Nursing Leadership and Management

BS NURSING / FOURTH YEAR

STUDENT ACTIVITY SHEET
Session # 1

LESSON TITLE: NURSING AS A PROFESSION Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can:
References:
1. Define profession;
2. Enumerate the criteria of a profession; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
3. Define a professional nurse; Venzon RN, MAN (2010), Professional Nursing In
4. Identify the qualifications and abilities of a professional The Phillippines 11th Edition: C & E Publishing, Inc.
nurse; and, 839 EDSA, South Triangle, Quezon City
5. Explain the BSN curriculum.

SUBJECT ORIENTATION
Your classroom instructor for this subject, Leadership and Management (with Professional Adjustment), is
____________________________. Your instructor will discuss to you the grading system, guidelines and policies.

MAIN LESSON

PROFESSION - an occupation or calling requiring advanced training and experience in some specific or specialized body of
knowledge which provides service to society in that special field.

CRITERIA OF A PROFESSION (According to William Shepard)

1. A profession must satisfy an indispensable social need and must be based upon well established and socially accepted
scientific principles.
2. It must demand adequate pre-professional and cultural training.
3. It must demand the possession of a body of specialized and systematized training.
4. It must give evidence of needed skills which the public does not possess; that is, skills which are partly inherent and partly
acquired.
5. It must have developed a scientific technique which is the result of tested experience.
6. It must require the exercise of discretion and judgment as to time and manner of the performance of duty. This is in
contrast to the kind of work which is subject to standardization in terms of unit performance or time element.
7. It must have a group of consciousness designed to extend scientific knowledge in technical language.
8. It must have sufficient self-impelling power to retain its members throughout life. It must not be used as a mere stepping
stone to other occupations.
9. It must recognize its obligations to society by insisting that its members live up to an established code of ethics.

QUALITIES OF A PROFESSION (Cited by Flexner and other authors)

1. A profession applies its body of knowledge in practical services that are vital to human welfare, and especially suited to
the tradition of seasoned practitioners shaping the skills of newcomers to the role.
2. It constantly enlarges the body of knowledge it uses and subsequently imposes on its members a lifelong obligation to
remain current in order to “do no harm”.
3. A profession functions autonomously (with authority) in the formulation of professional policy and in monitoring its practice
and practitioners.
4. It utilizes in its practice a well-defined and well-organized body of knowledge that is intellectual in nature and describes its
phenomena of concern.

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5. A profession has a clear standard of educational preparation for entry into practice.
6. A profession is distinguished by the presence of specific culture, norms, and other values that are common among its
members.

Genevieve K. and Roy W. Bixler also state that a profession

1. Utilizes in its practice a well-defined and well-organized body of specialized knowledge which is on the intellectual level of
higher learning;
2. Constantly enlarges the body of knowledge it uses, and improves its technique of education and service by the use of
scientific method;
3. Entrusts the education of its practitioners to institutions of higher education;
4. Applies its body of knowledge in practical services which are vital to human and social welfare;
5. Functions autonomously in the formulation of professional policy and in the control of professional activity;
6. Attracts individuals of intellectual and personal qualities who exalt service above personal gain and who recognize their
chosen occupation as a life work; and
7. Strives to compensate its practitioners by providing freedom to act on opportunity for continuous professional growth, and
economic security.

DEFINITION OF A PROFESSIONAL NURSE

- A professional nurse is a person who has completed a basic nursing education program and is licensed in his/her country
or state to practice professional nursing.

MEANING OF PROFESSIONAL NURSING

- The Philippine Nursing Act of 1991 (R.A. 7164) has been repealed by the Philippine Nursing Act of 2002 (R.A. 9173). Note
the changes in the scope of nursing practice.

ARTICLE VI
NURSING PRACTICE

SEC. 28. Scope of Nursing. — A person shall be deemed to be practicing nursing within the meaning of this Act when he/she
singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any
health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler,
pre-school, school age, adolescence, adulthood and old age. As independent practitioners, nurses are primarily responsible
for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other
health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of
suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to:

(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional
and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary
health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral,
topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In
case of suturing of perineal laceration, special training shall be provided according to protocol established;

(b) Establish linkages with community resources and coordination with the health team;

(c) Provide health education to individuals, families and communities;

(d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in
varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the
utilization of knowledge and decision-making skills of a registered nurse; and

(e) Undertake nursing and health human resource development training and research, which shall include, but not limited to,
the development of advance nursing practice;

Provided, That this section shall not apply to nursing students who perform nursing functions under the direct supervision of
a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is duty-bound to observe the
Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence
by continual learning through continuing professional education to be provided by the accredited professional organization
or any recognized professional nursing organization: Provided, finally, That the program and activity for the continuing
professional education shall be submitted to and approved by the Board.

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QUALIFICATIONS AND ABILITIES OF A PROFESSIONAL NURSE
A. Professional Preparation
The professional nurse must:
1. Have a license to practice nursing in the country;
2. Have a Bachelor of Science degree in Nursing; and
3. Be physically and mentally fit.
B. Personal Qualities and Professional Proficiencies
The personal qualities and professional proficiencies of a nurse include
1. Interest and willingness to works and learn with individuals/groups in a variety of settings;
2. A warm personality and concern for people;
3. Resourcefulness and creativity as well as well-balanced emotional condition;
4. Capacity and ability to work cooperatively with others;
5. Initiative to improve self and service;
6. Competence in performing work through the use of nursing process;
7. Skill in decision-making, communicating, and relating with others and being research oriented; and
8. Active participation in issues confronting nurses and nursing.

BASIC EDUCATIONAL PROGRAM IN NURSING

Until 1983, there was only one basic educational program in nursing - the four-year collegiate degree program leading to
the Bachelor of Science in Nursing. The basic three-year hospital-based program leading to the title Graduate in Nursing
was phased out. It is to be noted, however, that revision of this program continues as seen fit by the Council of Deans, the
Philippine Colleges of Nursing, the Commission on Higher Education, and nursing practitioners. Colleges may also add
courses that will enrich their curriculum.
However, effective School Year 1998-1999, the curriculum for the common two-year Associate in Health Science
Education (ASHE) was enforced.

THE BSN CURRICULUM

The four-year Bachelor of Science in Nursing Program offers a competency-based community oriented curriculum to
educate future nurse practitioners to assume their roles and responsibilities in the Philippine Health Care System. It aims to
prepare nurses for entry level positions in any healthcare setting in the country, I.e., hospitals, clinics, healthcare centers,
homes, and communities.
Specifically, the end-of-program competencies, also referred to as terminal competencies, expect a graduate to
1. Utilize the nursing process in the care of individuals, families, and community by
1.1. Assessing the client’s healthcare status,
1.2. Planning with client and/or significant others the nursing action based on identified needs and problems,
1.3. Implementing appropriate nursing interventions (wholly compensatory, partially compensatory, supportive,
educative),
1.4. Modifying interventions, and
1.5. Evaluating the results of nursing interventions accordingly based on criteria established;
2. Communicate effectively at all levels of healthcare in various settings by
2.1. Applying “therapeutic use of self’,
2.2. Documenting and reporting observations, responses to nursing actions, and
2.3. Relating with clients, families, communities, and groups and members of health team;
3. Utilize the elements of management in any healthcare setting by
3.1. Utilizing management process in the delivery of healthcare,
3.2. Participating in the formulation and implementation of policies, and
3.3. Working independently and/or in collaboration with others on matters promoting a better quality of life;
4. Utilize research findings in the care of clients; and
5. Assume responsibility for personal and professional growth and development by
5.1. Promoting professional and personal growth,
5.2. Accepting accountability for professional action, and
5.3. Participating in the solution of health/social problems.
Overall, the BSN program intends to produce a professional nurse who demonstrate the following behaviors:
1. Caring behavior (compassionate, competent and committed);
2. Ability to practice legal, ethico-moral, social responsibilities/accountabilities;
3. Critical and creative thinking; and
Skill in practicing S-K-A and values for the promotion of health, prevention of illness, restoration of health, alleviation of
suffering; assisting clients to face death with dignity and peace.

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CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Which of the following defines profession?

a. an occupation or calling
b. not requiring advanced training and experience in some specific body of knowledge
c. completion of basic nursing education program
d. provides service to society in all fields
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is/are included in the criteria of a profession? SATA.

a. A profession must satisfy an indispensable social need and must be based upon well established and socially
accepted scientific principles.
b. It must demand the possession of a body of specialized and systematized training.
c. A profession has a clear standard of educational preparation for entry into practice.
d. It must have developed a scientific technique which is the result of tested experience.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. All are cited as qualities of a profession, except.

a. It utilizes in its practice a well-defined and well-organized body of knowledge that is intellectual in nature and
describes its phenomena of concern.
b. A profession has a clear standard of educational preparation for entry into practice.
c. A profession is distinguished b the presence of specific culture, norms, and other values that are common
among its members.
d. Entrusts the education of its practitioners to institutions of higher education
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Who among the following cited and described the qualities of a profession?
a. Roy W. Bixler
b. Genevieve K.
c. Flexner
d. Webster
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. A professional nurse is:

a. A person who has completed a basic nursing education program
b. May or may not be licensed in his/her country
c. Distinguished by the presence of specific culture, norms, and other values
d. A member with lifelong obligations to remain current in order to “do no harm”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 4 of 7
6. The Philippine Nursing Act of 2002 is also known as:
a. R.A. 7164
b. R.A. 7146
c. R.A. 9173
d. R.A. 9137
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The scope of nursing can be found in which section of the Philippine Nursing Act of 2002?
a. 6
b. 28
c. 27
d. 26
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The professional nurse must: SATA.

a. Have a license to practice nursing in the country;
b. Have a Bachelor of Science degree in Nursing; and
c. Be physically and mentally fit.
d. A warm personality and concern for people
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The two-year program curriculum is also known as.

a. Bachelor of Science in Nursing
b. Graduate in Nursing
c. Associate in Health Science Education (ASHE)
d. Practical Nursing Program
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The BSN program intends to produce a professional nurse who demonstrates the following behaviors. SATA:
a. Caring behavior (compassionate, competent and committed);
b. Ability to practice legal, ethico-moral, social responsibilities/accountabilities;
c. Critical and creative thinking; and
d. Skill in practicing S-K-A and values for the promotion of health, prevention of illness, restoration of health,
alleviation of suffering; assisting clients to face death with dignity and peace.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________

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Education (Department of Nursing) 5 of 7
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

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You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This activity is to evaluate what you learned after the discussion and the activity.
3-2-1
Three things you learned:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________

Two things that you’d like to learn more about:

1. ________________________________________________________________________________
2. ________________________________________________________________________________

One question you still have:

1. ________________________________________________________________________________

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 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 2

LESSON TITLE: LICENSE TO PRACTICE NURSING Materials:

LEARNING OUTCOMES: Book, pen and notebook, index card/class list
Upon completion of this lesson, the nursing student can:
References:
1. Define license and registration;
2. Enumerate the requirements for registration and licensure Lydia M. Venzon RN, MAN, FPCHA Ronald M.
examination; Venzon RN, MAN (2010), Professional Nursing In
3. Learn the Oath of Professional Nurse; The Phillippines 11th Edition: C & E Publishing, Inc.
4. Identify grounds for revocation/suspension of license; and; 839 EDSA, South Triangle, Quezon City
5. Understand the concepts of due process.

LESSON PREVIEW/REVIEW
Based on the previous lesson, define profession, professional nurse and enumerate the qualifications and abilities of a
professional nurse.

MAIN LESSON

DEFINITION OF LICENSE
A license is a legal document given by the government that permits a person to offer to the public his or her skills and
knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license.
The license to practice nursing is granted by the appropriate authority to applicants or candidates who have fulfilled
certain established requirements. Such a license permits the nurse to practice within the country or state and gives him/her
the privilege of representing herself/himself as a licensed nurse.
The appropriate authority to administer, implement, and enforce the regulatory policies of government with respect to
the regulation and licensing of the various professions and occupations under its jurisdictions is the Professional Regulation
Commission (PRC).

Need for Licensure

The primary purpose of registration is to protect the health of the people by establishing minimum standards which
qualified practitioners must meet. Licensure discourages certain persons who may be tempted to misinterpret themselves
as nurses. It is the most important tool for legal control and enforcement of nursing practice. It is also used to gather
statistical data about nurses and nursing in the country.

DEFINITION OF REGISTRATION
Registration is the recording of names of persons who have qualified under the law to practice their respective
professions.
Nurses’ names are recorder in a registry or registration book which contains the following information:
1. Full name of registrant;
2. Number and date of registration;

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3. Age, sex and place of birth;
4. Place of business;
5. Post office address;
6. Name of school, college or university from which he or she graduated or in which he or she has studied;
7. Date of such graduation or term of study, together with the time spent in the study of the profession elsewhere, if any; and
8. All other degrees granted to him or her from other institutions of learning.
A certificate of registration is issued by the PRC to show such qualification.

Registration Required
Under the Philippine Nursing Act of 2002, R.A. 9173, Sections 12 and 20 state that license to practice nursing shall be
issued to those who pass the licensure examination or by reciprocity.

REGISTRATION BY RECIPROCITY (R.A. 9173, SEC. 20)

Reciprocity means mutuality in the grant and enjoyment of privileges between persons or nations. As applied to the
professions, it is a relation established by law, treaty or agreement between two countries or states, whereby each country
or state grants to citizens of each other, the privilege of being admitted to the practice of the profession within their
respective territorial jurisdictions.
Reciprocity is based on the principle of “do ut des” which means that for a country to expect a favor from another, it
should be willing to give a corresponding favor.
SEC. 20. Registration by Reciprocity. — A certificate of registration/professional license may be issued without
examination to nurses registered under the laws of a foreign state or country: Provided, That the requirements for
registration or licensing of nurses in said country are substantially the same as those prescribed under this Act: Provided,
further, That the laws of such state or country grant the same privileges to registered nurses of the Philippines on the same
basis as the subjects or citizens of such foreign state or country.
Specifically, these provisions are explained thus:
1. Nurses registered in the Philippines desiring to practice in said foreign state or country are granted under its laws the
same privileges as those accorded to its subjects or citizens and as are enforced by them. Proof of such reciprocity may be
verified from the Department of Foreign Affairs;
2. The applicant is a nurse registered under the law of her/his state or country;
3. The requirements for registration or licensing of nurses in a foreign country where the applicant is registered as nurse are
substantially the same as those prescribed under this Act; and
4. The applicant has resided in the Philippines for at least three consecutive years as provided by R.A. 5181.
Applicants for registration as nurses by reciprocity shall present to the Board of Nursing a properly completed
application on the prescribed form, together with their respective certificates of registration as nurse granted by their state or
country. In addition, the following shall be attached:
a. a certification from the Commission on Immigration and Deportation stating that they have been residents of the
Philippines for at least three (3) years prior to registration;
b. A copy of the law or petition thereof showing reciprocal practice with the Philippines; and
c. A copy of their officially approved Bachelor of Science in Nursing curriculum.
SEC. 21. Practice Through Special/Temporary Permit. A special/temporary permit may be issued by the Board to the
following persons subject to the approval of the Commission and upon payment of the prescribed fees:
(a) Licensed nurses from foreign countries/states whose service are either for a fee or free if they are internationally
well-known specialists or outstanding experts in any branch or specialty of nursing;
(b) Licensed nurses from foreign countries/states on medical mission whose services shall be free in a particular hospital,
center or clinic; and
(c) Licensed nurses from foreign countries/states employed by schools/colleges of nursing as exchange professors in a
branch or specialty of nursing;
Provided, however, That the special/temporary permit shall be effective only for the duration of the project, medical mission
or employment contract.

REGISTRATION BY EXAMINATION
A. Examination and Registration
SEC. 12. Licensure Examination. — All applicants for registration as a nurse and issuance of a certificate of registration
and professional identification card to practice nursing shall be required to pass a written examination which shall be given
by the Board in such places and dates as maybe designated by the Commission: Such examination must be in accordance
with and fully compliant with RA No. 8981, otherwise known as the “PRC Modernization Act of 2000.”
SEC. 13. Qualifications for Admission to the Licensure Examination. In order to be admitted to the examination for
nurses, an applicant must, at the time of filing his/her application, establish to the satisfaction of the Board he or she

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(a) Is a citizen of the Philippines, or a citizen or subject of a country which permits Filipino nurses to practice within its
territorial limits on the same basis as the subject or citizen of such country: Provided, That the requirements for the
registration or licensing of nurses in said country are substantially the same as those prescribed in this Act;
(b) Is of good moral character; and
(c) Is a holder of a Bachelor’s Degree in Nursing from a college or university that complies with the standards of nursing
education duly recognized by the proper government agency.

B. Requirements for Examination

For purposes of applying for the nursing licensure examination, the following documents are required of each applicant:
1. Original transcript of records with Special Order from the Department of education, Culture and Sports unless he/she is a
graduate of a level II accredited nursing program;
2. For state colleges and universities, original transcript of records with date of graduation;
3. Record of actual related learning experiences for the entire Bachelor of Science in Nursing program duly signed by the
Chief Nurse of the hospital or her duly authorized representative in addition to that of the Dean of the nursing school and the
clinical instructor;
4. Actual number of operating room scrubs and deliveries assisted, signed by the Chief Nurse or her duly authorized
representative in addition to that of the Dean of the nursing school and the clinical instructor;
5. Where applicable:
a. Birth Certificate;
b. Marriage Certificate;
c. Alien Certificate of Naturalization, and
d. Clearance showing dismissal of case from the Court of Prosecutor’s Office, if any.
The application form, together with the requirements, should be filed at the Professional Regulation Commission ten (10)
days prior to the first day of examination.
C. Fees for Examination and Registration
Applicants for licensure and for registration shall pay prescribed fees set by the Commission.
D. Scope of Examination
SEC. 14. Scope of Examination. — The scope of the examination for the practice of nursing in the Philippines shall be
determined by the Board. The Board shall take into consideration the objectives of the nursing curriculum, the broad areas
of nursing, and other related disciplines and competencies in determining the subjects of examinations.
Since May 1994, an integrated comprehensive nursing licensure examination has been designed to better measure the
level of competence or proficiency rather than the compartmentalized subject area examination. It cuts across clinical
nursing areas where examinees answer questions that necessitate recognition and understanding of concepts, theories,
and principles as well as the skills and attitudes involved in a given test problem situation. It draws knowledge from the five
broad areas of nursing - Fundamentals of Nursing; Maternal and Child Nursing; Community Health Nursing; Nursing of
Adolescents, Adults, and Aged; and Mental Health and Psychiatric Nursing, including Physiology and Anatomy,
Pharmacology and Therapeutics, Microbiology and Diet Therapy.
The examination shall be divided into four parts organized around four major goals in nursing: promotive, preventive,
curative, and rehabilitative.
E. Citizenship Requirements
The following are citizens of the Philippines as per Article IV Section 1-5 of the 1987 Philippines Constitution.
Section 1.
(1) Those who are citizens of the Philippines at the time of the adoption of the Constitution;
(2) Those who elect Philippine citizenship pursuant to the provisions of the Constitution of 1935.
Section 2. A female citizen of the Philippines who marries an alien shall retain her Philippine citizenship, unless by her
act or omission she is deemed, under the law, to have renounced her citizenship.
Section 3. Philippine citizenship may be lost or reacquired in the manner provided for by law.
Section 4. A natural-born citizen is one who is a citizen of the Philippines from birth without having to perform any act to
acquire or perfect the Philippine citizenship.
In jus sanguinis doctrine, the nationality of a person is determined by the law of his descent or parentage; the child
follows the citizenship of his father.
In jus soli doctrine, the nationality of a person is determined by the law of the place of his birth; the child born in a foreign
country, whatever may be the citizenship of the father, is a citizen of that country.
Naturalization is the act of adopting a foreigner and giving him the privileges of a native citizen.
F. Rating of the Nursing Licensure Examination
SEC. 15. Ratings. — In order to pass the examination, an examinee must obtain a general average of at least
seventy-five percent (75%) with a rating of not below sixty percent (60%) in any subject. An examinee who obtains an
average rating of seventy-five percent (75%) or higher but gets a rating below sixty percent (60%) in any subject must take
the examination again but only in the subject or subjects where he/she is rated below sixty percent (60%). In order to pass

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the succeeding examination, an examinee must obtain a rating of at least seventy-five percent (75%) in the subject or
subjects repeated.
Renewal examination shall be taken within two years after the last failed examination.
Reconsideration of Ratings. Requests for reconsideration of ratings may be entertained only on grounds of mechanical,
clerical or clear errors; or if it is conclusively shown that there had been malfeasance in the rating of papers. Such requests
should be filed with the Commission within ninety (90) days from the date of the official release of the examination results. It
is only after the review of the test papers that the examinee shall file the request for reconsideration in accordance with the
aforecited provision.
OATH-TAKING OF NURSES
Oath
All successful candidates in the examination shall be required to take an oath of profession before the Board or any
government official authorized to administer oaths prior to entering the nursing practice.
The schedule of mass oath-taking (date and place) is within fifteen days upon the release of the results of the licensure
examination, which is included in a press release by the Professional Regulation Commission.
The professional oath includes a pledge to support and defend the Constitution, bear true faith and allegiance to the
same, obey the laws, legal orders and decrees promulgated by the duly constituted authorities of the Philippines and
adherence to the ethical and professional standards of nursing.
The Commission, during the mass oath-taking, is assisted by the accredited professional organization. At this time, the
nurses are included as new members of their professional organization.

Oath of Professional Nurses

I, _______________ of _____________ hereby

solemnly swear that I will support and defend the
Constitution of the Philippines; that I will bear true faith
and allegiance to the same; that I will obey the laws, legal
orders, and executive orders promulgated by the duly
constituted authorities of the Republic of the Philippines;
and that I impose this obligation upon myself voluntarily,
without mental reservation or purpose of evasion.
I further solemnly swear that at all times and places
I will adhere closely to the ethical and professional rules
generally accepted by the Nursing Profession in the
Philippines, and that I will well and faithfully discharge
to the best of my ability the duties and obligations
incumbent upon a legally authorized nurse practitioner.
So help me God.

Issuance of Certificate of Registration/Professional License and Professional Identification Card

A certificate of registration/professional license as a nurse shall be issued to an applicant who passes the examination
upon payment of the prescribed fees. Every certificate of registration/professional license shall show the full name of
registrant, the serial number, the signature of the Chairperson of the Commission and of the Members of the Board, and the
official seal of the Commission.
A professional identification card, duly signed by the Chairperson of the Commission, bearing the date of registration,
license number and the date of issuance and expiration thereof shall likewise be issued to every registrant upon payment of
the required fees.

ANNUAL REGISTRATION
Every practicing professional or practitioner of the occupations regulated by the Professional Regulation Commission
shall pay fee for three (3) years which shall be paid on the professional’s birth month.
Should a professional fail to pay the annual registration fee on his/her birth month on the expiry year that it is due, a
surcharge of twenty percent shall be charged and for each calendar year thereafter that payment has not been made. It after
a lapse of five continuous years from the year it was last paid the annual registration fee has never been paid, the
delinquent’s certificate of registration shall be considered suspended and the practitioner’s name shall be dropped from the
annual roster for not having been in good standing. The professional may be reinstated only upon application and payment
of the required fee provided for registration as nurse without examination. Should a register nurse practitioner desire to stop
practicing his/her profession, he/she should inform the Board concerned in writing within one year from the time that he/she
stopped practicing in order to exempt him/her from the payment of annual registration fee. Should he/she intend to resume
practice his/her name shall be reinstated in the annual roster.

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 The annual registration card, at least for the calendar year immediately preceding, shall be presented to the collection
agent of the Bureau of Internal Revenue when paying his/her professional tax. The registration number, date of issuance,
and the year shown on the card shall be indicated on the official receipt as evidence that the payor is authorized by law to
practice the profession.
Automatic Registration of Nurses
All nurses whose names appear at the roster of nurses shall be automatically or ipso facto registered as nurses under
this Act upon its effectivity.

