reflect a systematic, proactive approach to management.
This approach is used widely in all types of organizations, health care included, but Clancy (2008) asserts
that today’s rapidly changing health care environment makes it more difficult to control events and predict
outcomes.