Non-registration and Non-issuance of Certificates of Registration/Professional License of Special/Temporary

Permit
No person convicted by final judgement of any criminal offense involving moral turpitude or any person guilty of immoral
or dishonorable conduct or any person declared by the court to be of unsound mind shall be registered and issued a
certificate of registration/professional license or a special/temporary permit.
The board shall furnish the applicant a written statement setting forth the reasons for its actions, which shall be
incorporated in the records of the Board.

RENEWAL OF THE NURSE’S LICENSE

Every registered nurse shall renew his/her license every three years with the Professional Regulation Commission on
the form prescribed, not later than the due date indicated in the Professional Regulation Commission license card and pay
the prescribed fee.
PRC Resolution Number 20047-179 series of 2004 entitled “Standardized Guidelines and Procedures for the
Implementation of the Continuing Professional Education Professionals” requires that the total CPE credits for registered
professionals with a Baccalaureate Degree shall be sixty (60) credits for three year. Any excess credits earned shall not be
carried over to the next three-year period except for doctoral and masteral degrees.

REVOCATION OR SUSPENSION OF CERTIFICATES OF REGISTRATION

The license to practice nursing is not a permanent or vested right since it may be granted upon condition and it may be
held subject to conditions. If these conditions are breached or violated, the authority that issues such may revoke this
license. A license cannot be revoked arbitrarily, it can only be revoked for special causes.
As provided by the Philippine Nursing Act of 2002 R.A. 9173, Section 23, the Nursing Board of the Professional
Regulation Commission shall have the power to revoke or suspend the certificate or registration/professional license or
cancel the special/temporary permit of a nurse upon any of the following grounds:
(a) For any of the causes mentioned in Section 22 of RA 9173;
(b) For unprofessional and unethical conduct;
(c) For gross incompetence or serious ignorance;
(d) For malpractice or negligence in the practice of nursing;
(e) For the use of fraud, deceit, or false statements in obtaining a certificate of registration/professional license or a
temporary/special permit;
(f) For violation of this Act, the implementing rules and regulations, Code of Ethics for nurses and Code of Technical
Standards for nursing practice, policies of the Board and the Commission, or the conditions and limitations for the issuance
of the temporary/special permit; or
(g) For practicing his/her profession during his/her suspension from such practice;
Provided, however, That the suspension of the certificate of registration/professional license shall be for a period not
exceeding four (4) years.

RE-ISSUANCE OF REVOKED CERTIFICATES

SEC. 24. Re-issuance of Revoked Certificates and Replacement of Lost Certificates. The Board may, after the
expiration of a maximum of four (4) years from the date of revocation of a certificate, for reasons of equity and justice and
when the cause for revocation has disappeared or has been cured and corrected, upon proper application therefor and the
payment of the required fees, issue another copy of the certificate of registration/professional license.
A new certificate of registration/professional license to replace the certificate that has been lost, destroyed or mutilated
may be issued, subject to the rules of the Board.
Suspension means that the nurse is not allowed to practice temporarily until final judgement of the case against him or
her is rendered. The license is not confiscated.
On the other hand, revocation means that the license to practice is confiscated either temporarily or permanently.

Prohibitions in the Practice of Nursing

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 A fine of not less than fifty thousand pesos (P50,000.00) nor more than one hundred thousand pesos (P100,000.00) or
imprisonment of not less than one (1) year nor more than six (6) years, or both, upon the discretion of the court, shall be
imposed upon:
(a) any person practicing nursing in the Philippines within the meaning of this Act:
(1) without a certificate of registration/professional license and professional identification card or special temporary permit or
without having been declared exempt from examination in accordance with the provision of this Act; or
(2) who uses as his/her own certificates of registration/professional license and professional identification card or special
temporary permit of another; or
(3) who uses an invalid certificate of registration/professional license, a suspended or revoked certificate of
registration/professional license, or an expired or cancelled special/temporary permit; or

(4) who gives any false evidence to the Board in order to obtain a certificate of registration/professional license, a
professional identification card or special permit; or
(5) who falsely poses or advertises as a registered and licensed nurse or uses any other means that tend to convey the
impression that he/she is a registered and licensed nurse; or
(6) who appends B.S.N./R.N. (Bachelor of Science in Nursing/Registered Nurse) or any similar appendage to his/her name
without having been conferred said degree or registration; or
(7) who, as a registered and licensed nurse, abets or assists the illegal practice of a person who is not lawfully qualified to
practice nursing.

(b) any person or the chief executive officer of a juridical entity who undertakes in-service educational programs or who
conducts review classes for both local and foreign examination without permit/clearance from the Board and the
Commission; or

(c) any person or employer of nurses who violate the minimum base pay of nurses and the incentives and benefits that
should be accorded them as specified in Sections 32 and 34; or

(d) any person or the chief executive officer of a juridical entity violating any provision of this Act and its rules and
regulations.

DUE PROCESS OF LAW

Concepts of Due Process
Under the Bill of Rights provided in the Constitution of the Philippines, “no person shall be deprived of life, liberty or
property without due process of law nor shall any person be denied equal protection of the laws.
The term “due process of law” is defined as a “law which means before it condemns, which proceeds upon inquiry and
renders judgment only after trial”. This means that every citizen shall hold his life, liberty, property and immunities under
protection of the general rule which governs society. Due process of law means such exercise of the powers of the
government as the settled maxim of law permits and sanctions. The fundamental requirement of due process of law is an
opportunity for hearing and defense.

FUNDAMENTALS REQUIREMENTS OF DUE PROCESS

Following are the fundamental requirements of due process as provided in Article III Section 14 of the New Constitution:
stating that no person shall be held to answer for a criminal offense without due process of law.
The Constitutional rights of the accused are enumerated as follows:
1. The accused is presumed innocent until the contrary is proved;
2. The right to free access to the courts and adequate legal assistance;
3. The right to remain silent and to have competent and independent counsel preferably of his/her own choice. If he/she
cannot afford the services of a counsel, he/she must be provided one;
4. The right to bail and protection against excessive bail;
5. The right to presumption of innocence until the contrary is proved;
6. The right to be heard by himself/herself and counsel;
7. The right to be informed of the nature or the cause of the accusation against him/her;
8. The right to have a speedy, impartial, and public trial;
9. The right to meet the witness face to face;
10. The right to have a compulsory process to secure the attention of witnesses face to face and the production of
evidence on his/her behalf;
11. The right against self-incrimination;
12. The right, when under investigation for the commission of an offense, to remain silent and to counsel, and to be
informed of his/her right;
13. The right against the use of force, violence, threat, intimidation or any other means which vitiates the free will;

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 14. The right against cruel and usual punishment;
15. The right against excessive fines; and
16. The right against double jeopardy.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Which of the following defines a license?

a. Record of names of persons
b. Recorded in a registry
c. A legal document given by the government
d. Mutuality in the grant and enjoyment of privileges between persons or nations
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Who is the appropriate authority to administer, implement, and enforce the regulatory policies of government with
respect to the regulation and licensing of the various professions?
a. Congress
b. President of the Philippines
c. Board of Nursing
d. PRC
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Nurses’ names are recorder in a registry or registration book which contains the following information: SATA
a. Place of business;
b. Post office address;
c. Name of school, college or university from which he or she graduated or in which he or she has studied;
d. Date of such graduation or term of study, together with the time spent in the study of the profession elsewhere,
if any
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. In what section of the RA 9173 was registration by reciprocity defined?

a. 20
b. 21
c. 13
d. 14
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. In registration by reciprocity, how many years does the applicant needs to reside in the Philippines?
a. 1
b. 2
c. 3
d. 4
ANSWER: ________

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RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Which of the following competencies is not included in the integrated comprehensive nursing licensure examination?
a. Theoretical Foundations of Nursing
b. Maternal and Child Nursing
c. Mental Health and Psychiatric Nursing
d. Pharmacology and Therapeutics
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. This doctrine states that the nationality of a person is determined by the law of his descent or parentage?
a. Jus soli
b. Jos suli
c. Jus sanguinis
d. Jus sanguinos
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The schedule of mass aoth-taking is within how many days upon the release of the results?
a. 2 years
b. 90 days
c. 15 days
d. 1 year
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. What PRC resolutions requires professionals to have a total of 60 CPE credits before renewal of license?
a. Article IV Section 1-5
b. PRC Resolution Number 2004-179 series of 2004
c. PRC Resolution Number 179-2004 series of 2004
d. PRC Resolution Number 2002-179 series of 2002
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The following are grounds for revocation/suspension of a professional’s license. SATA
a. For any of the causes mentioned in Section 22 of RA 7164;
b. For unprofessional and unethical conduct;
c. For gross incompetence or serious ignorance;
d. For malpractice or negligence in the practice of nursing;
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________

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Education (Department of Nursing) 8 of 9
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what you learned after the discussion and the activity.
1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 3

LESSON TITLE:THE LICENSING BOARD Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Identify who has the power to regulate the profession; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Enumerate qualifications of members to the nursing board; Venzon RN, MAN (2010), Professional Nursing In
and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Understand the Powers and Duties of the Board. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, Complete the Oath of Professional Nurses below.

Oath of Professional Nurses

I, _______________ of _____________ hereby

solemnly swear that I will ________ and _______ the
________________________; that I will bear true faith
and _____________ to the same; that I will obey the laws, legal
orders, and executive orders _______________ by the duly
constituted authorities of the _____________________;
and that I impose this ___________ upon myself voluntarily,
without mental reservation or purpose of ________.
I further solemnly swear that at all times and places
I will adhere closely to the ________ and professional rules
generally accepted by the ___________ _______________ in the
Philippines, and that I will well and _________ discharge
to the best of my ability the duties and ___________
incumbent upon a legally authorized nurse ______________.
So help me God.

MAIN LESSON

POWER TO REGULLATE THE PROFESSION

THE POWER to regulate the established professions in the Philippines and to examine the applicants to practice the same
is vested upon the Professional Regulation Commission (PRC) as created by Presidential Decree 223. The PRC is now an
agency of its own. The regulatory power with respect to the nursing profession is conferred upon the Professional
Regulatory Board of Nursing. However, PD 223 has been repealed by RA 8981, “The PRC Modernization Act of 2000”.

ORGANIZATION AND COMPOSITION

Republic Act 9173 provides for the creation of a Professional Regulatory Board of Nursing.
SEC. 4. Composition of the Board. The Board created under Section 3, Article III of the said Nursing Act shall be
composed of a Chairperson and six (6) members, representing the three (3) areas of nursing, namely, nursing education,
nursing service, and community health nursing. The Board shall be under the administrative supervision and control of the
Commission, and as such:
a. All records of the Board, including applications for examinations, administrative and other investigative cases
conducted by the Board shall be under the custody of the Commission; and
b. The Commission shall designate the Secretary of the Board and shall provide the secretariat and other support
services needed by the Board to implement the provisions of the said Nursing Act.
APRC- can issue subpoena Board-odd number President oppoints
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 Members of the Board are appointed by the President of the Philippines and confirmed by the Commission on
Appointments. Members of the Board of Nursing may be appointed by:
1. Regular appointment. The Philippine Nurses Association certifies for appointment to the Nursing Board of the
Professional Regulation Commission, twelve candidates who possess the required qualifications. They are ranked
accordingly. The list of the twelve certified nominee are forwarded to the Commissioner of the Professional Regulation
Commission for further screening. The Commissioner, in turn, submits the first six from the list to the President of the
Philippines. The President appoints the board member. Such appointment is confirmed by the Commission in
Appointments.
2. Ad Interim appointment. A board member is appointed in the meantime to fill in a vacancy or perform the duties of
an office during the absence of the regular incumbent. There is no definite term of appointment.
3. Doctrine of Hold-Over. In this instance, a member of the Nursing Board is permitted to continue to exercise the
functions of the office after the end of his/her lawful term until replaced. Naglapse term pero pinagpatuloy parin ng pres
SEC. 5. Appointment. The Chairperson and six members shall be appointed by the President of the Republic of the
Philippines upon the recommendation of the Commission: Provided, That all those who will be recommended by the
Commission to the President for appointment shall be duly licensed/registered nurses chosen only from among the
nominees submitted by the accredited professional organization of nurses in the Philippines to the Commission to fill up
vacancies. For this purpose, the following shall strictly be observed/complied with:
a. The Commission shall, before the last year of the term of office of any member, notify and request the accredited
professional organization of nurses in the Philippines to submit to the Commission at least three (3) qualified
nominees per vacancy.
b. The accredited professional organization of nurses shall upon receipt of the Commission’s request screen and
rank qualified nurses only for the purpose and submit three (3) nominees, per vacancy, to the Commission not
later than three months before the vacancy occurs.
c. The Commission, upon receipt of the list of nominees of the accredited professional organization of nurses in the
Philippines, shall rank said nominees and submit to the President of the Philippines two (2) nominees, per
vacancy, not later than two (2) months before the vacancy occurs, with the request that the appointment be issued
not later than thirty (30) days before the scheduled licensure examinations.
d. Reappointment shall be subject to the provisions of E.O. No. 496.
e. The necessary operating procedures to ensure strict compliance therewith shall be embodied in a Memorandum
of Agreement (M0A)by the Commission and the accredited professional organization of nurses.

QUALIFICATIONS OF MEMBERS TO THE NURSING BOARD

SEC. 6. Qualifications of the Chairperson and Members. The Chairperson and members of the Board shall, at the time
of their appointment, possess the following qualifications:
a. a natural born citizen and resident of the Philippines;
b. a member of good standing of the accredited professional organization of nurses;
c. a registered nurse and holder of a master's degree in nursing, education or other allied medical profession
conferred by a college or university duly recognized by the Government, provided that the Chairperson and
majority of the Members must be holders of a master's degree in nursing;
d. must have at least ten (10) years of continuous practice of the profession prior to appointment, the last five (5)
years of which must be in the Philippines; and
e. must not have been convicted of any offense involving moral turpitude.
Membership to the Board shall represent the three areas of nursing, namely, nursing education, and community health
nursing.

Requirements Upon Qualification as Chairperson and Member of the Board. Any person appointed as Chairperson or
Member of the Board shall:
a. Immediately resign from any teaching position in any school, college, university or institution offering bachelor of
Science in Nursing and/or review program for the local nursing board examinations;
b. immediately resign from any office or employment in the private sector and/in the government or any subdivision,
agency or instrumentality thereof, including government-owned and/or controlled corporations or their
subsidiaries; and
c. not have any pecuniary interest in, or administrative supervision over any institution offering Bachelor of Science in
Nursing including review classes.
Pecuniary interest refers to involvement of husband/wife, children, brothers/sisters, mother/father in any activity that
will conflict with his/her position in the Board, particularly money matters.

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TERM OF OFFICE
The Chairperson and Members shall hold office for a period of three (3) years and until their successors shall have been
appointed and qualified, provided that:
a. no Chairperson and Member shall be appointed and/or reappointed for more than two (2) terms or a period of six
(6) years;
b. appointment to a vacancy that occurs before the expiration of the term of office of the Chairperson/Member shall
cover only the unexpired portion of the term of the immediate predecessor; and
c. the Chairperson and Member shall take the proper oath of office prior to the performance of his/her duties.
The incumbent Chairperson and Members of the Board shall continue to serve for the remainder of their terms under
RA No. 7164 until their replacements shall have been appointed by the President and shall have been duly qualified.

COMPENSATION
SEC. 7. Compensation of Board Members. The Chairperson and Members of the Board shall receive compensation and
allowances comparable to the compensation and allowances received by the Chairperson and Members of other
professional regulatory boards. They are paid based on the principle of quantum meruit which means "as much as they
deserve".

REMOVAL OR SUSPENSION OF BOARD MEMBERS

SEC. 11. Removal or Suspension of Board Members. The President may remove or suspend any member of the Board
after having been given the opportunity to defend himself/herself in a proper administrative investigation, on the following
grounds:
(a) continued neglect of duty or incompetence;
(b) commission or toleration of irregularities in the licensure examination; and
(c) unprofessional, immoral or dishonorable conduct.

POWERS, FUNCTIONS AND RESPONSIBILITIES OF VARIOUS BOARDS (AS PER RA 8981-THE MODERNIZATION
ACT OF 2000)
The various professional regulatory boards shall retain the following functions and responsibilities:
a. to regulate the practice of the professions in accordance with the provisions of their respective professional
regulatory laws;
b. to monitor the conditions affecting the practice of the profession or occupation under their respective jurisdictions
and whenever necessary, adopt such measures as may be deemed proper for the enhancement of the
profession/occupation and/or them maintenance of high professional, ethical, and technical standards and for this
purpose the members of the Board duly authorized by the Commission with deputized employees of the
Commission, may conduct ocular inspections in industrial, mechanical, electrical or chemical plants or
establishments, hospitals, clinics, laboratories, testing facilities, mines and quarries, other engineering facilities,
and in the case of schools, in coordination with the Commission on Higher Education (CHED);
c. to hear and investigate cases arising from violations of their respective laws, the rules and regulations
promulgated thereunder and their Codes of Ethics and, for this purpose may issue summons, subpoena and
subpoena duces tecum to alleged violators and/or witnesses to compel their attendance in such investigations or
hearings: Provided, That, the decision of the Professional Regulatory Board shall, unless appealed to the
Commission, become final and statutory after fifteen (15) days from receipt of notice of judgment or decision;
d. to delegate the hearing or investigation of administrative cases filed before them except in cases where the issue
or question involved strictly concerns the practice of the profession or occupation, in which case, the hearing shall
be prescribed over by at least one (1) member of the Board concerned assisted by a Legal or Hearing Officer of the
Commission;
e. to conduct, through the Legal Officers of the Commission, summary proceedings on minor violations of their
respective regulatory laws, violations of the rules and regulations issued by the boards to implement their
respective laws, including violations of the general instructions to examinees committed by the examinees and
render summary judgment thereon which shall, unless appealed to the Commission, become final and executory
after fifteen (150 days from receipt of notice or judgment or decision;
f. subject to final approval by the Commission, to recommend registration without examination and the issuance of
corresponding certificate of registration and professional identification card;
g. after due process, to suspend, revoke or reinstate certificate of registration or license provided by law;
h. to prepare, adopt and issue the syllabi or tables of specifications of the subjects for examination in consultation
with the academe: determine and prepare the questions for the licensure examinations which shall strictly be
within the scope of the syllabus or table of specifications of the subject for examination, score and rate the
examination papers with the name and signature of the Board Member concerned appearing thereto, and submit
the results in all subjects duly signed by all members of the Board to the Commission within ten (10) days from the

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 last day of the examination unless extended by the Commission, determine he appropriate passing general rating
in an examination if not provided for in the law regulating the profession; and
i. to prepare an annual report of the accomplishments on programs, projects and activities of the Board during the
year for submission to the Commission after the close of each calendar year and make appropriate
recommendations on issues or problems affecting the profession to the Commission.

Administrative Supervision of the Board, Custodian of its Records, Secretariat and Support Services
The Board shall be under the administrative supervision of the Commission. All records of the Board, including
applications for examinations, administrative and other investigative cases conducted by the Board shall be under the
custody of the Commission.
The Commission shall designate the Secretary of the Board and support services to implement the provisions of this Act.

Powers and Duties of the Board

SEC. 11. Powers, Duties, Functions and Responsibilities of the Board of Nursing. The Board shall supervise and
regulate the practice of the nursing profession in the Philippines. As such, pursuant to the provisions of R.A. No. 9173 and
R.A. No. 8981, otherwise known as "PRC Modernization Act of 2000", the Board shall have the following specific powers,
functions, duties and responsibilities:
a. conduct the licensure examination for nurses;
b. issue, suspend or revoke certificates of registration for the practice of nursing
c. monitor and enforce quality standards of nursing practice in the Philippines and exercise the powers necessary to
ensure the maintenance of efficient, ethical and technical, moral and professional standards in the practice of
nursing taking into account the health needs of the nation;
d. ensure quality nursing education by examining the prescribed facilities of universities or colleges of nursing or
departments of nursing education and those seeking permission to open nursing courses to ensure that standards
of nursing education are properly complied with and maintained at all times. The authority to open and close
colleges of nursing and/or nursing education programs shall be vested on the Commission on Higher Education
upon written recommendation of the Board;
e. conduct hearings and investigations to resolve complaints against nurse practitioners for unethical and
unprofessional conduct and violation of this Act, or its rules and regulations. In connection therewith, the Board,
upon application with the court, is empowered to: in court as evidence
asking someone to
bringthesomething
1. issue subpoena ad testificandum
Yung two uny
sinasummoned-
and subpoena duces tecum to secure appearance of respondents and
witnesses and the production of documents, and
2. punish with contempt persons obstructing, impeding and/or otherwise interfering with the conduct of such
proceedings;
f. adopt and promulgate a Code of Ethics and a Code of Technical Standards for the practice of nursing in
coordination and consultation with the accredited professional organization of nurses within one (1) year from the
effectivity of the subject Nursing Act;
g. recognize nursing specialty organizations in coordination with the accredited professional organization. The
recognition of nursing specialty organizations shall be based on the criteria jointly developed by the Board of
Nursing and the Accredited Professional Organization;
h. subject to the review and approval of the Commission, prescribe, adopt, issue and promulgate guidelines,
regulations, measures, and decisions as may be necessary for the improvement of nursing practice, advancement
of the profession, and for the proper and full enforcement of the provisions of the "Philippine Nursing Act of 2002";
i. submit an annual report to the Commission at the close of its calendar year giving detailed account of its
proceedings and the accomplishments during the year and making recommendations for the adoption of
measures that will upgrade and improve the conditions affecting the practice of the nursing profession; and
1. in coordination with the accredited professional organization and appropriate government and private agencies,
initiate, undertake and conduct studies on health, human research production and utilization and development.

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CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Professional Regulation Commission was created by:

a. RA 8189
b. PD 223
c. PD 233
d. RA 8981
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The PRC Modernization Act of 2000 is also known as:

a. RA 7164
b. RA 9173
c. RA 8981
d. RA 8189
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Which of the following is true regarding the composition of the Board of Nursing?
a. Composed of a Chairperson and six (6) members, representing the three (3) areas of nursing, namely, nursing
education, nursing service, and community health nursing.
b. Composed of a Chairperson and seven (7) members, representing the three (3) areas of nursing, namely,
nursing education, nursing service, and community health nursing.
c. Composed of a Chairperson and five (5) members, representing the three (3) areas of nursing, namely, nursing
education, nursing service, and community health nursing.
d. Composed of a Chairperson and nine (9) members, representing the three (3) areas of nursing, namely,
nursing education, nursing service, and community health nursing.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. If the member of the Board was appointed to fill in a vacancy or perform the duties of an office during the absence of a
regular incumbent, he/she was appointed by:
a. Regular appointment
b. Ad Interim Appointment
c. Doctrine of Hold-over
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. A member of the Nursing Board is permitted to continue to exercise the functions of the office after the end of his/her
lawful term until replaced. This type of appointment is:
a. Regular appointment
b. Ad Interim Appointment
c. Doctrine of Hold-over
d. None of the above
ANSWER: ________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 7
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Who appoints the chairperson and members of the Nursing Board?

a. PRC
b. BON
c. Senators
d. President of the Philippines
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Reappointment shall be subject to the provisions of:

a. PD 223
b. EO No. 469
c. EO No. 496
d. PD 233
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The following are the qualifications of the chairperson and members. SATA
a. a natural born citizen and resident of the Philippines
b. a member of good standing of the accredited professional organization of nurses
c. a registered nurse and holder of a master's degree in nursing, education or other allied medical profession
conferred by a college or university duly recognized by the Government, provided that the Chairperson and
majority of the Members must be holders of a master's degree in nursing
d. must have at least ten (10) years of continuous practice of the profession prior to appointment, the last five (5)
years of which must be in the Philippines
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. What refers to involvement of husband/wife, children, brothers/sisters, mother/father in any activity that will conflict with
his/her position in the Board, particularly money matters?
a. Peculiary Interest
b. Pecuniary Interest
c. Peconiary Interest
d. Pecumiary Interest
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The compensation of the Board members is base on what principle that means “as much as they deserve”?
a. Subpoena ad testificandum
b. Subpoena duces tecum
c. Quantum meruit
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 6 of 7
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT: The Muddiest Point

This activity is to evaluate what you learned after the discussion and the activity.
In today’s session, what was least clear to you?
_______________________________________________________________________________________________

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Education (Department of Nursing) 7 of 7
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 4

LESSON TITLE: DIFFERENT FIELDS OF NURSING Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Enumerate the different fields of Nursing; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Discuss the advantages and disadvantages of the different Venzon RN, MAN (2010), Professional Nursing In
fields of Nursing; and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Enumerate the qualifications of each fields of Nursing. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Give 3 laws mentioned in the previous lesson and briefly explain:
1.
2.
3.

MAIN LESSON

CLASSIFICATION OF FIELDS OF NURSING IN GENERAL

The fields of nursing may be classified according to the following:
1. Hospital or Institutional Nursing
2. Public Health Nursing or Community Health Nursing
3. Private Duty or Special Duty Nursing
4. Industrial or Occupational Health Nursing
5. Nursing Education
6. Military Nursing
7. School Nursing
8. Clinic Nursing
9. Independent Nursing Practice

INSTITUTIONAL NURSING
Nursing in hospitals and related health facilities such as extended care facilities, nursing homes, and neighborhood
clinics, comprises all of the basic components of comprehensive patient care and family health. The concept of the modem
hospital as a community health center where in-patient and out-patient care are continuous describes the goal of medical
care in most general hospitals.
The educational qualification for beginning practitioners is a Bachelor of Science degree in Nursing. The nurse, as a
member of the healthcare team, participates in all phases of patient care of the acutely ill, the convalescing and the
ambulatory patient. The nurse cares for the patient in the hospital or in the out-patient department and plans for the nursing
care needs of the patient about to be discharged. The nurse performs nursing measures that and will meet the patient's
physical, emotional, social and spiritual health needs while in the institution and helps him and his family plan for his further
healthcare needs when he returns home. The nurse's functions involve assessment of the patient’s needs for nursing and
planning for giving or providing the care indicated whether this be personal care, rehabilitation measures or health
instructions. These functions include participation in the research and training activities carried on in the hospital, teaching
auxiliary personnel, and assisting in teaching and supervision of nursing and/or midwifery students, if there are affiliates in
the said institution.

Advantages of Staff Nursing in Hospitals

1. There is always a supervisor whom one can consult if problems exist.
2. Nurses are updated with new trends in medicine and in the nursing care of patients.

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Education (Department of Nursing) 1 of 14
3. They undergo rotation to different units and have a chance to determine their special area of choice before they are
assigned permanently in one area such as Medicine, Pediatrics, Surgery, ICU-CCU, Obstetrics, Operating Room,
Delivery Room, etc.
4. They have an eight-hour day and a forty-hour week duty which provide for two days of rest away from duty. They have
provisions for sick leaves, holidays, and vacations with pay according to personnel policies of the institution.
5. They have the chance to get promoted to higher positions if they are qualified.
6. Salary increases are given periodically according to merit system thereby increasing their initiative and best efforts.
7. They are considered an important member of the health team in providing care to the patients.
8. More staff development programs are available in hospitals.

Disadvantages of Staff Nursing in Hospitals

The disadvantages usually do not outweigh the advantages
1. There is a great the advantages, possibility of understaffing which may require nurses to put in overtime work and
sacrifice some of their plans. This is especially true in hospitals where budget for personnel is limited.
2. Because of the bulk of work, some staff nurses do not find time to improve their skills through continuing education
programs. Or, if the hospitals are in far-flung areas, no continuing education programs are provided.
3. Administrative problems and overwork may tend to dissatisfy the staff nurse.

Qualifications of Nursing Service Administrators

Section 29 of RA 9173 specifies that a person occupying supervisory or managerial position requiring knowledge of
nursing must:
(a) be a registered nurse in the Philippines;
(b) have at least two (2) years of experience in general nursing service administration;
(c) possess a Bachelor of Science degree in Nursing, with at least nine (9) units in management and administration courses
at the graduate level; and
(d) be a member of good standing of the accredited professional organization of nurses.
It is provided, however, that a person occupying the position of chief nurse or director of nursing service shall, in addition
to the foregoing qualifications, possess:
(a) at least five (5) years of experience in a supervisory or managerial position in nursing; and
(b) a master's degree in Nursing.
It is further provided that for primary hospitals, the minimum academic qualifications and experiences for a chief nurse
shall be as specified in subsections (a), (b), and (c) of this section: Provided, furthermore, That for chief nurses in the public
health agencies, those who have a master's degree in public health/community health nursing shall be given priority.
Provided, even further, That for chief nurses in military hospitals, priority shall be given to those who have finished a
master's degree in nursing and have completed the General Staff Course (GSC): Provided, finally, That those occupying
such positions before the effectivity of this Act shall be given a period of (5) years within which to qualify.
Anew trend in hospital nursing is clinical specialization. Nurses train in a special field of nursing of their choice. Courses
to prepare nurses desiring to perfect their clinical opportunities are offered in universities, usually at the master’s level.
These nurses must have the experience required before applying for a position as an expert practitioner.
Memorandum Circular No. 2000-05, series of 2000 of the Professional Regulation Commission, Board of Nursing,
mandates the implementation of this provision of the Philippine Nursing Act.

Nursing Specialty Certification

In this country, a Nursing Specialty Certification Program has been adopted by the Board of Nursing through Resolution
No. 14 series of 1999, and created a Nursing Certification Council under it to oversee the administration of new programs by
the Specialty Certification Boards.
SEC. 29. Comprehensive Nursing Specialty Program. Within ninety (90) days from the effectivity of this Act, the Board,
in coordination with the accredited professional organization, recognized specialty organizations and the Department of
Health, is hereby mandated to formulate and develop a comprehensive nursing specialty program that would upgrade the
level of skill and competence of specialty nurse clinicians in the country, such as but not limited to the areas of critical care,
oncology, renal and such other areas as may be determined by the Board.
The beneficiaries of this program are obliged to serve in any Philippine hospital for a period of at least two (2) years of
continuous service.
SEC. 33. Funding for the Comprehensive Nursing Specialty Program. The annual financial requirement needed to train
at least ten percent (10%) of the nursing staff of the participating government hospital shall be chargeable against the
income of the Philippine Charity Sweepstakes Office and the Philippine Amusement and Gaming Corporation, which shall
equally share in the costs and shall be released to the Department of Health subject to accounting and auditing procedures:
Provided, That the Department of Health shall set the criteria for the availment of this program.

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Education (Department of Nursing) 2 of 14
Benefits of Certification
Certification offers advantage to the individual nurse, the nursing profession, and the healthcare delivery system.
1. Nurses certified to be above minimum standards improve the quality of patient care.
2. Certification measures expertise beyond that which is measured in basic licensure.
3. Certification ensures continued competence in the changing world of healthcare.
4. Certification is a means of confronting the demands of healthcare.
5. It is a lifelong learning that advances nursing skill and knowledge to move the profession forward.
6. It enhances the nurse's self-image and the public's view of the profession.
What is the future of hospital nursing? All indications point to the development of additional nursing specialization that
will attract large numbers of nurses with varied educational backgrounds and who have had many kinds of clinical
experiences such as critical care nursing, neonatal care nursing, and rehabilitative nursing. Hospitals will continue to be the
principal employers of registered nurses in the foreseeable future.

PUBLIC HEALTH/COMMUNITY HEALTH NURSING

Public health community health nursing have often been used interchangeably. The National League of Philippine
Government Nurses, in developing the Standards of Public Health Nursing Practice in the Philippines (2006), differentiated
the two as follows:
a. Public Health Nursing refers to the practice of nursing in the 7 local, national and city health departments which
include health centers and public schools. It is community health nursing practice in the public sector.
b. Community health nursing is broader as it encompasses nursing practice in a variety of roles, which at times
include independent nursing practice.
In the nursing curriculum and in the licensure examination for nurses, the term used is community health nursing.
It includes parish nursing, in community mental health nursing, and school nursing.
The National Health Program of the Philippines gives as much emphasis on the promotion of health and prevention of
diseases rather than care of the sick. It needs a deeper involvement and close cooperation among all members of the health
team such as physicians, nurses, epidemiologists, dentists, sanitary inspectors, sanitary engineers, nutritionists, health
educators, social workers, the community, and the barangay leaders.
Effective coordination can best be achieved if all members have an understanding of, and respect for, each other's
function.

Advantages of Community Health Nursing

1. The focus of nursing care is on family and community health rather than on an individual basis. Here, the nurse will be
able to see the total picture of family and community health situation.
2. It gives the nurse a better perspective of the health conditions of the community and the health programs conceived and
implemented by the government, and to appreciate the nurses' role in nation building.
3. It maximizes efforts to improvise where there are no sufficient facilities, supplies, and equipment.
4. It enables the nurse to utilize various community resources and maximize coordination with other members of the health
team.
5. Focus of care is more on educational and preventive aspects. Thus, nurses have the privilege of contributing to the
program for healthy citizenry especially among the rural poor.
6. Individuals, families and communities are motivated to assume responsibility for their own healthcare.

Disadvantages of Community Health Nursing

1. Cases found in community health nursing are limited mostly to chronic and/or communicable diseases.
2. There are more hazards in public health than in hospital nursing, such as exposure to elements (inclement weather,
heat of sun, rain), dog or snake bites, accidents, etc.
3. There are no fixed hours of work. The nurse may be called upon any time of the day or night.
4. Some claim that community health nursing is not as exciting nor as glamorous as hospital work.
5. Facilities for care of the sick are limited so that practice or skills may also be limited.
6. The community health nurse may not be immediately aware of changes or trends in the fields of medicine or nursing.
7. Community health nursing is not a place for introverts. A nurse has to be outgoing to meet people.
8. There is no immediate supervisor to consult in case of emergency.
With the implementation of Primary Health Care, public health nurses are kept up-to-date through various continuing
education programs conducted by the Department of Health and Regional Health Offices. The entry salary of a community
health nurse is the same as that of a Senior or Head Nurse in government hospitals.

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Education (Department of Nursing) 3 of 14
NURSES IN IN-SERVICE EDUCATION PROGRAMS
In-service education programs have been in existence for many years both in hospitals and public health agencies. This
is one way of improving service in these agencies. Many tertiary hospitals and public health agencies have nursing staff in
charge of staff development training and research.
Nurses in this field need:
1. skills in nursing practice, therefore they must have at least two years experience in basic nursing practice;
2. understanding of skills in teaching, supervision, and consultation;
3. understanding of the relationship of these persons to the process of administration and research;
4. understanding of the broad problems and desirable practices in patient care planning; and
5. understanding of and skill in the use of problem-solving approach to resolve everyday problems in the practice of
nursing and in-service education in the areas of concern;
6. understanding of the role and functions of the revising personnel in this area of in education;
7. understanding of self and others involved in in-service education within the various agencies in nursing; and
8. ability to plan and implement programs for different kinds of nursing personnel.
Nursing Coordinators for Staff Development need to have at least four years of clinical practice and research and a
Master's Degree in Nursing. Nurse Instructors for in-service training programs need at least two years of experience in
clinical practice and research and a Master's Degree in Nursing preferably with a clinical specialization.
With the advent of Quality Assurance Programs in health services, nurses may also be employed as Quality Assurance
Coordinators in agencies where these programs are required. Nurses in this field need experience in clinical nursing and
research too.
General st
PRIVATE DUTY NURSING * specialis
Nurses in private practice are expected to be expert clinicians as well as expert generalists in nursing. They use the title
Private Duty Nurse, Private Nurse Practitioner, Special Duty Nurse or Private Duty Nurse Specialist.

Definition of Private Duty Practitioner

A private duty nurse is a registered nurse who undertakes to give comprehensive nursing care to a client on a
one-to-one ratio. She/he is an independent contractor. The patient may be provided care in the hospital or in the home.
Private duty nurse practitioners are grouped into two categories.
1. General Private Duty Nurse. The general private duty nurse has the capabilities for providing basic nursing care to
any type of patient, among which are:
a. assessment of the physical conditions and interpretation of the significance of his/her findings as basis for
planning the nursing care;
b. identification of emotional and social factors and relating these to signs and symptoms observed;
c. application of scientific principles in the performance of nursing techniques;
d. working with patient's family so that they gain understanding of his/her illness and cooperate towards
promoting early recovery of the patient;
e. utilization of laboratory and diagnostic tests in promoting progress of care and enhancing his/her own
usefulness as a health teacher and counselor;
f. knowledge and recognition of pharmacological effects of drugs and medications, their implications for nursing
actions as needed; and
g. interpretation of doctor's orders concerning medicines and treatments and communicating the same
effectively to the patient and carrying them out promptly and accurately with understanding of cause and
effects.
2. Private Duty Nurse Specialist. In addition to the foregoing abilities expected of the general nurse practitioner and
as a result of his/her specialized preparation, a private duty nurse specialist also demonstrates the following
competencies:
a. skill in handling, operating, and monitoring other complicated devices;
b. skill in interpreting data gathered from ECG, EEG, laboratory diagnostic results and vital signs;
c. skill in observing signs and symptoms and their favorable or untoward significance in the progress of patient
care; and
d. promptness and adeptness in instituting appropriate nursing measures.

Qualifications of a Private Nurse Practitioner

A private nurse practitioner must:
1. be a registered nurse in the Philippines;
2. have the following documents for the current year:
a. Professional Tax Receipt (PTR)
b. Professional Regulation Commission Card (PRC), and
c. Residence Certificate;

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Education (Department of Nursing) 4 of 14
3. have at least two (2) years of bedside nursing experience as a professional nurse in a general hospital immediately prior
to application;
4. be acceptable to the Director of Nursing Service as suitable for orientation to do private duty nursing;
5. be a full time private duty nurse;
6. preferably have undergone a Critical Care Nursing Course; and
7. be a certified I.V. Nurse therapist by the ANSAP (Association of Nursing Science Administrators of the Philippines).

Requirements
A private nurse practitioner is required
1. to undergo orientation in the hospital as conducted by the Nursing Service office;
2. to have the complete paraphernalia, e.g., blood pressure apparatus, pen light, bandage scissors, red and blue or black
pens, and clip board;
3. to wear full white nurse's uniform (cap, stockings, closed white shoes, I.D. Pin). Uniform blazers may be used if required
by the hospital;
4. to have medical certificate from a certified medical center or laboratory with chest-x-ray result, complete blood count,
urine and stool examination;
5. to give two (2) character references;
6. to acquire, for succeeding years, certificate of three( 3) seminars or continuing education programs attended; and
7. to show certification as an I.V. Therapist by the ANSAP.
The private duty nurse is expected to follow the rules and regulations of the hospital regarding nursing procedures, use
and procurement of equipment and supplies, system of medications, charting, diets, precaution techniques and others. As in
other fields of nursing, he/she is expected to adhere to the code of ethics and practice.

General Guidelines
1. Although a private duty nurse is considered an independent contractor, she/he is directly under the supervision of the
nursing service in the hospital, or of the Head Nurse in the unit. She/he is expected to make a comprehensive verbal
report to the Chief Nurse or Supervisor when they visit the patient and submit a written report to the Head Nurse at the
close of the shift. If relief is needed during meals or in time of other necessities, the Head Nurse should be notified so
that a reliever can be provided.
2. The private duty nurse is responsible for the nursing care of the patient. Nursing care encompasses the patient's welfare
physically, mentally and spiritually. The nurse is equally responsible for maintaining a safe, sanitary, and healthful
environment for the patient, and for the care of equipment used and other facilities provided in the room.
3. The private duty nurse shall endeavor to give complete nursing care before going off-duty.
4. While the private duty nurse on house case is directly responsible to the 'attending physician of the patient, a regular
monthly service audit shall be given to the Director of Nursing Service who referred her/him for employment.

Policies and guidelines for nurses accompanying patients out of the country
1. Passport and other travel papers. All expenses for fees and processing of visa and travel papers are paid for by the
patient or his/her representative.
a. Passport, paid round-trip ticket, and other papers should be in the possession of the private duty nurse at all times.
b. A travel and accidental insurance in the amount of P50,000.00 shall be provided for the private duty nurse and
paid for by the patient or his representative effective 72 hours before departure and throughout the period of stay
abroad while in the employment of the patient.
c. The corresponding amount of salary computed at eight (8) hours multiplied by two (2) shifts and the number of
days the patient plans to be out of the country shall be left in the Philippines for ready withdrawal by the private
duty nurse's authorized representative on designated dates per agreement of parties concerned.
d. A daily travel allowance in addition to the Private Duty Nurse's regular salary while out of the country is negotiable
with the employer.
e. The female private duty nurse who is caring for a male patient must be provided a separate room for rest periods.
f. All hotel, lodging and food expenses while out of town or out of the country shall be paid for by the employer.
2. The private duty nurse is required to:
a. leave with the Private Duty Nurses' Association in the Philippines her/his possible address of destination and
tentative duration of duty;
b. report presence to the nearest nursing organization in the area; and
c. report to the Philippine Nurses Association his/her arrival in the country.

Advantages of Private Duty Practice

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Education (Department of Nursing) 5 of 14
Private duty practice gives the following advantages:
1. the chance to see life as it really is, to study human nature and to know at close range interesting people of different
nationalities, cultures, religion and status;
2. the opportunity to make real friends through close association with the patient and his family;
3. the chance to travel and see the world
4. the ability to own time, adjust work and private life satisfactorily, and direct off-duty time into enjoyable leisure;
5. the chance to keep abreast with new knowledge and procedures which provide an exciting, stimulating experience, with
infinite variety of problems to solve and personal satisfaction to be gleaned; and
6. the challenge of giving his/her best in providing care and having the satisfaction of seeing its results.

Disadvantages of Private Duty Practice

1. Some private duty nurses create a situation in which the patients become totally dependent on them.
2. Many private duty nurses graduated so long ago and have not upgraded their knowledge and skills.
3. There are not enough nurses for evening and night shifts, for holiday, weekends, and vacation periods.
4. Being a lone practitioner minimizes opportunity for developing good relationships with other hospital personnel.
5. Some private duty nurses resent supervision by hospital staff.
6. Little assistance is given by the Head Nurse when the patient is critically ill and the private duty nurse needs help in
giving treatment or in changing the position of the patient. The private duty nurse sometimes goes without meals
because the Head Nurse does not arrange for relief when the patient cannot be left alone.
7. Private duty nurses have very little or no participation in professional activities. If they ever do, they do so on their own
time and expense.
8. Nurses who are very experienced and well-qualified receive the same fees as the new graduates.
9. Private duty nurses face problems in private practice being independent contractors and there is greater need for liability
insurance.
10. There are no retirement, insurance and medicare benefits unless the private duty nurses provide these for themselves.
The Private Duty Nurses Association of the Philippines defined the categories of the private nursing practitioners in
1975. In February 1976, it submitted to the Philippine Nurses Association the proposal to revise the rates from a twelve-hour
basis to an eight-hour basis. Standard rates for Private Duty Nursing was approved by the Board of Directors of the
Philippine Nurses Association in February 1976.
The rates to be charged for private duty are determined by the Private Duty Nurses Association of the Philippines.
Anyone interested may verify from the Philippine Nurses Association Headquarters or at the Nursing Service Office of
Lourdes Hospital in Mandaluyong City.

OCCUPATIONAL HEALTH NURSING OR INDUSTRIAL NURSING' company nurse (First aid)

Occupational Health Nursing was once called industrial nursing. In 1958, industrial nurses in the United States elected
to call themselves occupational health nurses to reflect the broader and changing scope of practice within the specialty.
Most of these nurses have experienced working in hospitals, in public health or some other branch of the profession.
Few nurses go into occupational health nursing. This is because occupational health nurses often work alone, and must
therefore possess maturity, experience, and wise judgment.
Occupational health nursing is the specialty practice that provides and delivers healthcare services to workers. The
practice focuses on promotion, protection, and supervision of workers' health within the context of a safe and healthy work
environment. Occupational health nursing is autonomous and occupational health nurses make independent nursing
judgements in providing health services.
Since occupational health nurses work alone in situations where they may have to give immediate care to patients with
serious injuries, they need to be fully informed about their legal responsibilities. The first consideration is the patient's
welfare. They must make use of whatever first aid and nursing measures they judge necessary, bearing in mind their
professional limitations. Emergency or more extreme measures may be used during life-and-death situations. Their actions
will be judged against the yardstick of reasonable, prudent nursing practice.
As in other fields of nursing, a Bachelor's Degree in Nursing is required of occupational health nurses. This field of
nursing requires special skills. A good preparation is a year or more in emergency nursing, such as actual nursing
experience under the direction of a skillful nurse in this field. Helpful skills include ability to take and read ECGs, eye
screening, audiometer testing, laboratory tests, and X-ray.
In addition, industrial nurses must know company policies on personnel, insurance benefits, sick leave, pay rates, health
programs, medical matters and records. Since industrial nurses may have only part-time or on-call medical direction, they
may find themselves custodians of employees' health records, counselors and advisers of the workers, interpreters of
company policies, health and safety teachers as well as first aiders to the injured.
Most occupational nurses have to bargain individually for their salaries. Only few employers hire enough nurses to make
up a bargaining unit. This has hurt salaries in industrial nursing to an extent and pay is probably less than in hospital work.
But there are compensations. Often, the industrial nurse works only during day hours. They are off duty on weekends most

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Education (Department of Nursing) 6 of 14
of the time. Exceptions to these are nurses in large plants which may require overtime work. There are usually seniority
wage increases, pensions, and insurances.
Fortunately, beginners in this field have a wide variety of help available. Valuable literature may be obtained from many
sources. They may also seek support from fellow practitioners through the Occupational Health Nurses Association of the
Philippines.

NURSING EDUCATION
Career opportunities in nursing education are better today than before. There is a chronic teacher shortage in all nursing
education programs. Nurses who like to consider teaching as their field of expertise will have to consider the following
qualifications.

Qualifications of the Faculty

A member of the faculty in a college of nursing teaching professional courses must:
(a) be a registered nurse in the Philippines;
(b) have at least one (1) year of clinical practice in a field of specialization;
(c) be a member of good standing in the accredited professional organization of nurses; and
(d) be a holder of a master's degree in nursing, education, or other allied medical and health sciences conferred by a
college or university duly recognized by the Government of the Republic of the Philippines.
The practice of some schools to hire as faculty members those underboard nurses or those without any experience
contributes to the poor quality of nursing students who later will become incompetent nurses themselves. This practice also
subjects said nurses and their employers to legal problems that may arise later.
Personal qualities and special abilities of faculty members include:
1. capability to promote interest in the subject they teach; stimulate the minds of the students, arouse enthusiasm,
quicken imagination, and awaken ambition;
2. competence in the particular field they teach;
3. resourcefulness with infinite patience, understanding, confidence and perseverance. They must be able to inspire
students to develop their fullest potential; and
4. expertise in providing nursing care in the chosen field aside from the qualities of good role models.
The career ladder in nursing education starts with a Clinical Instructor's position up to that of a Dean of a College of
Nursing.
A dean in a college of nursing should possess a Master's Degree in Nursing and must have at least five (5) years of
experience in teaching and supervision as per R.A. 9173. Those teaching at the Graduate Programs for nurses must
possess post-Master's Degree or a Doctoral Degree in Nursing.
Generally, salaries of those in the field of nursing education are higher than of those working in the hospitals. These vary
according to the teachers' experience, their fields of specialization and their educational attainments.
Nursing education is an interesting, important, and challenging field and the opportunities for well-prepared nursing
educators are numerous.

MILITARY NURSING Natural Born

The Nurse Corps
When the famed Tandang Sora led the nursing of the sick and wounded Katipunan revolutions in 1890, military nursing
in the Philippines may be said to have begun. However, the Nurse Corps we know today dates back more precisely about
three decades ago, shortly before the outbreak of World War II.
Commonwealth Act No. 1, commonly know as the National Defense Act, clearly provided the establishment of a medical
service in the army of the Philippines. However, the component corps were not specified. On September 5, 1938, the
National Defense Act was amended by Commonwealth Act. No. 385 whereby the different corps of the medical services
were explicitly spelled out, with the Nurse Corps being one of them. This is the date celebrated by the Nurse Corps as its
foundation day.
Inspite of the legal basis for its existence, the Nurse Corps was not organized until about mid-1940, when President
Manuel L. Quezon issued Executive Order No. 2167, dated April 15, 1940. This provided for the rules of the organization of
the Philippine Army Nurse Corps Reserve intended to be mobilized in the event the Philippines would be involved in the
impending war in the Far East. In accordance with this new legislation, nurses began to be commissioned as early as July
1940. At about this time in the US Army, the Army nurses were given only relative ranks as officers. Perhaps this was the
reason why those who were first commissioned under the Nurse Corps were only given relative ranks as second and third
lieutenant depending on their age, education, and experience.
To emphasize the female composition of the Corps, the term Nurse Corps as provided for in C.A. 385, was changed to
the Female Nurse Corps, pursuant to Commonwealth Act No. 569, dated June 7, 1940. By the end of 1941, there were
about 200 nurses commissioned into the Nurse Corps. For some unknown reasons, the legal basis of the Nurse Corps'
existence under the Philippine government became Executive Order No. 267, the provision of which was very far from the
benefits given by the USAFFE. To prevent a retrogression in the status of the military nurses, they began the long and

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Education (Department of Nursing) 7 of 14
tedious fight because the military authorities were not very sympathetic with the plight of military nurses. With the aid of the
Philippine Nurses Association, the military nurses were able to lobby at the Congress for the passage of a bill that would
re-designate the female nurses as a component of the Medical Service. As Nurse Corps, the members would be guaranteed
the same rights and privileges as those granted Nor. 203 the other members of the military. This resulted in the approval of
Republic Act on May 12, 1948 by Pres. Elpidio Quirino, placing the Nurse Corps in proper perspective among the other
military organizations.
R.A. 479 of June 10, 1950 amended R.A. 203, and gave credit to the services of military nurses during men war. It also
provided basis for determining the grade and rank, seniority, and retirement of NC officers. In August 1952, the title Army
Nurse Corps, Medical Service, was changed to Nurse Corps, AFP. Regular officers were integrated in 1953.
Prior to 1973 the Chief Nurse was merely a staff of the Office of the Surgeon General and had no direct management
and administrative functions in the AFP Nursing Service. With the activation of the Office of the Chief Nurse in the Armed
Forces of the Philippines and the designation of the Chief Nurse as Technical Staff of General Headquarters on June 21,
1973, the Chief Nurse has been afforded the prerogative to decide on matters purely affecting the Nurse Corps and the
nursing personnel in the Armed Forces of the Philippines. This position now holds the rank of a Brigadier General. The first
military nurse to hold this rank was Brig. Gen. Elvegia R. Mendoza.

Functions of the Nurse Corps, AFP

The AFP Nurse Corps provides comprehensive and quality nursing care to all military personnel, their dependents and
authorized relatives.
The functions of the AFP Nurse Corps may be grouped into three (3) broad areas:
1. to meet the nursing needs of today's patients in AFP medical facilities;
2. to prepare each Nurse Corps Officer (regular and reserve) for future assignments at a higher level of responsibility
in the different stations and general hospitals in times of peace and war; and
3. to teach and train enlisted personnel who perform nursing functions under supervision. Special emphasis is on
enlisted members who function in settings where there are no nurses.

Qualifications of the Military Nurse

Principle. The nurse consciously and scientifically intervenes in the health and illness environment for the purpose of
ensuring that the soldier, his family and other significant groups will have adequate personal care, maintenance, safety, and
comfort.
Rationale. The military nurse works at different health settings with various levels of responsibilities. As such, he/she must
have the professional, personal and other qualifications commensurate with job responsibilities.

Criterion I - Qualifications for Commission in the Reserve Force Nurse Corps

Anyone who wants to be commissioned in the Reserve Force Nurse Corps must
a. have a Bachelor of Science degree in Nursing from a duly recognized university/college;
b. be licensed to practice nursing;
c. be a natural-born Filipino citizen;
d. be single or has never been married for both male and female candidates. Female applicants must not positively be
found to have given birth to a living or still-born child;
e. be mentally and physically fit for military service and cleared by appropriate security agencies;
f. have a pleasing personality and a good moral character;
g. be skillful in
(1) applying the nursing process in meeting health/nursing needs of individuals/families/groups/communities,
(2) communicating and relating with others, and
(3) making sound/rational judgment in a given situation;
h. be interested and willing to work in both peaceful and wartime conditions;
i. not be more than thirty two (32) years of age at the time of commission; and
j. satisfy the following height requirements-
1) minimum of sixty two (62) inches for males, and a
2) minimum of sixty (60) inches for females.

Qualifications for Commission in the Regular Force, Nurse Corps

In addition to the requirements for commission in the Reserve Force, anyone who wants to be commissioned in the Regular
Force, Nurse Corps must
a. successfully pass the rigid screening and battery test for the purpose;
b. satisfy the height requirements of (PLEASE SEARCH THE INTERNET FOR THE LATEST HEIGHT REQUIREMENT)
1) minimum of 64 inches for males, and a
2) minimum of 62 inches for females; and
c. not be more than 26 years of age at the time of regular commission.

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Education (Department of Nursing) 8 of 14
Qualifications for Call to Active Duty (CAD)
Anyone who seeks to be qualified for CAD
a. must be commissioned;
b. must have at least one year nursing experience in a reputable health agency;
c. must have been cleared by appropriate security agency; and
d. must have passed the physical and mental examinations conducted by the appropriate authorities.

Qualifications for General Duty Nurse

Anyone who desires to be qualified as General Duty Nurse
a. would have the rank of Second Lieutenant;
b. must have adequate knowledge of general nursing theory and practice, including basic knowledge about biological,
social, and medical sciences and their application;
c. must have knowledge of new developments in the nursing field; and
d. must demonstrate ability to perform comprehensive nursing care,

Characteristics of the Work

As in other civilian hospitals, nursing service in the military seeks to provide the highest quality of nursing care to
patients: in-patients in the hospitals and out-patients in the dispensaries. Like in other hospitals, they also maintain different
sections like the surgical intensive care unit, the Operating Room and the Anesthesia Sections, The Recovery Ward,
OB-Gyne, Pediatrics, Neuropsychiatry, Nuclear Medicine Section, and the Family Planning Section manned by nurse
specialists who have been trained locally and abroad.
The medical corpsmen are highly trained enlisted personnel who help in the care of patients, especially the males.
Nursing attendants are unskilled non-professionals, who assist nurses and doctors in the wards. In times of emergency and
as the exigency of the service so requires, the corpsmen and attendants are authorized to do other medico-surgical
procedures like injection, giving medications, catheterizations, castings, intravenous infusions, circumcisions, suturing of
wounds, and other duties as may be required of them. Each of these medical assistants has his/her own specialized training
and is under the direct supervision and responsibility of the nurse or the surgeon.

Privileges and Benefits of a Military Nurse

Enumerated below are the benefits and privileges which military nurses are entitled to receive.
1. High salary rate and allowances according to rank:
a. as Second Lieutenant, they will initially receive the same base pay as officers of equivalent rank, incentive pay,
subsistence allowance, quarters allowance, clothing allowance, and others when applicable;
b. flight pay for flight nurses which is 50% of base pay;
c. hazard pay (radiation hazard pay) which is 20% of base
d. cold weather clothing allowance for those assigned in pay; cold regions like PMA in Baguio, or areas abroad; and
e. overseas pay when detailed to foreign countries on schooling, or on missions.
2. Glamour and prestige of the uniform, rank and position. All junior officers and enlisted personnel will salute and accord
them due military courtesy.
3. Hospitalization and free medical benefits for parents, dependents, authorized relatives with specialists' care.
4. Military schooling and basic training at the Armed Forces Medical Service School at the V. Luna Medical Center
(VLMC).
5. Opportunity to meet people who hold key positions in the AFP and in the government.
6. Opportunity to attend gala, social functions and parade.
7. Opportunity to travel abroad.

Flight Nursing in the Philippines

One field of nursing that is considered peculiar only to the military and to the Air Force is flight nursing or aero-space
nursing. A flight nurse is responsible for patients, military or otherwise, who have been evacuated from battle areas to the
nearest installation for treatment.
Air evacuation relieves congested areas, giving way to forward-moving vehicles and troops. It also reduces medical
personnel and supply requirements of military operations. Furthermore, it prevents the possible loss of life due to shock or
injuries and cuts down permanent disability to the minimum. Early hospitalization and faster relief from pain bolster the
morale of both patients and effective troops left in battle areas and places of assignment.
The aero-medical section of the different air bases of the Philippine Air Force is tasked with carrying out this mission in
line with the overall objective of the AFP Medical Service which is to conserve the fighting strength of the troops.
A flight nurse is a commissioned officer of the Nurse Corps in the active service, usually assigned in Philippine Air Force
(PAF), and who has undergone special training and instruction about flight nursing in the Philippines or abroad. To be

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considered really competent, he/she must be genuinely interested in flying and attending to patients even under the most
trying conditions around the clock; yet still able to perform regular hospital nursing duties when not on flight alert. If he/she
does not possess enough maturity and sense of responsibility, these taxing obligations are sufficient to make him/her a
liability.
A great percentage of flight missions include evacuation of civilians, mostly indigents, who come from areas not usually
reached by commercial airlines. On such missions, the flight nurse is the most important member of the aeromedical team.
More often than not, medical missions are performed without a flight surgeon. When such situations arise, the flight nurse
assumes full responsibility for the care of the patients.

SCHOOL HEALTH NURSING

School health nursing is very different from hospital nursing. School health nurses must like children a lot. They often
work alone, out of touch with other nurses, the hospital and all professional supports they have known. They are responsible
for the school's activities in the areas of health service, health education, and environmental health and safety.
The primary function of the school is education. The health program of each school is geared toward making the
students and faculty understand those programs which emphasize health promotion, prevention of disease, and
follow-through of any findings that may indicate a need for medical care and treatment. They perform a wide variety of
services including basic screening for vision, hearing, and risk factors that would interfere with the development of a healthy
lifestyle.
For a school nurse, team relationship with other members of the school staff and participation in their activities will
depend on the size of the school, the community, the health needs of the pupils, and availability of other personnel such as
social workers or guidance counselors.
Some responsibilities of the school nurse are:
1. organizing and implementing the school health program;
2. coordinating school health programs;
3. undertaking functions directly related to pupil's health;
4. evaluating school health programs; and
5. carrying out functions related to the health of school personnel.

Advantages of School Health Nursing

School nursing affords one the opportunity to watch children advance from grade to grade in school health. Hours are
usually good and there is no shift duty.

Disadvantages
Many school nurses do not update themselves on the current issues in nursing making them unaware of changes in the
nursing practice.
School nurses should enjoy working with children and should be able to work through, and with others to achieve their
objectives. They should accept the educational functions of the school and be committed to the promotion of health through
education.

CLINIC NURSING
Clinic nursing requires that a nurse possess general skills. Usually a doctor has been in general practice for a number of
years. It is with him that the nurse acts as a receptionist, answers phone, does the billing, takes x-rays and ECGs, changes
dressings, gives injections (such as BCG, DPT, or measles vaccine), and assists in physical examinations. The nurse may
even do autoclaving of instruments, keep records, order and store supplies, make follow-up calls and referrals for patients.
Teaching patients and their families has become an important function of the clinic nurse. Nurses in this field must have
excellent teaching and communication skills, exhibit organizational and leadership ability, possess good assessment skills,
and have good insight in order to anticipate and interpret the needs of their patients.
The advantages of clinic nursing are favorable working hours, the satisfaction of working with people they know and like
and who know and like them in return. Efficient clinic nurses are trusted in their judgement and share in planning the care of
the patient.
Generally, and on the average, clinic nurses receive a slightly lower salary than hospital nurses. A written contract
setting forth the professional and personal arrangements between the nurse and the employer can be mutually beneficial.

ADVANCED PRACTICE NURSING

This field of nursing is synonymous with specialization. Even specialization is a hallmark of a mature discipline. The
advanced practice nurse is an umbrella term for nurses who have specialized education and experience beyond the basic
nursing program. This advanced practice requires the knowledge skills and supervised skills obtained through graduate
study in nursing (either master's or doctoral degree). This field covers the role of the clinical nurse specialist.
The Clinical nurse specialist is also known as a nurse specialist, nurse clinician or clinical specialist. The clinical
specialist is an expert practitioner within a specialized field of nursing. Some may concentrate on cancer, rehabilitation, care

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Education (Department of Nursing) 10 of 14
of patients with ostomies, neurological conditions, psychiatry, and many other subspecialties. These nurses participate in a
range of subroles including direct patient care, research, teaching, consultation, and management.

INDEPENDENT NURSING PRACTICE

How would you like to hang at your gate or window a sign bearing your name and the words "Independent Nurse
Practitioner?" Here in the Philippines, there are already few nursing clinics, a group of nursing specialists, and a project
subsidized by the Philippine Nurses Association, wherein nurses do independent nurse practice.
As the term implies, "independent" means the nurse is self-employed and provides professional nursing services to
clients/ patients and their families. While some independent nursing practitioners set up their clinics near a hospital (as in the
case of the Psychiatric Nursing Specialists, Inc.), most of them are community-based. These nurses reach out and offer their
services rather than expect clients to seek their help. They perform both independent and collaborative roles. Healthcare
assessment, formulating plans for health maintenance, prevention strategies, continuation of supportive activities in critical
and complex health problems are all within the scope of nursing practice. They make referrals and collaborate with
physicians and other disciplines as needed by the client or family.
Independent nurse practitioners are accountable for their decisions. Whether their role is independent or collaborative, it
is based on the fact that each health care discipline offers an area of knowledge and expertise. Collaborative work is needed
for effective, efficient, and economical care. It is essential therefore that independent nurse practitioners acquire working
knowledge of the skills and expertise of other health workers.

Predicted Outcomes of the New Role of Nurses as Independent Nurse Practitioners

The growing interest in independent nursing practice is expected to contribute much to the improvement of health care
in the country.
1. It will encourage professional nurses to extend their capabilities and assume greater responsibilities for designated
areas of generalized nursing practice.
2. The amount of health care will be more increased and accessible to people.
3. The nurse's involvement in the client's family or community will increase the nurse's sensitivity and response to their
clients' needs.
4. Improvement of health services will help prevent serious illnesses and maintain positive community health programs.
5. It will provide data for nursing education, to validate and legitimize extended role practices for nurses.
Although independent nursing practice is a growing trend in our country today, several questions are hereby posed in
this regard.
1. Are our present graduates prepared to do independent nursing practice? If they are not, who shall provide this training?
2. At what point in their professional life may the nurses start this kind of practice?
3. Does our present curriculum provide for preparation in this field?
4. How does a nurse survey the field or area to determine the size of market for a particular service?
5. Can independent nursing practice support a practitioner economically?
6. How much shall they charge for their services? When can they expect to break even? When can they expect a liveable
income?
7. How can they advertise their services within ethical bounds?
8. What liabilities are common in this kind of practice?
9. How soon and how best will they be accepted within the community of their choice?
10. At these times when thousands of nurses are unemployed, is independent practice an answer to nursing
unemployment?
It is time that we assess our own resources to explore this new field of practice. But the initial preparation for this kind of
practice should have been incorporated first in nursing programs before nurses can assume this role effectively.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Nursing in hospitals and related health facilities such as extended care facilities, nursing homes, and neighborhood
clinics, comprises all of the basic components of comprehensive patient care and family health. This field of nursing is:
a. Hospital or Institutional Nursing
b. Public Health Nursing or Community Health Nursing
c. Industrial or Occupational Health Nursing
d. Nursing Education
ANSWER: ________

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Education (Department of Nursing) 11 of 14
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. In what section of the RA 9173 are qualifications of nursing service administrators be found?
a. 28
b. 29
c. 31
d. 33
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The beneficiaries of the comprehensive nursing specialty program are obligated to serve for how long in any Philippine
hospital?
a. 1 year
b. 2 years
c. 3 years
d. 4 years
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Public Health nursing refers to:

a. the practice of nursing in the 7 local, national and city health departments which include health centers and
public schools
b. nursing practice in a variety of roles, which at times include independent nursing practice
c. Both are correct
d. None are correct
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. The following are the qualifications of Nursing Coordinator for Staff Development, except.
a. 2 years clinical experience
b. 4 years clinical experience
c. Master’s Degree
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Private duty nurses use the following titles: SATA

a. Private Nurse Practitioner
b. Special Duty Nurse
c. Private Duty Nurse Specialist
d. Caregivers
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Private duty nurses should be an IV therapist certified by

a. PRC
b. BON
c. PNA

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Education (Department of Nursing) 12 of 14
 d. ANSAP
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Which of the following should a dean in a college of nursing have?

a. 1 year of clinical practice in a field of specialization
b. Post-Master’s Degree
c. Doctoral Degree in Nursing
d. 5 years teaching experience
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Who led the nursing of the sick and wounded Katipunan revolutionaries in 1890?
a. Elipido Quirino
b. Tandang Sora
c. Nurse Corps
d. Manuel Quezon
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The following are the responsibilities of a school nurse. SATA

a. organizing and implementing the school health program;
b. coordinating school health programs;
c. undertaking functions directly related to pupil's health;
d. evaluating school health programs
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________

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Education (Department of Nursing) 13 of 14
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Do Now Strategy

This activity is to evaluate what you learned after the discussion and the activity.

What field of nursing did you find interesting?

________________________________________________________________________________

Site 3 reasons
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________

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Education (Department of Nursing) 14 of 14
 Nursing Leadership and Management)
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 5

LESSON TITLE: CHOOSING, RETAINING, RESIGNING AND Materials:

DISMISSAL FROM A POSITION
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
References:
Upon completion of this lesson, the nursing student can:
Lydia M. Venzon RN, MAN, FPCHA Ronald M.
1. Enumerate factors in selecting a field of nursing; Venzon RN, MAN (2010), Professional Nursing In
2. Recognize important tips during an interview; and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Make their own application and resignation letter. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, list down five (5) fields in Nursing and explain briefly:
1.
2.
3.
4.
5.

MAIN LESSON

GUIDELINES IN CHOOSING A FIELD OF NURSING

PEOPLE have different motives or reasons for choosing a particular field of nursing. Nurses who have to make their
choices should think of long-range goals so that they can build up a career ladder in nursing.
The first consideration that nurses must make is self-evaluation. They need to consider their capacities, interests,
qualifications and goals. If necessary, they can ask the guidance of more experienced persons such as advisers, clinical
instructors, or their parents.

THERE ARE FACTORS TO CONSIDER IN MAKING A SELF-EVALUATION:

Qualifications
What is your educational qualification? Does it fit the job you are applying for? Beginning positions in nursing do not
usually require more than registration. You will be required to have a Bachelor's Degree in Nursing. Deans, Chief Nurses, or
Directors of Nursing Services are required to have a Master's Degree in Nursing if they will work in colleges or tertiary
training hospitals/ medical centers.
Years of Experience and Training
What are your experiences and training? Are these relevant to the position you are applying for? Special areas like the
Operating Room, Intensive Care Unit, Coronary Care Unit, and Emergency Room require nurses who have experience in
these areas. Staff nurse positions do not require any experience and training although such may help in the evaluation of
their applications.
Age and Physical Condition
Consider your age and physical condition. Most employers prefer Young nurses for beginning Positions. On the other
hand, older nurses may feel uneasy to start anew in staff nurse positions but may feel comfortable in administrative
Positions if qualified. Positions in public health may require extensive evaluation. An elderly nurse may not appreciate the
idea of exerting much effort in doing home visits. How much physical energy is required of the job? Can you work long hours
without tiring easily? Administrative positions will require nurses who are mature in judgment and decision-making and who
possess the educational qualification required by the Philippine Nursing Law (see R.A. 9173).
Emotional Stability and Goals in Life How is your emotional self? Can you be calm even under stress? Do you get along well
with people? Will you rather be alone or in a crowd? What is your primary aim in going to nursing: earn money or have the
satisfaction of helping people? Your own objectives and philosophy in life will determine to a great extent the kind of field you
wish to get into.

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Education (Department of Nursing) 1 of 9
FACTORS IN SELECTING A FIELD OF NURSING
1. Kind of work to be performed. Are you prepared for the job? Can you work under stress? Do you get along well
with people? Are you interested in it? What kinds of skills are needed? Is it hazardous?
2. Availability of the work. Will you choose a field of nursing that is crowded? Or where there is a shortage of
workers?
3. Hours of work. How many hours a day or week do you go on duty? Is your work rotated on shifts? Will you be paid
for extra hours of duty you will perform?
4. Qualifications. What are the requirements in terms of educational qualifications? Experience? Training?
5. Opportunities for advancement. What chances do you have in being promoted after several years of
employment? Will they allow you to go to school if you so desire? Are you allowed to attend professional
meetings/seminars on official time?
6. Method of Entering. Do you need an examination to enter? Do you need someone to recommend you?
7. Earning. How much is the initial salary? The maximum salary? Is salary paid weekly or every fifteen days? Is
additional pay given for overtime work?
8. Fringe benefits. How many days of vacation and sick leaves are given? Maternity leaves? Education leaves?
9. Other benefits. Are insurances, medicare, retirement benefits provided for? Can nurses participate in discussion
of condition of work?

Since individual nurses are free to choose the field of nursing they wish to enter, it is important that they choose wisely
and well. It is therefore imperative that they make a self-analysis and that of the work they want to enter into to see that these
are matched. Money or salary is not the only important factor. Most important will be the ability to give one's best, enjoy the
work and get along well with patients and members of the health team. The relationship that nurses have with their
co-workers and their attitudes towards their work will determine to a great extent their success or failure in their work. They
must choose the agency where they will be able to develop their fullest as professional nurses.
Once nurses become registered, they would want to find a job. Positions can be located through friends, newspapers,
magazines, employment or placement services.
Application for a position may be done in writing or through interview. Oftentimes, the latter supersedes the former.
A letter of application is important because it enables the employer to judge the applicant's scholarship ability.
Employers take interest in a well-written letter of application and usually arrange for an interview when they see one.

USEFUL POINTERS IN MAKING A LETTER OF APPLICATION

The letter of application enables the prospective employer to form an opinion about the nurse. Observe the following
when writing a letter of application:
1. Use clean, white, unlined paper. If you are working in an agency, do not use the agency's stationery with
letterhead.
2. Use ink or ball letter if pen in writing. You may want to type the you so prefer.
3. Use proper salutation. person to who Preferably know the name of the m the letter is to be addressed.
4. Observe proper margin and paragraphing. Use good English and correct spelling.
5. Write in a courteous manner. Ask permission before using permission has been position was obtained
permission a person's name as reference. Aft granted, write a letter of thanks especially if the desired
6. Enclose return postage so that the person to whom the letter is addressed will be encouraged to reply and will
not have to spend for postage in doing so.

A letter of application usually contains the following facts:

1. Source and purpose. The first paragraph usually contains the source of information concerning the vacancy and
the nurse's intent to apply to the position. These two points may be interchanged.
2. Qualifications. The second and third paragraphs must contain the applicant's qualifications, the school or college
from where he/she graduated, and the year of graduation. Experience and training along the field applied for may
also be included.
3. Reference. At least three names of persons who have given consent to the use of their names may be used as
references. These persons must know the applicant well enough in order to serve as good reference background.
Among the preferred references are former principals or deans, leading persons in the community, a parish priest
or a minister of one's church, a professional nurse or one's former instructor.
4. A request for a personal interview, if time and distance permits, is usually indicated in the last paragraph.

An example of an application letter is found on the next page. Data are fictitious.

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Education (Department of Nursing) 2 of 9
 SAMPLE APPLICATION LETTER

36 Daniel Tirona St.

Project 4, Quezon City
May 24, 2010

The Director of Nursing

St. Luke's Medical Center
Quezon City

Dear Madam:

I have learned from one of your staff nurses that you are in need of a Head Nurse in your Surgical Intensive Care
Unit. I wish to apply as one.
I am a graduate of the University of the Philippines, College of Nursing, Class 2005. I passed the Board
Examination for Nurses in June of the same year with a grade of 86.4%.
I have worked as staff nurse at the UP-PGH Medical Center from August 2005 to December 31, 2009. I have
taken a course in Coronary Care Nursing for two months at the same institution in 2006. I wish to transfer to a place
of work nearer my home.
The following persons have kindly consented to the use of their names as references:

1. MRS. ROSEMARIE B. SANTOS

Assistant Director for Nursing
UP-PGH Medical Center,
Taft Avenue, Manila
2. MRS. ESTELA S. CRUZ
Supervising Nurse
Medical Intensive Care Unit
Philippine General Hospital
Manila
3. MRS. FLOSERFINA R. CUEVAS
President
Philippine Nurses Association
Malate, Manila

Attached is my bio-data for your ready reference. I shall be available for a personn interview at your
convenience. Enclosed is a self-addressed, stamped envelope which may be used for your reply. I hope for your kind
consideration.

Very respectfully,

REBECCA M. RONQUILLO, B.S.N.,

*Data are fictitious

PERSONAL INTERVIEW

An interview is a face-to-face conference between two people about something. An interview between an applicant and
a prospective employer gives both a chance to assess each other.

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 For the employer it gives him/her a chance to assess the applicant's personality, alertness in answering questions,
poise, the command of the spoken language, and the like.
For the applicant, it gives him/her a background of the institution, its potential as a working place, its philosophy and
objectives, the the working conditions, among others.
The interview therefore is a two-way, process in which both the employer and the applicant discuss conditions of work
and other related topics. It is never meant that an interview be a one-way traffic where the prospective employer does all the
talking and questioning while the applicant sits and listens without saying a word unless spoken to. Religious or personal
beliefs or practices which may limit the performance of duties should be made known to the prospective employer. An
applicant sells himself/herself in an interview. He/She wants to convince the prospective employer that he/she is the best
applicant for the job. It is best that he/she prepares himself/herself to make a good first impression.
The following pointers will be of help in preparing for an interview.
1. Make an appointment either by mail or telephone. The Nursing Office or Personnel Division schedules time to
conduct interview. It is seldom that on-the-spot interviews are given.
2. Be at the place at the appointed time. It is necessary therefore that you start early from your place so that you
are at the agency ten to fifteen minutes before the time so you can relax and appear unhurried. Do not come during
breaks or mealtime. If you get delayed, apologize and state your reason. Do not insist on being interviewed as the
person who will interview you may have another business to attend to. Request for another schedule if he/she is
indisposed and be sure to be on time if he/she gives you another chance.
3. Know something about the institution where you will apply so that you can answer questions
intelligently. If possible, know the name of the person who will interview you, so you can use it. Be prepared to
answer questions that are likely to be asked.
4. Be at your best. If you are a female, be neat, with a simple hairdo, moderate make-up, modest dress. Do not
appear as if you are going to a party. If you have a tendency to perspire, use an anti-perspirant. If you are a male,
be sure your clothes are spotless and clean especially at the collar line. Have a decent haircut and be well-shaven.
5. Knock before you enter. Greet the person who lets you in and the person who will interview you. Wait until you
are offered to sit before you do so. Feel at ease. Sit properly. Do not slouch.
6. Bring credentials such as your registration card, residence certificate, tax account number and the like. If
possible, bring small photographs (1 x 1) to enclose in a personal data form. Bring a fountain pen or ballpen for
filling out forms. Do not borrow from the prospective employer.
7. Ask questions about the job. It may help in deciding if you like the position.
8. Thank the interviewer for giving you some of his or her time. If there are other applicants to be interviewed, do
not delay the interview unnecessarily.
9. Give yourself time to think about the position. Notify the prospective employer if you have changed your mind
or have transferred to another address. As a prospective work and the people whom employee you have an equal
right to choose the place of work and the people whom you can best work with.
10. If the prospective employer does not answer, you may write a follow-up letter stating your interest in the
position. It is possible that they may not have an immediate vacancy but your letter will show that you are
interested and they may give you first preference should one occur.

RETAINING A POSITION
Once you have obtained a position, strive to retain it and be successful in that chosen field. This will lead to :If-a action
and building a career in nursing.
How can you be successful in your chosen field of nursing? While there is no sure-fire formula for success the following
are suggested.
1. Have adequate knowledge and preparation for the job. Reading professional literature and attending clinical
conferences are some ways of updating your knowledge.
2. Have a well-developed personality. Cultivate a pleasing appearance. This gives a good first impression.
3. Develop good interpersonal relationship with your co-workers by
a. being enthusiastic in, and dedicated to your work and being sincere and considerate to others. Practice the
Golden Rule;
b. being tactful and dependable. Practice self-control. Hot-headed persons frequently encounter trouble;
c. developing ability to adhere to social amenities and being socially compatible. Remember: no man is an
island;
d. having self-confidence and being cheerful. See the bright side of life, believe that others can also do good
work; and
e. offering help when needed. A helping hand eases the burden of your co-workers.
4. Develop proficiency in communication, both in oral and in written forms.
5. Be able to adjust to working conditions and to life patterns characteristic of particular occupations and
communities. Filipinos are well-known for their pakikipag-kapwa tao or ability to relate with others and pakikisama
or ability to get along well with co-workers.

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Education (Department of Nursing) 4 of 9
 6. Keep abreast with advances in medicine, nursing, and related sciences by reading professional literature and
attending activities of professional organizations.

CAUSES OF FAILURE
Although nurses have the opportunity to get a good position, some may fail in their jobs. Causes of failure may be due to
any of the following:
1. incompetence or the lack of the required ability and knowledge for the particular job;
2. poor interpersonal relationships, lack of cooperation with co-workers, dishonesty, boastfulness, and inability to get along
with people;
3. personality defects such as imprudence in choosing friends, insincerity, conceit, sarcasm, lack of tact, envy,
discourtesy, being too argumentative, apathy towards work or being too sensitive;
4. inadequate knowledge in social conduct, too little time for relaxation and recreation, unwholesome or unwise choice of
recreation; and
5. indifference to need for professional growth, always finding reason for not attending professional meetings or joining the
professional organization.

HOW TO TURN FAILURE INTO SUCCESS

Nurses who accept their limitations know their weaknesses, and those who try to overcome them are more likely to
succeed than those who do not. There are more "average" nurses than the "geniuses." Those who are very bright in the
classroom may not always be successful in the field of nursing, while those who are willing to turn their weaknesses into
assets may be more successful.
Nurses should fit into and adjust to the position. This means being competent for the job, taking it with pride and doing
one's best at all times. They must continue to develop themselves professionally through observation, staff development
programs, and reading professional literature. Remember that proficiency means technical as well as human relation skills.

RESIGNING FROM A JOB

There are many reasons why nurses resign from their jobs. Primarily, the reason is to seek better positions whether in
the Philippines or abroad. Other reasons may be inability to adjust t other places. the work situation, marriage, children
and/or transfer of family to other places.
It is suggested that nurses keep their positions for at least two years if the position is acceptable to them. The first year
is usually spent in adjusting to the position, the second in helping them find the field of nursing specialty of their choice. They
should not change positions, as much as possible, more often than once within a year of service.
If nurses feel that they are not suited to the position, and feel that the advantages of leaving far outweigh the reasons for
staying it may be wise to make a change. It is, however, advised that they think over the whole situation. Seek assistance in
making decisions. If possible, involve the family especially if it will, in a way, affect them.
If offered a better position, talk it over with the employer. It is best to observe "an open-door policy." Leave a friendly
feeling towards superiors and co-workers. A reference from them may be needed later or one may decide to return to the
institution or agency. Goodwill is an asset that can be banked on.
Use prudence in accepting another position. Be sure it has more to offer in terms of salary, opportunity for promotion,
advancement or professional growth, and better chances o f adjusting to the new position than the present one.
A self-analysis may be necessary including the reason for transferring. Improvements may have to be made so that
unpleasant traits may not be carried on to the new position.
Give advance notice. A month is usually enough for those holding staff nurse positions. For those in teaching or
administrative positions, six months is recommended. Give the employer enough time to get a reliever.
Leave with a clean record. Clearance includes non-liability from responsibilities. Do not leave in the midst of activities in
the agency. Leave in the most gracious professional manner.
Write a letter of resignation. Observe the following points:
1. Give the date of resignation. It is good practice to complete the month from the date the notice of resignation is
filed. The date is usually effective on the 15th or at the end of the month, for easy computation of salaries, accrued
leaves, etc.
2. State the reason for resigning. Although you may have had an unhappy employment experience, it is important
to be courteous because the letter is usually on file and is usually referred to when the need arises. (An example of
a resignation letter is found on the next page. Data are fictitious.)
3. Express gratitude for kindness and consideration given during the period of employment. Express regret
for leaving regardless of the reasons.
4. Attach clearance for money, work, and property responsibilities. Never walk off from a position. This will
make one liable for breach of contract or abandonment of duty. This is sometimes referred to as "French Leave" or
AWOL (absence without official leave).

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Education (Department of Nursing) 5 of 9
DISMISSAL FROM A POSITION
It is seldom that a nurse gets dismissed. This is usually done for cause on the part of the nurse. Reasons may include
negligence, incompetence, malpractice, unprofessional behavior or breach of contract.
In assuming duties and responsibilities, nurses should be prudent in their actions in order that dismissal can be avoided
as subsequent employment is jeopardized. Due process of the law shall be observed before nurses can be dismissed from
their work.
In a society where success and failure permeate the family system, Filipino workers put high values on dangal (honor),
utang na loob (sense of gratitude), hiya (shame), damdamin (emotion), and pananagutan (responsibility). To them their kin's
success becomes the success of the family and dismissal is considered a family tragedy.
It is in this light that Filipino nurses strive to achieve their goals and prevent failures as much as possible.

SAMPLE RESIGNATION LETTER

16 Don Manuel, La Loma

Quezon City
November 30, 2009

THE DIRECTOR OF NURSING

St. Luke's Medical Center
Quezon City

Dear Madam:

I have the honor to tender my resignation as Head Nurse from this hospital effective the close of business hours
on December 31, 2009. I intend to go on full time studies for my Master's Degree in Nursing at the University of the
Philippines.
I regret to leave this place which I consider as my second home. I wish to thank you for giving me the
opportunity of joining the nursing service of this hospital. I also wish to thank the medical and nursing staff for
enabling me to learn as much as I did and for their kind attitude towards me.
I truly enjoyed my stay in the hospital. I hope that someday I may be given the same chance to serve it again.
Enclosed herewith are the clearance papers relative to my resignation.

Very respectfully,

GRACE V. RAMOS, B.S.N., R.N.

*Data are fictitious

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Which of the following is not a factor to consider in making self-evaluation?

a. Qualifications
b. Years of experience
c. Attitude
d. Age
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 6 of 9
2. The following are factors selecting a field of nursing. SATA.
a. Kind of work to be performed
b. Availability of work
c. Hours of work
d. Qualifications
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. In writing you application, which of the following is the least helpful?

a. Use clean white paper
b. Use proper salutation
c. Enclose return postage
d. Use pencil in writing
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. An application letter contains the following, except.

a. Source and purpose
b. Expression of gratitude
c. Reference
d. A request for personal interview
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Which of the following is true about personal interview?

a. Face-to-face conference between two people
b. Interview between an employer and an applicant
c. Give chance to assess each other
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Which of the following pointers is the least helpful to give an applicant who will undergo interview?
a. Make a personal appointment
b. Be at the place at the appointed time
c. Be at your best
d. Ask questions about the job
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. If you are a female, which of the following is the most helpful tip when going for an interview?
a. Moderate to heavy make up
b. Any dress
c. Simple hairdo
d. Wear accessories that can catch the employer’s attention
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 7 of 9
8. If you are a male, which of the following is the most helpful tip when going for an interview?
a. Make sure your clothes are clean
b. Have a decent haircut
c. Be well shaven
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Causes of failure in a job may be due to the following, except.

a. Incompetence
b. Dishonesty
c. Balance time for relaxation and recreation
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. When writing your resignation letter, observe the following points. SATA
a. Give the date of resignation
b. State the reason for resigning
c. Express gratitude for kindness and consideration given during the period of employment
d. Attach clearance for money
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________

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Education (Department of Nursing) 8 of 9
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Do Now Strategy

This activity is to evaluate what you learned after the discussion and the activity.

v Make your own Application and Resignation Letter (Attached here upon submission of the module)
Format (Refer to the sample Application and Resignation Letter in this module):
ü Paper size: Letter (21.5 cm x 27.9 cm)
ü Margins: Normal (Top & Bottom: 2.54 cm; Left & Right: 3.18 cm)
ü Font and Font Size: Arial (11)

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Education (Department of Nursing) 9 of 9
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 6

LESSON TITLE: CONTRACTS Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define a contract; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Enumerate the different kinds of contract; and, Venzon RN, MAN (2010), Professional Nursing In
3. Recognize the requisites of a contract. The Phillippines 11th Edition: C & E Publishing, Inc.
839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW

Based on the previous lesson, give the 9 factors in selecting a field of Nursing.

MAIN LESSON

A CONTRACT is a meeting of minds between two persons whereby one binds himself, with respect to the other, to give
something or to render some service.
A contract is a promise or a set of promises which the law recognizes as a duty and when that duty is not performed, the
law provides a remedy.
When a nurse enters into a contract with an employer, it is usually an agreement to be paid a certain amount of money
and be provided certain benefits in exchange for such services.

KINDS OF CONTRACTS
1. A formal contract refers to an agreement among parties involved and is required to be in writing by some special
laws. Examples are marriage contracts, mortgages, deeds of sale or work contracts.
2. An informal contract is one which is concluded as the result of a written document or correspondence where the
law does not require the same to be in writing, or as the result of oral and spoken discussion between the parties or
conduct between the parties, evidence and intention to contract.
3. An express contract is one in which the conditions and terms of the contract are given orally or in writing by the
parties concerned.' An example of this is usually found in formal contracts wherein the kind of services offered,
salary, date and time of effectivity including fringe benefits, if any, are specified. If a private duty nurse is asked by
a physician to go on special duty for his patient and the patient himself and his relatives do j not object to the
service, it is implied that the private duty nurse will be paid under the doctrine of facio ut des which means "I do that
you may give."
4. An implied contract is one that is concluded as a result of acts of conduct of the parties to which the law ascribes
an objective intention to enter into a contract.' To avoid subsequent problems, nurses are advised to clarify the
terms and conditions of employment before assumption of work with the prospective employer.
5. A void contract is one that is inexistent from the very beginning and therefore may not be enforced.

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Education (Department of Nursing) 1 of 6
 6. An illegal contract is one that is expressly prohibited by law. Examples of void and illegal contracts are found
towards the end of this chapter.

REQUISITES OF A CONTRACT
1. To have a contract, two or more persons must participate.
2. The parties involved must give consent to the contract.
3. The object which is the subject matter of the contract must be specified such as:
a. all things which are not outside the commerce of man;
b. all rights which are not intransmissible;
c. future inheritance in cases expressly authorized by law; and
d. all services which are not contrary to law, morals, good customs, public order, and public policy.
4. The cause of obligation is established. The time, price, and subject matter are expressed. Generally, the length of
time of a contract for services is at least equal to the period for which wages or salaries are payable. Thus, if one is
engaged on yearly rates, the length of time of the contract will be at least one year.
5. Contracting parties must have the legal capacity to enter into a contract. They must
a. be of legal age;
b. be of sound mind;
c. not be under the influence of intoxicating drugs, or fear of bodily harm; and
d. not be suffering from physical disability such as those who are mentally incompetent.

Married women have the full capacity to go into a contract except in some cases when it is specified that the husband
should agree to such contract. Examples mortgaging of property. Married female nurses will need written consent from their
husbands if they are going to work abroad.
Persons under 18 years of age may not go into contract without the consent of the parents. However, when parents give
up control over the supervision of a minor and the latter keeps his own wages, he may be regarded as "emancipated" or
freed even though he continues to live at home. In such cases, the father is not liable for the services given to the child. Also,
a nurse cannot charge the parents for services given the married minor or child since marriage emancipates or releases the
child from parental responsibility!
Problems arise because nurses do not clarify the provisions in their contract. Will their religion prohibit them to assist in
the administration of blood transfusion as in the case of Jehovah's witnesses? Can a Roman Catholic nurse assist in a legal
abortion? What will be the nurse's stand in the case of AIDS patients? Can they legally refuse to take care of AIDS patients
by claiming that such may endanger not only their health but also that of their families?
It is imperative that nurses clarify the conditions of work during the interview. They should anticipate such possibilities of
being asked to do what their religion or their personal convictions forbid them to do. In so doing, their chances of being hired
may be lessened but this will be definitely better than the possibility of a legal suit later. If they accept positions that may
pose danger to their lives or health, they assume the risk. They should take the necessary precautions to minimize the said
risks.

INEXISTENT CONTRACTS
The following contracts are void or inexistent from the beginning.
1. Those whose cause, object or purpose are contrary to law, morals, good customs, public order or public policy.
2. Those whose cause or object did not exist from the time of transaction.
3. Those whose object is outside the commerce of man.
4. Those which contemplate an impossible service.
5. Those where the intention of the parties relative to the principal object cannot be ascertained.
6. Those expressly prohibited or declared void by law.
7. Those which are absolutely simulated or fictitious.

VOIDABLE CONTRACTS
The following contracts are voidable or annullable, even though there may have been no damage to the contracting
parties.
1. Those contracts wherein one of the parties is incapable of giving consent to a contract.
2. Those whose consent is vitiated by mistake, violence, intimidation, undue influence or fraud.

ILLEGAL CONTRACTS
Contracts obtained through use of fraud (deception and trickery,) undue (unlawful) influence or duress (coercion) in
securing such, and those that are expressly prohibited by law are illegal.
Following are examples of illegal contracts:

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Education (Department of Nursing) 2 of 6
 1. Those that are made in protection of the law. If a nurse proceeds to administer intravenous injection without
special training and according to protocol established, she/ he violates RA 9173, the Philippine Nursing A ct of
2002.
2. Consent obtained by fraud. If a nurse obtained the consent of a patient or the family to be given services,
through misrepresentation that she/he is licensed although she/he is not, such contract is illegal.
3. Those obtained under duress. Duress means actual or threat A of violence or imprisonment in order to obtain
consent. nurse may be forced to sign a contract under threat of dismissal.
4. Those obtained under undue influence. If a nurse who has been taking care of an elderly patient uses her close
relationship to acquire high salary or other options as property, such contract is invalid as it is illegal.
5. Those obtained through material misrepresentation, Aside from fraud, material misrepresentation may permit
a person to avoid or cancel a contract. Suppose a midwife applied as nurse in an agency and was soon found not
to be a registered nurse, the contract that she signed becomes illegal because she misled the employer that she is
a nurse.

BREACH OF CONTRACT
Breach of contract is failure to perform an agreement, whether expressed or implied, without cause.
The following constitute breach of contract for nursing services:"
1. prevention of performance;
2. failure to perform because of inconvenience or difficulty;
3. failure of cooperation in performance;
4. abandonment of duty (i.e., leaving unconscious patients, going off-duty without endorsement, loafing while on
duty);
5. substitution of performance; and
6. failure to use due care.

LEGAL EXCUSES IN REFUSING, NEGLECTING OR FAILURE TO PERFORM A CONTRACT

Following are legal excuses in refusing, neglecting or failure to perform a contract:
1. discovery of material misrepresentation made and relied upon;
2. where performance would be illegal;
3. where performance is made impossible by reason of illness;
4. where performance is made impossible by death of patient or nurse;
5. where performance is made for Other reasons; and
6. where contract is insufficient.

ADVANTAGES OF WRITTEN CONTRACTS

Many nurses fear written contracts. The following are the re t advantages of written contracts over oral ones.
1. A written contract is certain. It avoids the uncertainty of human memory.
2. It can specify a definite time within which it is binding so as to protect both sides against sudden changes without
notice. It also fixes a time limit after which conditions are no longer binding but may be opened for rediscussion.
3. It sets a standard and relieves an individual professional person from haggling over compensation.
4. It is more likely to be open and well-known so that the use of written contracts tends to establish minimum
standards for professional practitioners and to protect them against discrimination in compensation.
5. It is definite and can be definite on many details which may otherwise stimulate favoritism or caprice even among
professionals, such as hours of work, vacation allowances, holiday privileges, health and insurance provisions.
6. It can provide a definite procedure in case of complaints about substandard work, so that the employer has a clear
course and the professional nurse has protection against arbitrary action.
7. It creates a minimum of certainty and security for the professional employee so that he/she is free to concentrate
on his/her work without concern for the details which the written contract has settled.

Definite commitments stipulated in a contract are hours of work and salary, and responsibilities including the course to
be taken in case non-fulfilment of the terms of contract.

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Education (Department of Nursing) 3 of 6
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. This is a meeting of minds between two persons whereby one binds himself, with respect to the other, to give something
or to render some service.
a. Agreement
b. Memorandum
c. Contract
d. Law
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
2. A contract that is concluded as a result of acts of conduct of the parties to which the law ascribes an objective intention
to enter into a contract.
a. Formal contract
b. Informal contract
c. Express contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. This the type of contract in which the conditions and terms of the contract are given orally or in writing by the parties
concerned.
a. Formal contract
b. Informal contract
c. Express contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. The doctrine “facio ut des” means

a. I do that you may give
b. I give that you may do
c. I receive what I deserve
d. I deserve what I receive
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. What contract is concluded as the result of a written document or correspondence where the law does not require the
same to be in writing?
a. Formal contract
b. Informal contract
c. Express contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 4 of 6
6. This contract refers to an agreement among parties involved and is required to be in writing by some special laws.
a. Formal contract
b. Informal contract
c. Express contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. What contract is expressly prohibited by law?

a. Formal contract
b. Illegal contract
c. Void contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. This contract is inexistent from the very beginning and therefore may not be enforced.
a. Formal contract
b. Illegal contract
c. Void contract
d. Implied contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The following contracts are void or inexistent from the beginning. SATA
a. Those whose cause, object or purpose are contrary to law, morals, good customs, public order or public policy.
b. Those whose cause or object did not exist from the time of transaction.
c. Those whose object is outside the commerce of man.
d. Those which contemplate an impossible service.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. A failure to perform an agreement

a. Inexistent contract
b. Voidable contract
c. Illegal contract
d. Breach of contract
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what you learned after the discussion and the activity.
1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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 Nursing Leadership and Management
STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR
Session # 7

LESSON TITLE: NURSING ETHICS Materials:

LEARNING OUTCOMES: Book, pen and notebook, index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define ethics; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Enumerate the Ethical Principles and Universal Principles; Venzon RN, MAN (2010), Professional Nursing In
and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Recognize patients’ and nurses’ responsibilities. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, give a kind of contract and give an example situation:

MAIN LESSON

ETHICS came from the Greek word ethos which means moral duty. Ethics refers to a standard to examine and
understand moral life. Ethical theories, principles and codes of conduct serve as guides of human conduct provided by
ethical systems. Ethics studies how people make judgment in regard to right or wrong.
Morals, on the other hand, are specific ways of behavior or of accomplishing ethical practices. Morality is derived from
the 1 Greek word moralis which refers to social consensus about moral conduct for human beings and society. Human
decency, right or wrong, good or evil, proper or improper, cruel or benevolent acts are explained in terms of morality.'
Ethics is about making choices that are best for the individual or society at certain times and in particular situations and
then evaluating such choices and outcomes. Ethicist Joseph Fletcher differentiates morality from ethics. He states that
morality is what you believe is right and good while ethics is the critical reflection about morality and rational analysis about
it.
Professional ethics is a branch of moral science concerned with the obligations that a member of the profession owes to
the public. Health care ethics, on the other hand, is the division of ethics that relates to human health. It resides in the realm
of human values, morals, customs, personal beliefs, and faith.
Bio-ethics is a specific domain of ethics that focuses on moral issues in the field of health care. It evolved into a discipline
all on its own as a result of life and death dilemmas faced by health care practitioners. It is a systematic study of human
behavior in the field of life science and health care in the light of moral values and principles. While originally, bio-ethics was
concerned with ethical issues described with medical practice, it has expanded to issues surrounding health and biological
sciences and social issues including environmental concerns.
As members of the health team, nurses have to make independent decisions in the performance of their daily duties.
Within the health team, however, many decisions are also made interdependently. Also, nurses are expected to exhibit
bio-ethical behavior in their professional duties. Knowledge of ethical challenges enable them to hone their skills in decision
making regarding their patients' life-and-death issues and integrate ethical principles and theories into their practice thereby
helping them resolve moral conflicts.
Nursing ethics is related to all the principles of right conduct as they apply to the profession. Nursing ethics reinforces
the nurses' ideals and motives in order to maximize the effectivity of their service.
Oftentimes, nurses find it difficult to resolve ethical issues partly because they do not have the sensitivity to recognize
ethical problems and conflicts or to display the needed knowledge and experience in every situation that they face.
Johnstone defines nursing ethics as the "examination of all ethical and bio-ethical issues from the perspective of nursing
theory and nursing ethics." Vercoe, et.al., emphasize that "the field of nursing ethics be focused on the needs and
experiences of practicing nurses, the exploration of its meaning and that of ethical practice in terms of the perception of
these nurses.

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Education (Department of Nursing) 1 of 13
ETHICAL PRINCIPLES AND OTHER APPROACHES

Teleological Approach
Teleology comes from the Greek word telos or "goal or end." This is expressed in the maxim, "the right thing to do is the
good thing to do." The teleological approach is also termed as act utilitarianism where the good resides in the promotion of
happiness or the greatest net increase of pleasure over pain.
In recent formulation of act utilitarianism, Joseph Fletcher, a situation ethicist, holds that good is agape, the general
goodwill or love for humanity. In the final analysis human need determines what is or what is not ethical. If the act helps
people, then it is a good act, and if it hurts people, then it is a bad one.
In his writings, Fletcher provides the guidelines for making ethical decisions: These are:
1. consideration for people as human beings;
2. consideration of consequences;
3. proportionate good to come from the choices;
4. propriety of actual needs over ideal or potential needs;
5. a desire to enlarge choices and reduce chance; and
6. a courageous acceptance of the consequence of the decision.

An example may be given of a City Health Department planning for their annual budget. To which program should they
allot a bigger budget—the modernization of the city hospital or the nutrition and immunization programs of the
poverty-stricken families of the city? Will promotion of health and prevention of illness have priority over treatment of illness
and rehabilitation?

Deontological Approach or Duty-Oriented Theory

The word deontology came from the Greek word deon which means duty. In this theory, the ethicist feels that the basic
rightness or wrongness of an act depends on the intrinsic nature rather than upon the situation or its consequences.
Immanuel Kant, a German philosopher and ethicist in the 18th century, defines a person as a "rational human being with
freedom and social worth." A person is morally good and admirable if his actions are done from a sense of duty and reason.
He states that it is only through dutiful actions that people have moral worth. Even when individuals do not want to fulfill their
duty, Kant believes that they are required to do so.7
Suppose a nurse is assigned to care for a patient with AIDS. Could she reasonably refuse to care for the patient on the
ground that the patient's condition may threaten her health? As practitioners of the art of healing, nurses are to take care of
the sick even if patients have conditions that threaten their personal health. Nurses, however, must observe the necessary
precautions to protect their health.

Virtue Ethics Approach

Virtue ethics, known as aretaic ethics (from the Greek word arete), is focused primarily on the heart of the person
performing the act. It focuses on the traits and virtues of a good person such as courage, temperance, wisdom, and justice.
However, doing the right thing is not all that is needed. One must have the right motivation, disposition and traits for
being good and doing right such as courage, magnanimity, honesty, justice, and beneficence.
Intellectual virtue is the power to deliberate about things good for oneself. Moral virtues, on the other hand, must be lived
over time in order to be learned. Nurses, when faced with a particular situation must be able to know what to do. They must
be able to integrate virtue ethics with duty.
Suppose a student is requested by her classmate, who is also her best friend, to let her copy in their examination so that
she will pass. The student should not allow this to happen as formal cooperation in an evil act is never allowed. She will be
as equally guilty as the one who will cheat as she will be serving as an accomplice to the evil act.

DIVINE COMMAND ETHICS

Divine command ethics is based on the theory that there is a Supreme or Divine being that sets down the rules to
provide guidance to moral decisions. For Christians, these rules are found in the Ten Commandments. Differences in
religion, however, pose problems such as what to do when the decision would conflict with one's religious beliefs. For
example, members of the Jehovah's Witnesses will not receive blood transfusion even if their lives will be put in danger.
Suppose a nurse is approached by a friend who quests for re an abortion. The nurse refuses but refers the friend to a
doctor who can perform it. This is a violation of the divine command, "Thou shall not kill." It violates the principle relating to
the origin and destruction of life which states, "The owner of life is man, but it is God who gave him that life, therefore no one
has a right to take life except God."
The divine command is also applicable to cases of euthanasia, which is the direct killing of people who may not have
committed any crime deserving of death, but because of mental, or physical conditions are considered worthless to society.
Examples of these are patients in persistent vegetative state whose relatives request that the respiratory ventilators be
turned off or the feeding tubes be removed to put an end to both the patients' and the relatives' suffering.

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UNIVERSAL PRINCIPLES OF BIOMEDICAL ETHICS
In health care delivery, basic ethical principles assist the health professionals to determine right or wrong in regard to
value issues involving the pursuit of health, alleviation of suffering, and assisting patients towards peaceful death. These are
autonomy, veracity, beneficence, nonmaleficence, and justice.

Autonomy — Autonomy comes from the Greek word autos meaning self and nomos meaning governance. It involves
self-determination and freedom to choose and implement one's decision, free from deceit, duress, constraint or coercion.
This is called informed consent. The kind of information provided the patient and his family is within their level of
understanding that they may evaluate the risks and the other options open to them. This includes allowing the patient to
refuse treatment if he so decides; disclosure of his ailment, prognosis, mode of treatment; and maintaining confidentiality.
Restrictions on autonomy may occur when there is potential harm to others such as communicable diseases or acts of
violence.
The person making the decision must be deemed competent. He must have the intellectual capacity to make a rational
decision and he must be of legal age. The decision should be of his own free will and he should not be coerced or put under
duress to do so. Every adult of sound mind must have the right to determine what should be done to his body. Therapeutic
privilege is the legal exception of the rule of informed consent, which allows the caregiver to proceed with the care in case of
emergency, incompetence, waiver or implied consent.

Veracity-To maximize the efficiency of healthcare, the patient and the healthcare providers are bound to tell the truth.
The patient has the responsibility to provide, to the best of his knowledge, accurate and complete information about his
complaints, past illness, previous hospitalizations, medications being taken, allergies, religious restrictions, and other
matters relevant to his health. If the patient cannot provide the information, his family or significant others should do so in
order that accurate diagnosis could be arrived at and immediate treatment provided.
The physician should tell the patient and his family his diagnosis, plan of care, treatment and possible risks involved,
length of treatment, possible expenses, and other options they make take if there be any.
There are times, however, that the physician or health practitioner is requested not to tell the relative the exact nature of
the patient's illness. Sometimes, the relative requests the physician not to tell the patient his true diagnosis or condition. At
times the practitioner himself intentionally withholds information according to his sound judgment when such revelation
would do more harm to an emotionally unstable or depressed person. This is called a benevolent deception.
Several cases are therein cited:
1. A young, married male who was diagnosed to have AIDS, requests the doctor not to tell his diagnosis to his wife.
2. The children of an aged grandmother suffering from metastatic cancer request the doctor not to tell their mother
her diagnosis and instead to proceed with the chemotherapy.
In the case cited above of the young, married man who has AIDS, telling the wife would be far more advantageous so
that she can be examined, protected or treated as the case may be. She would be able to use proper precautionary
measures for herself, understand the husband's illness, and participate in his care.
In the case of the grandmother, gently telling her the truth would help convince her to participate in the treatment plan
including spiritual preparation towards peaceful death.
It is very important that health care workers be very discreet in providing information. While telling the truth increases
their credibility, it is oftentimes how they say this information that makes them acceptable or not.

Beneficence — The principle of beneficence refers to acts of kindness and mercy that directly benefit the patient. These
acts promote the health of the patient, prevent illness or complications, alleviate suffering, and assist towards peaceful
death if the inevitable comes.
The Patient's Bill of Rights helps the health practitioners provide more effective patient care. The patient has the right to
1. considerate and respectful care;
2. relevant, current and understandable information concerning diagnosis, treatment prognosis, specific procedures,
treatment, risks involved, medically reasonable alternative benefits needed to make informed consent;
3. make decisions regarding his plan of care; in case of refusal, he is entitled to other appropriate care and service or
be transferred to another hospital;
4. have advance directive (such as a living will) concerning treatment or designating a surrogate decision maker;
5. every consideration of his privacy such as in case discussion, consultation and treatment;
6. confidentiality of communications and records;
7. review his records concerning his medical care and have these explained to him except when restricted by law;
8. be informed of business relationship among the hospital, educational institution, health care providers that may
influence the patient's treatment and care;
9. consent or decline to participate in experimental research affecting his care;
10. reasonable continuity of care when appropriate and be informed of other care options when hospital care is no
longer appropriate; and
11. be informed of hospital policies and practices that relate to patient care.

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 All activities provided to patients must be conducted with deep considerations of their values and dignity.

Nonmaleficence —In some way the principle of nonmaleficence is similar to the principle of beneficence. The
distinction lies in the fact that the principle of beneficence is stated in a positive form while nonmaleficence is stated as an
admonition in the negative form to remind health practitioners to do no harm.
Examples of nonmaleficence is not assisting in or performing abortion, not assisting persons to commit suicide, not
performing euthanasia or mercy killing, or not willfully subjecting patients to experimental drugs whose potential harm may
be greater than the expected benefit, and not harming a person's reputation by revealing confidential information.
What benefit does it give a patient who is in persistent vegetative state to be attached to a respirator, or for a dying
person to be given cardiopulmonary resuscitation? Should a dying person in pain be given a sedative, when the health
practitioner knows it would cause respiratory depression or arrest?
Nurses should remember that human life is inviolable. They should do what is best for the patient. When biological death
is imminent, they should not abandon the patient. Treating them with respect, providing nursing measures safely, gently and
with kindness, and providing psychological and spiritual support allow the patient to die with dignity and peace.. Nurses
should not participate in treatments or procedures that will harm the patient. They should make their stand known and
should withdraw from the team if what is to be done is against their conscience.

Justice— In healthcare, refers to the right to demand to be treated justly, fairly and equally.
Article XIII of the Philippine Constitution guarantees that the state shall adopt an integrated and comprehensive
approach to health development and shall endeavor to make essential goods, health and social services available to all
people at affordable cost. There shall be priority for the needs of the underprivileged, the sick, the elderly and the disabled,
the women and children. The state shall endeavor to provide free medical care to paupers, establish and maintain an
effective food and drug regulatory system, and undertake appropriate health manpower development and research
responsive to the country's health needs and problems. It shall establish a special agency for disabled persons for their
rehabilitation.
To this end, the Department of Health affirms that health is a basic human right. To make this right a reality, the DOH
shall work to make quality health services available and affordable by mobilizing resources, providing means to better
health, and arousing community participation.
The National Health Insurance Act of 1995 provides for a universal compulsory health insurance program in the country.
Employees from private and public sectors are covered with Medicare privileges. Even the self-employed such as drivers,
vendors, beauticians, may become members of the Social Security System and will be entitled to insurance benefits,
hospitalization, and discounted out-patient services.
Republic Act 7432 called the Senior Citizens Act, gives honor and justice to the elderly by giving 20 percent discount in
public establishments such as restaurants, and pharmacies; public utility vehicles; and hospitals including free medical and
dental check-up and free hospitalization in all government hospitals.
In allocating budget for the promotion of health, prevention of illness, and for health education and immunization, more
benefits can be expected in terms of lessened morbidity and mortality rates.
Common methods for distribution of goods and resources are based on fair opportunity rule where every person is given
an equal share according to need, merit, contribution, effort and social worth.
The fair opportunity rule is based on the egalitarian theory that emphasizes equal access to goods and services. The
"the greatest good for utilitarian theory employs the maxim, the greatest number." Thus government authorities should
carefully think about the dilemma of whether the government should spend more for the care of one child with congenital
defect over the need to protect the lives of thousands of children who would benefit from mass immunization against
communicable diseases.
Hospitals put up triage schemes to determine who should be served first. One criterion often put up is that of medical
prognosis or medical utility or who among the patients is most likely to survive. The next criterion is social utility or social
value or worth, the ability to pay, or first-come-first-served basis.
To be ethically sound, the criteria selected must favor more the socially disadvantaged, and those incapacitated by
illness. Nurses should utilize their critical thinking ability and skills, listen carefully and objectively and analyze facts. Ethical
principles and values should be used in making moral decisions. Open communication between patients, their families, and
the health team results in acceptance of decisions and congenial relationships.

ETHICS COMMITTEES IN HOSPITALS AND THE ROLE OF MEDICAL ETHICISTS

There is a growing trend for hospitals to have formal ethics committees. These may be composed of philosophers,
doctors, nurses, lawyers, clergy or social workers. They discuss sensitive issues such as when to withdraw or withhold
treatment for an adult and the treatment of a severely handicapped newborn. Some may include topics such as the right to
die, informal consent, right to choose or refuse treatment, right to know who is treating the patient.
Discussion usually begins with a description of the patient's condition and medical history. Most often, conflicts involve
families and doctors; and where doctors want to treat or continue to treat a patient and the family wants to do nothing.
Research proposals involving human subjects are also reviewed.

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 Some cases that have reached worldwide attention are:
1. the removal of Terri Schiavo's stomach feeding tube upon his husband's request to the Court as she was in a
persistent vegetative state for 15 years;
2. the Nancy Beth Cruzan case in Missouri, United States where the Supreme Court denied her parents' request to
remove her feeding tube. She was in vegetative state for seven years;
3. the California couple who conceived a child in the hope that the baby would be a bone marrow donor for its
seventeen year-old sister who is acutely ill of leukemia;
4. the couple convicted of manslaughter for the death of their 2-1/2 year-old son because they failed to seek medical
attention and the baby died of intestinal obstruction; and
5. the doctor who assisted a woman sick of Alzheimer's disease to commit suicide.

RESPONSIBILITIES OF NURSES TO THE PATIENTS

The primary responsibility of nurses to the patients is to give them the kind of care their condition needs regardless of
their race, creed, color, nationality or status. In so doing, the patients' care shall be based on needs, the physician's orders,
and the ailment; and shall involve the patients and their families so that they or any number of the family can participate in
their care.
Nurses are advised to become familiar with the patient's Bill of Rights and observe its provisions14.
Because nurses are given compensation for their services, they should not accept tips or expensive gifts that may
induce them to give more care to favored patients and neglect those who cannot give. It is advocated that they treat patients
in a manner that will show concern whether the patient is rich or poor.
When nurses are engaged by patients or any agency, they shall complete said service on the length of time stipulated in
the contract. They may not leave their patients or any agency without proper permission or resignation or without relief.
Nurses can be sued for breach of contract or abandonment of duty if they do.
Nurses should commit themselves to the welfare of those entrusted to their care. They should be loyal to their sworn
duty This is termed role fidelity.

CONFIDENTIALITY OF INFORMATION
Confidential information is also termed as privileged communication because it is given based on trust. Patients and/or
their relatives are expected to give the necessary information so that proper diagnosis and treatment could be made.
Patients and their families are entitled to know information or facts within the limits determined by the physician. If the
patients insist on knowing their diagnosis, nurses may only repeat what doctors wish to disclose.
Any information gathered by nurses during the course of caring for their patients should always be treated confidential.
This duty extends even after the patients' death. Confidential information may be revealed only when:
1. patients themselves permit such revelation as in the case 00 of claim for hospitalization, insurance benefits,
among others;
2. the case is medico-legal such as attempted suicide, gunshot wounds which have to be reported to the local police
or NBI or constabulary;
3. the patients are ill of communicable disease and public safety may be jeopardized; and
4. given to members of the health team if information is relevant to his care.
Confidential information may also be revealed as provided for by law in Article IV, Section 4(1) of the New Constitution,
which states that: "The privacy of communication and correspondence shall be inviolable except upon lawful order of the
court or when and order require otherwise."

PATIENTS' RESPONSIBILITIES
Just as the agency and the staff are expected to inform the patients of their rights, they are also expected to inform these
patients of their responsibilities which include the following:
1. Providing information. A patient has the responsibility to provide—to the best of his/her knowledge—accurate
and complete information about his/her complaints, past illnesses, hospitalization, medications, and other matters
relating to his/her health. Changes in status and level of understanding must also be communicated. If the patient
cannot provide said information, the family is responsible for doing so in his/her behalf.
2. Complying with instructions. A patient is responsible for complying with the treatment plan recommended by
the attending physician or health team that is primarily responsible for his/her health care. He/She is expected to
keep his/her appointments, abide by the hospital rules, and inform those concerned if he/she cannot keep them.
3. Informing the physician of refusal to treatment. A patient who refuses treatment or to be compliant with the
treatment regimen must inform the physician of his decision.
4. Paying hospital charges. If the patient is in the Pay Service, he/she is responsible for ensuring that financial
obligations of his/her health care are fullfilled as promptly as possible.
5. Following hospital rules and regulations. The patient is responsible for following the hospital's rules and
regulations and shall advise his/her family to do so, too.

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 6. Showing respect and consideration. The patient must be considerate of the rights of other patients and hospital
personnel and shall assist in the control of noise, smoking, and/or playing of loud music on radio. The patient must
respect the property of other persons and that of the hospital. Since the nurses are the closest caregivers, they are
the most logical guardians of the patient's rights. It shall also be part of their duties to inform the patients and their
relatives, upon admission, of the responsibilities expected of them.

Bill of Rights for Registered Nurses

Registered nurses promote and restore health, prevent illness, and protect the people entrusted to their care. They work
to alleviate the suffering experienced by individuals, families, groups, and communities. In so doing, nurses provide services
that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health
problems, without restriction in regard to social or economic status. To maximize the contributions nurses make to society, it
is necessary to protect the dignity and autonomy of nurses in the workplace. To that end, the following rights must be
afforded.
1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive
nursing care.
2. Nurses have the right to practice in environments that allow them to act in accordance with professional standards
and legally authorized scopes of practice.
3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the
Code of Ethics for Nurses and its interpretive statements.
4. Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, and
professional responsibilities.
6. Nurses have the right to a work environment that is safe for themselves and their patients.
7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all
practice settings.

NURSES' RESPONSIBILITIES IN RESEARCH ON HUMAN SUBJECTS

The Helsinki Declaration of 1964 issued guidelines on medical research. In 1975 it differentiated two major types of
research: that which is essentially therapeutic and that which is directed toward developing scientific knowledge and has no
therapeutic value for the subjects. The declaration emphasizes that the research subjects must be informed when a clinical
or non-clinical study will be of no personal benefit to them to avoid any suspicion to the contrary.
The American Nurses Association's Human Rights Guidelines for Nurses in Clinical and Other Research specified
several important entities:
1. Employment in Settings Where Research is Conducted. Employees in work settings that carry potential risks
shall be informed about these, how to recognize these risks and how to take the proper precautions to counteract
harmful effects and unnecessary danger.
2. Vigilant Protection of Human Subject's Rights. Prior to participation in any activities that go beyond established
and accepted procedures, the prospective subjects must be informed. Special mechanisms shall be devised to
safeguard the confidentiality of information and protection of human dignity.
3. Scope of Application. These guidelines apply to all individuals involved in research activities, including patients,
organ donors, informants, normal volunteers, students and vulnerable populations, such as the mentally retarded
and prisoners.
4. Supporting Accrual of Knowledge. Nurses have an obligation to support the accrual of knowledge that
broadens scientific underpinnings of nursing practice and delivery of nursing services.
5. Informed Consent. Consent to participate in researches safeguards the basic rights to self-determination. There
shall be no direct nor indirect coercion. He should be given in detail the full benefits or possible harm that may
happen to him. If possible, the investigator shall secure the consent himself so that any questions or clarifications
can be made immediately.
6. Representation on Human Rights Committee. A Human Rights Committee is formulated to ensure that the
individual rights of patients are not denied. The nursing profession has an obligation to publicly support the
inclusion of nurses to these committees.

BASIC HUMAN RIGHTS OF RESEARCH SUBJECTS

Adequate protection of human subjects includes their legal as well as moral rights. They must be given the right to
informed consent, the right to refuse or withdraw from participation, privacy, confidentiality or anonymity of data and
protection from harm.
1. Right to Informed Consent. Recognition of self-determination and thorough comprehension of the proposed
participation are the two components of self-determination. Self-determination means free consent is pre-requisite
to any human involvement. The subjects must also understand the risks involved, the benefits anticipated, time

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 and energy requirements and any anticipated loss of dignity or autonomy; any anticipated pain or discomfort,
psychological stress or embarrassment; and the way the data will be handled and reported.
2. The Right to Refuse and/or Withdraw from Participation. The person has the right to refuse to participate.
There shall be neither recrimination for refusal nor for withdrawing from participation. Nurses shall explore the
subject's reason for refusing. Refusal to participate can be minimized, if at the onset the subject has been given
careful and honest opinion on what is to be done.
3. Right to Privacy. This right includes privacy of one's thoughts, opinions and physical presence and privacyof
one's records. The subject has the freedom to decide the time, the extent and circumstances he/she will
willingly share his/her presence, thoughts, beliefs, attitudes and behavior with others.
4. Right to Confidentiality or Anonymity of Data. Data about the research subjects shall be handled confidentially.
Data shall be available only to the research staff and shall be reported anonymously. Data shall not be used other
than for the specific purpose for which the subject gave consent and shall not be made public or available to
others. The identity of the agency shall be protected. This shall be done unless knowledge about the setting is
necessary in the interpretation of the data. After the report is written, all data by which individuals can be identified
shall be destroyed. They shall be burned or shredded and not dropped into the wastebasket as someone may find
and use them for other purposes.
5. Right to be Protected from Harm. There shall be appropriate balance between potential benefits of the research
and the risks assumed by the subjects. This is called the risk-benefit ratio in which the benefits outweigh the harm.
Minimal risk is defined as exposure to the possibility of injury going beyond everyday situations. These include
physical, legal, emotional, financial, and social harm.
Sometimes, the subject may experience undue anxiety if the instrument evokes disturbing feelings.
Debriefing is a process of disclosing to the subject all information that was previously withheld. Referral to counselling
shall be included in the study protocol if necessary.

VULNERABLE SUBJECTS
Subjects who are mentally ill or legally incompetent such as the unconscious, or are in unique situations, like fetuses,
require special attention. Those who are mentally ill, mentally retarded, unconscious and minors are incapable of evaluating
the risks involved and cannot be given consent in their own behalf. Consent of parents or guardians are required.
Investigative studies regarding fetuses shall have the consent in the presence of a third person because of the possible
danger or injury to it. The Philippine Constitution guarantees the protection of the life of the mother and the life of the unborn.
Students are vulnerable as their participation or non-participation may affect their grades. Employees may participate
because of the influence it may bring to their promotion, salary increases or bonuses. It must be explained to them that this
is not so.

INVESTIGATIVE STUDIES AND MEDICAL REGIMEN

When the medical regimen of a research subject will be affected, it is best that there be proper coordination with the
physician in charge. The investigative study shall not, in any way, be in conflict with the medical regimen. Drugs to be used
by the investigators must have a medical prescription.
An example of this was an experiment done in a government hospital where banana leaves were used to promote
healing of decubitus ulcers of bedridden patients. This study was coordinated with the physicians in the unit. Even though
the treatment method which consisted of cleaning, massaging the area around the wound, relief of pressure, and putting
banana leaves beneath the area with ulcer were all within the scope of nursing practice, the success of the study was further
enhanced since the doctors refrained from ordering topically-applied medications.

EXPERIMENTAL SUBJECT'S BILL OF RIGHTS

Below are the rights of every person who is asked to participate in a research study. An experimental subject has the
right to:
1. be told what that study is trying to find out;
2. be told what will happen to himself/herself and whether the procedure, drugs, or devices are different from what
are used in standard practice;
3. be told of the frequent or important risks, side effects or discomforts of the things that will happen to himself/ herself
for research purposes;
4. be told if he/she can expect any benefit from participating, and if so, what the benefits may be;
5. be told the other choices he/she has and how he/she may become better or worse than being in the study;
6. be allowed to ask y any question concerning the stud both before agreeing to be involved and durin course of the
study; g the
7. be told what sort of treatment is available if any complications arise;
8. refuse to participate at all or to change his/her mind about participation after the study is started. This decision will
not affect his/her right to receive the care he/she would receive if he/she were not in the study;
9. receive a copy of the signed and dated consent form; and

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Education (Department of Nursing) 7 of 13
 10. be free from pressure when considering whether he/she wishes to agree to be in the study.

SAMPLE FORM: Consent Letter

Name of Agency
Address
Consent to be a Research Subject

TO WHOM IT MAY CONCERN:

I have been informed by my doctor that I have not been responding well to the chemotherapy I have
received unlike other patients who have the same condition. He has advised cobalt therapy.
The amount of radiation I will be exposed to is relatively small. However, small doses may also cause
potential harm and these risks were already explained to me. I may have other examinations during the
treatment. I may call him at his clinic as stated below, if I have further questions about the treatment.
I have received a copy of this form and the Experimental Subject's Bill of Rights to keep. I have the right to
refuse to participate or to withdraw any time without any prejudice to my care in this agency.

Date:
Subject's Signature

Date:
Investigator's Signature

Clinic Address
Telephone Number

If the subject has other questions, he/she may ask the research, or his assistant, if he/she may contact the agency's
review board concerned with the protection of volunteers in research projects.
Participation in research is voluntary. One has the right to refuse to participate, and the right to withdraw without any
jeopardy to his/her care.

RESPONSIBILITIES OF THE NURSE TO THE PHYSICIAN

Section 28 (a) of R.A. 9173 states that:
It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to,
traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures,
comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral, topical and
parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of
suturing of perineal laceration, special training shall be provided according to protocol established.

It is therefore expected that nurses will not only carry out doctor's orders but help plan and implement patient care as
well. Patient's condition should be reported including results of therapies so that management of care can be properly
monitored and modified as necessary.
If any of the medical orders were not carried out for some reason (e.g., medications are unavailable, or a patient refuses
to accept them), such shall not only be brought to the attention of the physician but also noted properly in the patient's chart.
Explore patient's reason for refusal. Clarify misconceptions as needed.
Nurses shall familiarize themselves with the various routines, methods or idiosyncrasies of physicians, so that smooth
relationships can be maintained. In case the patient has a complaint against the physician, this shall be tactfully brought to
the latter's attention.
Any case of illegal, incompetent or unethical practice by any member of the health team shall be brought to the attention
of the appropriate authority through channels within the institutional or agency setting.
Nurses shall remember that any medical act relegated to them is illegal because it is specified in the Medical Law that
any licensed nurse who does this, even if supervised, can be held for illegal practice of medicine.

RESPONSIBILITIES OF NURSES TO THEIR COLLEAGUES

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Education (Department of Nursing) 8 of 13
 Nurses are expected to be able to get along smoothly with their colleagues. There may be instances where a nurse may
have a different opinion, or may not like certain people. This shall be the exception rather than the rule.A mature person
easily blends in any situation. Nurses shall adjust themselves to the organization and know its policies and procedures.
They shall establish good working relationships with co-workers. If one has a grievance he/she should bring it to the
attention of the proper authority rather than talk about it with others who may not be able to help. Most agencies have
grievance procedures to be followed.
It is important that nurses know their place in the total organization so that they may cooperate, coordinate and
maximize their work. Loyalty and consideration of others while at work will foster these relationships further.
Nurses who are cranky, too sensitive, who "backbite," who do not see any good in their colleagues, are the type of
nurses who will not be happy in their work.
Situations, such as when nurses see their colleagues neglect their duties or are incompetent shall be brought to the
attention of the immediate supervisor or appropriate authority within the agency setting before any life could be endangered.
Constructive criticism is always welcome but not fault-finding. Fault-finders, gossipers, and those who are fond of intrigues
will surely resent it too if they become the target of their own practices.

RESPONSIBILITIES OF NURSES TO THEMSELVES

Since nurses carry personal responsibility for nursing practice and for maintaining competence by continuous learning,
it is expected that every possible means shall be utilized by them to develop their skills. Their conduct must bring credit to
the profession. Just like any other professional, nurses are looked upon with respect in the community. They shall therefore
endeavor to live a life that will uphold their self respect.
Especially when nurses are on duty, they shall try to look neat and attractive. Female nurses are advised to use
moderate make-up and have a neat hair style. They shall wear uniforms that are neither too short nor tight-fitting that will
tend to restrict movement, nor expose unnecessarily any part of the body while giving care to the patients. Clean uniforms
and clean bodies tend to enhance the image of nurses. Use of anti-perspirant is advised most especially during hot summer
months. Male nurses are likewise advised to be clean-shaven, with hair clipped close to the nape instead of flowing to the
shoulders.
The use of the uniform shall be specified in the policy of the hospital/agency. It shall be worn only when on duty. Dining
in public, shopping or going to the market while in uniform is discouraged. Nurses' caps are worn only while on duty. These
are either carried in bags or are left in their places of assignment. Jewelry such as earrings, necklaces or bracelets are not
worn while on duty. However, wedding rings, school rings or school pins may be worn.
Nurses are looked upon by nursing students as their role models. Therefore, especially while they are on duty, they must
act in a manner that is worth emulating. Sincere and compassionate attitudes towards patients are caught by those around
them. Soon their working environment becomes permeated with a good working relationship that is so vital in dealing with
patients.

LIVING WILLS OR ADVANCE DIRECTIVES

There is a trend in the use of living Wills or advance directives. While this is not yet widely used in the Philippines, it is
used extensively in the United States. Hospitals are required to provide health-care proxy forms to patients being
admitted. These are called living wills and advance directives. The patient designates a health care representative,
usually a member of the family, a friend, or a family physician to make decisions for him/her when he/she is unable,
due to physical or mental incapacity, to make his/her own health care decision. This includes decisions to accept or
refuse any treatment, service or procedure used to diagnose or treat his/her physical or mental condition and decisions to
provide, withhold or withdraw life-sustaining measures.
Circumstances are stated in which various forms of medical treatment including life-sustaining measures shall be
provided, withheld or discontinued. The desire to make anatomical gifts after death are also indicated in the will, if
the patient desires to do so.
This living will is signed by the patient. It is witnessed by two other persons who declare that the patient signed
the will, that the latter appears to be of sound mind, free of duress or undue influence. The witnesses must be 18 years
of age or older, and are not designated as the person's health care representative or alternate as such. This living will is
attached to the patient's chart. This directive has a force of law.

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Education (Department of Nursing) 9 of 13
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Ethics came from this word which means moral duty:

a. Eros
b. Etos
c. Ethos
d. Ehos
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. What ethical approach focuses primarily on the heart of the person performing the act?
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. During the pandemic, nurses caring for Covid-19 patients despite the risks is an example based on what ethical
approach?
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. This approach is expressed in the maxim, “the right thing to do is the good thing to do”:
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. In healthcare, this refers to the right to demand, to be treated justly, fairly and equally:
a. Autonomy
b. Veracity
c. Beneficence
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 10 of 13
6. This is stated as an admonition in the negative form to remind health practitioners to do no harm:
a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. This refers to acts of kindness and mercy that directly benefit the patient:
a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. When the patient and the healthcare providers are bound to tell the truth to maximize the efficiency of healthcare, this
principle is:
a. Autonomy
b. Veracity
c. Justice
d. Beneficence
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. This principle involves self-determination and freedom to choose and implement one's decision, free from deceit,
duress, constraint or coercion:
a. Autonomy
b. Veracity
c. Justice
d. Beneficence
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The Senior Citizens Act is known as:

a. RA 7423
b. RA 3274
c. RA 7432
d. RA 4732
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 11 of 13
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 12 of 13
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This closure activity is to evaluate AL Strategy:what you learned after the discussion and the activity.
Three things you learned:

1) _______________________________________________________________________________________________

2) _______________________________________________________________________________________________

3) _______________________________________________________________________________________________

Two things that you’d like to learn more about:

1) _______________________________________________________________________________________________

2) _______________________________________________________________________________________________

One question you still have:

1) _______________________________________________________________________________________________

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Education (Department of Nursing) 13 of 13
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 8

LESSON TITLE: MORAL AND SPIRITUAL Materials:

RESPONSIBILITIES OF NURSES
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
References:
Upon completion of this lesson, the nursing student can:
Lydia M. Venzon RN, MAN, FPCHA Ronald M.
1. Define the Good Samaritan Act; Venzon RN, MAN (2010), Professional Nursing In
2. Enumerate the Moral Principles; and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Recognize the spiritual commitment of nurses. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, give the 5 Universal Principles of Biomedical Ethics and briefly define each:
1.

2.

3.

4.

5.

MAIN LESSON

NURSES, whatever their religion, must be God-loving and God-fearing. They must realize that the nursing profession is
a commitment both to God and people. They should emphasize the importance of providing spiritual care as a vital aspect of
nursing care. They must uphold the sanctity of human life.

MORAL PRINCIPLES
When a nurse is confronted with situations where moral judgment is necessary, the nurse may be guided by the
following principles or rules:
1. The Golden Rule. God said, "Do unto others what you would like others do unto you." Since nurses like others to
treat them kindly and with respect, they should be willing to do the same to others too.
2. The Two fold Effect. When a nurse is faced with a situation which may have both good and bad effects, how
should she choose which one to follow? The basis of action may be the following:
a. that the action must be morally good;
b. that the good effect must be willed and the bad effect merely allowed;
c. that the good effect must not come from an evil action but from the initial action itself directly; and
d. that the good effect must be greater than the bad effect
It is not morally good if a boy steals in order to alleviate his hunger because the action itself is already bad. On the
other hand, if a patient who has cancer of the uterus submits to hysterectomy she will not be able to bear a child.
If she doe, not have the operation, she will die. It is the gynecologist's intention to help the mother and not to harm
her. The surgeon's action is morally good since saving the mother's life is of primary importance. Also the doctor
himself did not will that the patient lose her child-bearing function.
3. The Principle of Totality. The whole is greater than any of its parts. Suppose a man's foot is gangrenous, should
he consent to an amputation? Since the amputation will save the patient's life and he can still walk through the aid
of crutches or artificial limbs, he can consent to an operation. The nurse can help the patient understand this.
4. Epikia. "Exception to the general rule." It is a reasonable presumption that the authority making the law will not
wish to bind a person in some particular case, even though the case is covered by the letter of the law. If a mental

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 patient went berserk and the doctor could not be contacted, the patient may be restrained by virtue of epikia.
Another example of this is allowing a relative to see a seriously ill patient who expresses the desire to see the
former although it is not yet visiting hours.
5. One who acts through an agent is himself responsible. For example, a patient wants to have an abortion and
asks a nurse if she can do it. The nurse refuses, but then recommends a doctor who is capable of performing an
abortion. The nurse becomes liable to such a crime, since he/she is an accomplice of the said doctor.
6. No one is obliged to betray himself/herself .In testifying before a court, no one can force any person to answer
a question if such will incriminate him/her.
7. The end does not justify the means. Giving a sleeping tablet to a chronically ill person so he/she can die in
peace is morally wrong.
A physician in the United States assisted a woman, diagnosed as having Alzheimer's disease, in committing
suicide. This is both legally and morally wrong.
8. Defects of nature may be corrected. Patients with a harelip or cleft palate may have their defects corrected by
plastic surgery.
What shall be the role of the nurse in a case in which parents of a severely deformed newborn child
(Down's Syndrome with intestinal atresia) refuse to feed and allow their child to starve to death?
Withholding nutrition can constitute nursing neglect and expose the nurse to criminal charges of
negligence or conspiracy to commit murder.
9. If one is willing to cooperate in the act, no injustice is done to him/her. Suppose a patient subjects
himself/herself willingly to an experimental drug and he/she has been told of the possible effects of the same, is of
right age, and is sane, there is no violation of human rights.
10. A little more or less does not change the substance of an act. If a nurse gets medicine from a hospital stock
without permission or without prescription, he/she will be guilty of theft even if he/she got only one tablet of the
same.
11. The greatest good for the greatest number. During an epidemic, immunization against communicable diseases
is administered to the people. Although there may be some who may have slight reactions to the vaccine, the
greater majority of the population shall be considered rather than the isolated few. This is called the utilitarian
principle.
12. No one is held to the impossible. To promise that a patient with heart transplant will live may be an impossibility.
Yet, such procedures are done in the hope of saving or prolonging a patient's life. The doctor or the nurse cannot
be held to the impossible if they have done their best to take care of the patient and the latter dies.
13. The morality of cooperation. Formal cooperation in an evil act is never allowed. Immoral operations such as
abortion shall not be participated upon by a nurse even if the doctor commands it.
14. Principle relating to the origin and destruction of life. one of God's commandments is "Thou shall not kill." If
God has given man a life, will it mean that God has already ceded his right to man? And if life contains with it a free
will for man to perform what he thinks is best for him and his environs, where, then, does the right of God begin?
Where does the right of man begin or end? Assuming that God gave life to man, who will know that God does
abhor a man who takes his own life? Man may appear only a puppet of God, if God will not let go of his
creation—man— to do what is best for him, i.e., including euthanasia.

Euthanasia is direct killing of people who may not have committed any crime deserving of death, but because of
mental or physical defects, are considered worthless to society. Mercy killing is not allowed because it will lessen the
incentive for medical research. It will also be possible to arrange for the death of an enemy or a wealthy relative. Many
patients surprise doctors by recovering from illness. In legalized euthanasia, they are already dead.
Giving of narcotics to a dying person shall be withheld if there is no physical pain. He must be left conscious for as
long as God does not take his consciousness away.
The state recognizes the sanctity of human life. It shall protect the life of the mother and the unborn from the time
of conception. Any direct attack on the life of a fetus for whatever cause is immoral. A fetus shall be buried in
consecrated grounds. If it is dead and came from a dead mother, it shall be buried with the mother.

SPIRITUAL COMMITMENT OF NURSES

When we speak of holistic care this means that the spiritual aspect is included as well.
The Code of Ethics' for Filipino nurses lists provision of spiritual environment as one of the responsibilities of the nurse
Christian nurses often refer to the Bible for inspirational passage that will enhance and strengthen their love and concern for
their fellowmen. Muslims find appropriate passages in their Quran.
St. Paul's message to the Colossians is very apt for nurses. He said, "You are the chosen people of God. He loves you
and chose you for His own. So then, clothe yourselves with compassion, kindness, humility, gentleness, and patience."
The nurse's ministry is reflected in God's two great commandments: "Love the Lord God with all your heart, and with all
your soul and with all your mind" and "Love your neighbors as yourself."

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 The role of nurses in providing non-prejudicial, non-discriminatory care can well be based on the story of the good
Samaritan. God has asked us to love one another as He loves us.
Jesus' healing ministry includes among others, enabling blind men to see' and the hemorrhaging woman to be healed as
she touched His garment.' He has exhorted us, "not to become tired of doing good, for if we do not give up, the time will
come when we will reap the harvest."
Doing one's duties with a cheerful heart does good like medicine but a broken spirit makes one sick.
God gave assurance that man will inherit the kingdom of God, "for whenever we feed the hungry, give water to the
thirsty, take in a stranger, and visit those in prison, we have done these to God."
Patients and families who are troubled with illness or anxiety will certainly look up to a compassionate nurse for
understanding and kindness. There are times, however, that the patient and/ or his family may need the assistance of a
nurse in calling a priest or minister of their faith. Many hospitals have resident priests or chaplains and addresses of
ministers or imams who can be called immediately upon request.
Stillbirths of Catholic parents are given emergency baptism by saying, "I baptize you (give the name), in the name of the
Father, and of the Son, and of the Holy Spirit."
If there is danger of death, Roman Catholic patients are obliged to receive the sacraments. Confession and communion
are recommended. If the patient is admitted to the hospital, he/ she must be informed of the availability of a priest to care for
his/her spiritual needs. The nurse is obliged to call the priest when needed.
When danger of death is remote, reference when priest is making rounds is sufficient. When a patient is receiving;
opiates, delay its administration until the priest arrives so that the patient can have the opportunity to express sorrow for
his/her sins and make his/her confession.
The non-Roman Catholic patient likewise looks up to his or her minister for spiritual guidance. A prudent nurse
anticipates this need of the patient and makes arrangements that the minister or imam is contacted. In the absence of one,
a nurse can read favorite passages from the Bible for the patient. The Lord's Prayer may be recited for or with the patient.
Muslim nurses provide comfort and prayers to patients of the same faith by quoting passages from the Quran. "Patients
are encouraged to put their trust in Allah for He is compassionate and merciful and shall relieve them of their burdens."
"Allah is the Lord of kindness to believers; He is their protector and the best of their helpers;" He loves those who put
their trust (in Him)" and He loves those who do good. In serving the sick and the dying, Allah assures that for those who keep
their duty to the Lord, for them are Gardens underneath which rivers flow, wherein they will be safe forever."
In general, it is the nurse who recognizes the spiritual needs of the patient and gives the latter peace of mind and comfort
to face what lies ahead of him/her.

THE GOOD SAMARITAN LAW

There are many persons who refuse to give emergency aid to victims of accidents due to liabilities they may incur later.
Although no one is legally compelled to do so, it will not be ethically and morally right to leave persons without aid especially
if one has the skill and the knowledge to save lives.
In the United States, the Good Samaritan Law has been passed to encourage on-the-spot volunteer first aid in
emergency situations by persons with the proper knowledge and skill. A nurse therefore who renders first aid or treatment at
the scene of an emergency and who does so within the standard of care, acting in good faith, is relieved of the
consequences of the act.
The Good Samaritan Act is based on the biblical story of a man who aided an injured person who was waylaid by
thieves and was left half-dead. The Samaritan took care of him with compassion, bound up his wounds, brought him to an
inn, and took care of him." Jesus told the story of the good Samaritan to illustrate how we can love our neighbors.

NURSES AND SUFFERING

Nurses observe human suffering everyday—patients in pain, others suffering emotionally, or may even be dying.
Nurses who have emotional and spiritual maturity are more able to assist patients who are depressed, fearful or confused
about the outcome of hospitalization or illness to them.
A Christian nurse's duty is not only to give physical care but to pray for or with them so that they may also have spiritual
healing and to make them feel that God is with them always. Psalm 23 says, "Ye though I walk through the valley of the
shadow of death, I shall fear no evil, for Thou art with me —Thy rod and Thy staff they comfort me." This will make them feel
that God cares for them so that they may find strength and encouragement in the midst of pain and suffering.'

LIFE IN GOD'S SERVICE

Nurses can use their different gifts in accordance with the grace that God has given them. If their gift is to speak God's
message, they should do it according to the faith that they have; if it is to serve, they should serve; if it is to teach, they should
teach; if it is to encourage others, they should do so. Whoever shares with others should do so generously; whoever has
authority should work hard; whoever shows kindness to others should do so cheerfully.

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 CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. “Exception to the general rule” refers to what moral principle?

a. Epikia
b. The Golden Rule
c. The two-fold effect
d. The principle of totality
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. God said, "Do unto others what you would like others do unto you." This moral principle is
a. Epikia
b. The Golden Rule
c. The two-fold effect
d. The principle of totality
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The whole is greater than any of its parts. Refers to

a. Epikia
b. The Golden Rule
c. The two-fold effect
d. The principle of totality
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. When a nurse is faced with a situation which may have both good and bad effects, how should she choose which one to
follow? The basis of action may be the following: SATA
a. that the action must be morally good;
b. that the good effect must be merely allowed and willed the bad effect ;
c. that the good effect must not come from an evil action but from the initial action itself directly; and
d. that the good effect must be greater than the bad effect
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Giving a sleeping tablet to a chronically ill person so he/she can die in peace is morally wrong. This is based on the
principle
a. One who acts through an agent is himself/herself responsible.
b. No one is obliged to betray himself/herself.
c. The end does not justify the means.
d. Defects of nature may be corrected.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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 6. Patients with a harelip or cleft palate may have their defects corrected by plastic surgery. This is stated in what moral
principle?
a. One who acts through an agent is himself/herself responsible.
b. No one is obliged to betray himself/herself.
c. The end does not justify the means.
d. Defects of nature may be corrected.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. In testifying before a court, no one can force any person to answer a question if such will incriminate him/her. This is
supported by the moral principle.
a. One who acts through an agent is himself/herself responsible.
b. No one is obliged to betray himself/herself.
c. The end does not justify the means.
d. Defects of nature may be corrected.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. During an epidemic, immunization against communicable diseases is administered to the people. This is based on the
moral principle
a. The greatest good for the greatest number.
b. A little more or less does not change the substance of an act.
c. The morality of cooperation
d. Principle relating to the origin and destruction of life.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Immoral operations such as abortion shall not be participated upon by a nurse even if the doctor commands it. This is
stated on the moral principle
a. The greatest good for the greatest number.
b. A little more or less does not change the substance of an act.
c. The morality of cooperation
d. Principle relating to the origin and destruction of life.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. This is based on the biblical story of a man who aided an injured person who was waylaid by thieves and was left
half-dead.
a. Good Samaritan Act
b. Euthanasia
c. Dying patient’s bill of rights
d. Christian Nurse’s duty
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

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 1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Sentence Summary

This closure activity is to evaluate what you learned after the discussion and the activity.
Give one-sentence summary about The Good Samaritan Law.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 09

LESSON TITLE: CODE OF ETHICS FOR FILIPINO NURSES Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define Code of Ethics; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Enumerate the general principles of the Code of Good Venzon RN, MAN (2010), Professional Nursing In
Governance; and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Recognize the amended Code of Ethics for Nurses. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, enumerate the 14 Moral Principles:
1. 8.
2. 9.
3. 10.
4. 11.
5. 12.
6. 13.
7. 14.

MAIN LESSON

Codes of Ethics are systematic guides for developing ethical behavior. They answer normative questions of what beliefs
and values should be morally accepted. It should be noted, however, that no code could possibly provide absolute or

-
complete rules that are free from conflict and ambiguity.

CODE OF GOOD GOVERNANCE

The Code of Good Governance promulgated by the Professional Regulation Commission on July 23, 2003 states that
the hallmark of all professionals is their willingness to accept a set of professional and ethical principles which they will follow
in the conduct of their daily lives. The acceptance of these principles requires the maintenance of a standard of conduct
higher than what is required by law.
This code is adopted by the Professional Regulation Commission and the 42 Professional Regulatory Boards to cover
an environment of good governance in which all Filipino professionals shall perform their duties.

GENERAL PRINCIPLES
The general principles of the Code of Good Governance include the following:
1. Service to Others. This implies a commitment to a life of sacrifice and genuine selflessness in carrying out their
professional duties even at the expense of personal gain.
2. Integrity and Objectivity. Professionals should perform their responsibilities with the highest sense of integrity
and imbued with nationalism and spiritual values. They should maintain objectivity, be free from conflicts of
interest, refrain from engaging in any activity that would prejudice their abilities to ethically carry out their duties nor
make any representations that would likely cause a reasonable person to misunderstand and be deceived.
3. Professional Competence. A certain level of competence is necessary, i.e., knowledge, technical skills, attitudes
and experience, in undertaking only those professional services they can reasonably deliver. It is their express
obligation to keep up with new knowledge and techniques in their field and upgrade their level of competence,
taking part in a lifelong continuing education program.
4. Solidarity and Teamwork. Each professional shall maintain and support one professional organization that
promotes a deep spirit of solidarity and teamwork among its members.

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 5. Social and Civic Responsibility. Professionals shall always carry out their professional duties with due
consideration of the broader interest of the public, serve them with professional concern consistent with their
responsibilities to society and as Filipinos, contribute to the attainment of the country's national objectives.
6. Global Competitiveness. Professionals shall remain open to the challenges of a more dynamic and
interconnected world, rise up to global standards and maintain levels of professional practices fully aligned with
global best practices.
7. Equality of All Professions. All professionals shall treat their colleagues with respect and strive to be fair in their
dealings with one another. No one group of professionals is superior to or above others. All professions perform an
equally important, yet distinct, service to society. In the eyes of the Professional Regulation Commission, all
professions are equal and therefore, every one shall treat other professionals with respect and fairness.

The professional Code of Ethics for Filipino nurses provides direction for the nurses to act morally. It strongly
emphasizes the four-fold responsibility of nurses i.e., to promote health, prevent illness, alleviate suffering and restore
health; the universality of the nursing practice, the scope of their responsibilities to the people they serve, to their
co-workers, to society and environment, and to their profession.
Prior to 1984, the Code of Ethics used by Filipino nurses was the code promulgated by the International Council of
Nurses. In 1982, the Philippine Nurses Association Special Committee, under the chairmanship of Dean Emeritus Julita V.
Sotejo, developed a Code of Ethics for Filipino nurses. This was approved by the House of Delegates of the Philippine
Nurses Association but was not implemented.
In 1984, the Board of Nursing, Professional Regulation Commission adopted the Code of Ethics of the International
Council for Nurses through Board Resolution No. 633 adding promotion of spiritual environment as the fifth-fold
responsibility of the nurse. This is also included in The Scope of Nursing Practice Article VI Sec. 28 of the Philippine Nursing
Act of 2002 Ra 9175.
In 1989, the Code of Ethics promulgated by the Philippine Nurses Association was approved by the Professional
Regulation Commission and through Board Resolution No. 1955 was recommended for use. This was approved by the
general assembly of the Philippine Nurses Association during the Nurses Week convention in October 25, 1990.

AMENDED CODE OF ETHICS FOR NURSES

Pursuant to Section 3 of Republic Act No. 877, known as the Philippine Nursing Law, and Section 6 of P.D. No. 223, the
amended Code of Ethics for Nurses recommended and endorsed by the Philippine Nurse Association was adopted to
govern the practice of nursing in the Philippines.
A new Code of Ethics for Registered Nurses has been promulgated by the Board of Nursing, in coordination and in
consultation with the Accredited Professional Organization (PNA). In its formulation, the Code of Good Governance for the
Professions was adopted and integrated, as they apply to the nursing profession.
After consultation on October 23, 2003 at Iloilo City with the accredited professional organization of registered nurses,
the PNA, and other affiliated organizations of registered nurses, the Code was adopted under Republic Act 9173 and
promulgated by the Board of Nursing under Resolution No. 220 Series of 2004 last July 14, 2004.

ARTICLE I
PREAMBLE
Sec. 1. Health is a fundamental right of every individual. The Filipino registered nurse believing in the worth and dignity
of each human being, recognizes the primary responsibility to reserve health at all cost. This responsibility encompasses
promotion of health, prevention of illness, alleviation of suffering, and restoration of health. However, when the foregoing are
n t possible, assistance towards a peaceful death shall be his/her obligation.
Sec. 2. To assume this responsibility, registered nurses have to gain knowledge and understanding of man's cultural,
social, spiritual, psychological, and ecological aspects of illness, utilizing the therapeutic process. Cultural diversity and
political and socio-economic status are inherent factors to effective nursing care.
Sec. 3. The desire for the respect and confidence of clientele, colleagues, co-workers, and the members of the community
provides the incentive to attain and maintain the highest possible degree of ethical conduct.

ARTICLE II
REGISTERED NURSES AND PEOPLE
Sec. 4.Ethical Principles
1. Values, customs, and spiritual beliefs held by the individual shall be respected.
2. Individual freedom to make rational and unconstrained decisions shall be respected.
3. Personal information acquired in the process of giving nursing care shall be held in strict confidence.
Sec. 5. Guidelines to be observed
Registered Nurses must
a. consider the individuality and totality of patients when they administer care;
b. respect the spiritual beliefs and practices of patients regarding diet and treatment;

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 c. uphold the rights of individuals; and
d. take into consideration the culture and values of patients in providing nursing care. However, in the event of
conflicts, their welfare and safety must take precedence.

ARTICLE III
REGISTERED NURSES AND PRACTICE
Sec. 6.Ethical Principles
1. Human life is inviolable.
2. Quality and excellence in the care of patients are the goals of nursing practice.
3. Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.
Sec. 7.Guidelines to be observed
Registered Nurses must
a. know the definition and scope of nursing practice which are in the provisions of R.A. No. 9173, known as the
"Philippine Nursing Act of 2002" and Board Res. No. 425, Series of 2003, the "Rules and Regulations
Implementing the Philippine Nursing Act of 2002", (the IRR);
b. be aware of their duties and responsibilities in the practice of their profession as defined in the "Philippine Nursing
Act of 2002" and the IRR;
c. acquire and develop the necessary competence in knowledge, skills, and attitudes to effectively render
appropriate nursing services through varied learning situations;
d. if they are administrators, be responsible in providing favorable environment for the growth and development of
Registered Nurses in their charge;
e. e. be cognizant that professional programs for specialty certification by the BON are accredited through the
Nursing Specialty Certification Council (NSCC);
f. see to it that quality nursing care and practice meet the optimum standards of safe nursing practice;
g. insure that modification of practice shall consider the principles of safe nursing practice;
h. if in position of authority in a work environment, be normally and legally responsible for devising a system of
minimizing occurrences of ineffective and unlawful nursing practice; and
i. ensure that patient's records shall be available only if they are to be issued to those who are professionally and
directly involved in their care and when they are required by law.
Sec. 8.Ethical Principle
4. Registered Nurses are the advocates of the patients: they shall take appropriate steps to safeguard their rights
and privileges.
Sec. 9.Guidelines to be observed
Registered Nurses must
a. respect the "Patients' Bill of Rights" in the delivery of nursing care;
b. provide the patients or their families with all pertinent information except those which may be deemed harmful to
their well-being; and
c. uphold the patients' rights when conflict arises regarding management of their care.
Sec. 10.Ethical Principle
5. Registered Nurses are aware that their actions have professional, ethical, moral and legal dimensions. They strive
to perform their work in the best interest of all concerned.
Sec. 11.Guidelines to be observed
Registered Nurses must
a. perform their professional duties in conformity with existing laws, rules, regulations, measures, and generally
accepted principle of moral conduct and proper decorum;
b. not allow themselves to be used in advertisement that should demean the image of the profession (i.e., indecent
exposure, violation of dress code, seductive behavior, etc.);
c. decline any gift, favor or hospitality which might be interpreted as capitalizing on patients;
d. not demand and receive any commission, fee or emolument for recommending or referring a patient to a
physician, a co-nurse or another healthcare worker; not to pay any commission, fee or other compensation to the
one referring or recommending a patient to them for nursing care;
e. avoid any abuse of the privileged relationship which exists with patients and of the privileged access allowed to
their property, residence or workplace.

ARTICLE IV
REGISTERED NURSES AND CO-WORKERS
Sec. 12.Ethical Principles
1. The Registered Nurse is in solidarity with other members of the healthcare team in working for the patient's best
interest.

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 2. The Registered Nurse maintains collegial and collaborative working relationship with colleagues and other
healthcare providers.
Sec. 13. Guidelines to be observed
Registered Nurses must
a. maintain their professional role/identity while working with other members of the health team;
b. conform with group activities as those of a health team should be based in acceptable, ethico-legal standards;
c. contribute to the professional growth and development of other members of the health team;
d. actively participate in professional organizations;
e. not act in any manner prejudicial to other professions;
f. honor and safeguard the reputation and dignity of the members of nursing and other professions; refrain from
making unfair and unwarranted comments or criticisms on their competence, conduct, and procedures; or not do
anything that will bring discredit to a colleague and to any member of other professions; and
g. respect the rights of their co-workers.

ARTICLE V
REGISTERED NURSES, SOCIETY, AND ENVIRONMENT
Sec. 14.Ethical Principles
1. The preservation of life, respect for human rights, and promotion of healthy environment shall be a commitment of
a Registered Nurse.
2. The establishment of linkages with the public in promoting local, national, and international efforts to meet health
and social needs of the people as a contributing member of society is a noble concern of a Registered Nurse.
Sec. 15.Guidelines to be observed
Registered Nurses must
a. be conscious of their obligations as citizens and, as such, be involved in community concerns;
b. be equipped with knowledge of health resources within the community, and take active roles in primary healthcare;
c. actively participate in programs, projects, and activities that respond to the problems of society;
d. lead their lives in conformity with the principles of right conduct and proper decorum; and
e. project an image that will uplift the nursing profession at all times.

ARTICLE VI
REGISTERED NURSES AND THE PROFESSION
Sec. 16.Ethical Principles
1. Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal.
2. Compliance with the by-laws of the accredited professional organization (PNA), and other professional
organizations of which the Registered Nurse is a member is a lofty duty.
3. Commitment to continual learning and active participation in the development and growth of the profession are
commendable obligations.
4. Contribution to the improvement of the socio-economic conditions and general welfare of nurses through
appropriate legislation is a practice and visionary mission.
Sec. 17.Guidelines to be observed
Registered Nurses must
a. be members of the accredited professional organization which is the PNA;
b. strictly adhere to the nursing standards;
c. participate actively in the growth and development of the nursing profession;
d. strive to secure equitable socio-economic and work conditions in nursing through appropriate legislation and other
means; and
e. assert the implementation of labor and work standards.

ARTICLE VII
ADMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY
Section 18
The Certificate of Registration of the Registered Nurse shall either be revoked or suspended for violation of any
provisions of this Code pursuant to Sec. 23 (f), Art. IV of R.A. No. 9173 and Sec. 23 (f), rule III of Board Res. No. 425, Series
of 2003, the IRR.

CHECK FOR UNDERSTANDING

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 You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. These are systematic guides for developing ethical behavior:

a. Code of morality
b. Code of ethics
c. Moral principles
d. Ethical principles
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The Code of Good Governance promulgated by the Professional Regulation Commission on:
a. June 23, 2003
b. July 23, 2003
c. October 25, 1990
d. July 14, 2004
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The general principles of the Code of Good Governance include the following: SATA
a. Service to Others
b. Integrity and Observance
c. Professional Competence
d. Solidarity and Teamwork
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Questions 4-10 refers to Articles and its Title of the amended Code of Ethics for Nurses

4. Registered Nurses and Practice is:

a. Article I
b. Article II
c. Article III
d. Article IV
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Article I is:
a. The Preamble
b. Registered Nurses and Practice
c. Registered Nurses and People
d. Registered Nurses and Co-Workers
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Article 5 is:
a. Registered Nurses and People

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 b. Registered Nurses and Practice
c. Registered Nurses and Co-workers
d. Registered Nurses, Society, and Environment
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Registered Nurses and People is:

a. Article I
b. Article II
c. Article III
d. Article IV
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Registered Nurses and the Profession is:

a. Article IV
b. Article V
c. Article VI
d. Article VII
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Administrative Penalties, Repealing Clause and Effectivity:

a. Article IV
b. Article V
c. Article VI
a. Article VII
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Registered Nurses and Co-workers is:

a. Article IV
b. Article V
c. Article VI
d. Article VII
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT The Muddiest Point

This activity is to evaluate what you learned after the discussion and the activity.
In today’s session, what was least clear to you?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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 Nursing Leadership and Management)
STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR
Session # 10

LESSON TITLE: LAWS GOVERNING THE PRACTICE OF Materials:

NURSING (PART 1)
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
References:
Upon completion of this lesson, the nursing student can:
Lydia M. Venzon RN, MAN, FPCHA
1. Define Law; Ronald M. Venzon RN MAN (2010), Professional
2. Enumerate the different Laws Governing the Practice of Nursing In The Philippines 11th Edition: C & E
Nursing; and, Publishing, Inc. 839 EDSA, South Triangle,
3. Recognize the Implementing Rules and Regulations of RA Quezon City
9173.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give the title of the 7 articles of the amended Code of Ethics its Articles and Title:
ARTICLE I -
ARTICLE II -
ARTICLE III -
ARTICLE IV -
ARTICLE V -
ARTICLE VI -
ARTICLE VII -

Executive Judiciary Legislative

MAIN LESSON , ,

DEFINITION AND MEANING OF LAW

A law is defined as the sum total of rules and regulations by which society is governed. It is man-made and regulates
social conduct in a formal and binding way. It reflects society's needs, attitudes and mores."
A law may also be defined as a rule of conduct pronounced by controlling authority and which may be enforced. There
are three essential characteristics of every law. The first one is the authority or the right to declare that the rule exists. The
second is that such rule is pronounced or expressed and that its source can be identified. Lastly, a right to enforce the
same must be provided.
The controlling authority in our system is the government. The fundamental law of the government is the Constitution.
It contains the principles on which the government is founded, regulates the division of sovereign powers, directs to what
persons each of these powers is to be entrusted, and specifies the manner by which these powers shall be exercised.
The first essential to a pronounced law is that it must be declared in writing. The reason for this is to be able to
must abide in
enforce control. The principal sources of these pronouncements are (1) the Constitution, (2) the statutes or legislations,
-

(3) the regulations issued by the Executive Branch of the government, (4) case decisions or judicial opinions, (5)
Presidential Decrees, and (6) Letters of Instruction.
When a rule of conduct is pronounced by a law-making body, it must be issued in writing and in such manner that its
meaning is dear and concise. When a law-making body enacts rules of conduct, there are always provisions setting forth
the consequences for violations.
-
act because we are under American

A BRIEF HISTORY OF THE PHILIPPINE NURSING LAW

The first law that had to do with the practice of nursing was Act No. 2493 of 1915, which regulated the practice of
medicine. This act provided for the examination and registration of nurses in the Philippine Islands.
During that time, the applicants needed to be only twenty years old, in good physical health, and of good moral
character. Graduates of intermediate courses of public schools could enter the school of nursing which was then giving
only two years-and-a-half of instruction. These graduates were called first-class nurses. Those who desired to be second-
class nurses filed an application with the district health officer in the district where they resided.
In 1919, Act 2808 was passed. This was known as the First True Nursing Law. It created, among others, a board of
examiners for nurses. However, it was in 1920 that the first board examination in the Philippines was given.

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 Congress enacted The Philippine Nursing Law, otherwise known as Republic Act 877, on June 19, 1953.
Provisions included the organization of the Board of Examiners for nurses, provisions regarding nursing schools and
colleges, examination, registration of nurses including sundry provisions relative to the practice of nursing.
Two important sections of R.A. 877 pertained to the need for registration as nurse before anyone could practice
nursing in the country.

SEC. 16, ART IV. Inhibition against practice of nursing. Unless exempt from registration, no person shall
practice or offer to practice nursing in the Philippines as defined in this Act, without holding a valid certificate of
registration as nurse issued by the Board of Examiners for Nurses: provided, however, that for the protection of
life and the promotion of health, or for the prevention of illness and any communicable disease any person
practicing or offering to practice professional nursing in the Philippines must submit evidence that he/she is qualified
to practice, and shall be licensed as hereinafter provided.

Section 30 Article V not only prohibits the practice of nursing without a certificate of registration issued by the
Board of Nursing but also provides the penalty for doing so.(writing BSN or RN without being one) Material misinterpretation

Prohibition in the practice of nursing. Penal Provision. Any person who shall practice nursing in the Philippines
within the meaning of this Act, without a certificate of registration issued in accordance with the provisions of this Act,
or without having been declared exempt for examination and registration, or any person presenting or using as his or
her own the certificate of registration of another, or any person giving any false or forged evidence to the Board in
order to obtain a certificate of registration, or any person assuming, using or advertising as a registered nurse, or
appending to his/her name the letters R.N. or B.S.N. without having been conferred such titles or degree in a legally
constituted school, college or university or Board of Examiners duly authorized by the government to confer the
same, or advertising any title or description tending to convey the impression that she/he is a nurse, e.g., using the
nurse's uniform and cap without holding a valid certificate of registration from the Board, or any person violating any
provision of this Act, shall be guilty of misdemeanor and shall upon conviction, be sentenced to a fine of not less
than one year or more than five years, or both in the discretion of the court.

On June 18, 1966, Republic Act 4704 amended certain portions of R.A. 877. Following were among the most salient
changes: BON 3 5 - -

1. The membership of the Board of Examiners for Nurses was increased from three to five members.
2. Members of the Board were to be appointed by the President of the Philippines with the consent of the
Commission on Appointments and no longer "upon recommendation of the Commission of Civil Service."
3. The requisite academic degree for members of the Board was a Master's Degree, instead of a Baccalaureate
Degree in Nursing.
4. A disqualifying age limit for a Board Member was fixed. No person was eligible for membership in the board if
he/ she was over 65 years of age, heretofore, no such age disqualification was provided by law.
5. The maximum total compensation which a member of the Board of Examiners for Nurses could receive was
raised from P12,000.00 per annum, as provided in the 1965-1966 Appropriation Act (Republic Act No. 4642) to
P18,000.00 yearly.
6. The academic qualification for Deans, Directors and principals of Colleges and Schools of Nursing was raised
from the level of a Baccalaureate Degree to that of a Master's Degree in Nursing.
7. The areas of study required for entrance to colleges and schools of nursing were generalized to include courses
in physical, biological, social and behavioral sciences, as well as humanities, chemistry, psychology and
zoology.
8. The scope of nursing practice was broadened to circumscribe the whole management of the care of patients and
the acts constituting professional practice of nursing were spelled out to include such services as reporting,
recording and evaluation of a patient's case, supervision of persons contributing to the nursing care of patients,
execution of nursing procedures and techniques, direction and education to secure physical and mental care
and the application and execution of physician's orders concerning treatment and medication.
9. The date of holding of nurse's examination was no longer fixed but adjusted to the official closing of the
semestral term of classes in colleges and schools of nursing.
10. The minimum age required of applicants for admission to the nurse's examination was lowered from 21 to 18
years of age, but no candidate who passed the examination was permitted to practice the profession until he or
she reached the age of 21. under civil code age of maturity is 2/

There were, however, changes in this Act. Prior to this amendment, the National League of Philippine Government
Nurses and the Philippine Nurses Association were the two nursing associations that recommended candidates to the
Board of Nursing, Now, it is only the Philippine Nurses Association that is accredited by the Professional Regulation
Commission to certify that the candidates to the Nursing Board possess the qualifications required for appointment.

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 The compensation of Nursing Board members is specified by the Professional Regulation Commission. Their
compensation is equal to that given the chairman and members of the other government boards situated in analogous
circumstances.
Republic Act 7164, introduced by Senator Heherson Alvarez, codified and revised all the laws regulating the practice
of nursing in the Philippines. It was known as the Philippine Nursing Act of 1991 which included the following changes.
1. Redefinition of the scope of nursing practice to emphasize
a. the use of the nursing process as a scientific discipline in arriving at an appropriate nursing action and care,
b. the teaching, management, leadership, and decision making roles of the nurse, and
c. the undertaking of and participation in studies and research by nurses;
2. Requiring a faculty member who was appointed to the Board of Nursing to resign from his/her teaching position
at the time of appointment and not one year preceding his/ her appointment as provided in Republic Act 877,
as amended;
3. Updating a faculty's educational qualification by requiring a Master's Degree in Nursing or related fields or its
equivalent in terms of experience and specification as pre-requisite to teaching;
4. Specification of qualifications of administrators of nursing services; and
5. Inclusion of the phrase "Unethical conduct" as one of the reasons for revocation and suspension of certificate of
registration.

One of the landmarks in the history of the nursing profession in the Philippines was the Presidential Proclamation of a
Nurses' Week. Under Proclamation No. 539 dated October 17, 1958 the President of the Philippines designated the last
week of October of every year, beginning in 1958, as Nurses' Week. The purpose of dedicating a period in a year for the
promotion of the ideals of the nursing profession was to develop consciousness and availability of nursing resources in
the Philippines.
Presidential Decree No. 223 issued on June 23, 1973 created the Professional Regulation Commission and
prescribed its powers and functions. Where before the function to regulate the different professions was under the Civil
Service Commission, this now belonged to the Professional Regulation Commission. This office was directly under the
Office of the President of the Philippines.
1. The fee for the nurse's examination was increased from P50.00 to P75.00 and the fee for registration as nurse
after passing the examination was increased from P20.00 to P40.00.
2. An applicant for registration as nurse without examination had to pay a statutory fee equal to the sum of the
examination fee and a registration fee, or a total amount of P115.00.
3. The annual registration fee should be paid on or before the 20th of January of the year. Failure to pay entailed a
surcharge of 20 percent and such additional charge was imposed for each year that the annual registration fee
was not paid, and if non-payment of the fee lasted for five consecutive years, the nurse concerned was deemed
as not of good standing and her certificate of registration should thereby be considered suspended and her
name removed from the annual roster.
4. Nurses in inactive status were exempted from paying the annual registration fee, provided they properly
informed the Nursing Board that they had stopped practicing their profession. Reinstatement to nursing practice
and in the annual roster of an inactive nurse could be effected by a request in writing and the payment of the
annual registration fee for the current year.

PRC Memorandum No. 2005-02 dated March 3, 2005, implementing the revised rates of fees charged and collected
by the Commission on Appointment.
Letter of Instruction No. 1000 from then President Ferdinand Marcos, dated March 20, 1980, required that members
of accredited professional organizations shall be given priority in the hiring of employees in the government service and in
the engagement of professional services.
Republic Act 1612 stated that a privilege tax shall be paid before any business or occupation can be lawfully begun
or pursued. The occupation or professional tax for nurses was P50.00 payable annually on or before January 31. Any
person who pursued any occupation without paying the tax required by law was liable to pay a fine not exceeding
P1,000.00 or imprisonment, for a term not exceeding six months or both. Any person who did not pay his annual privilege
tax for the current year was fined not less than P200.00 and not more than P500.00. Nurses working in the government
service were exempted from paying the privilege tax. PTR-valid anywhere in the PH (yearly payment)
Previously, a nurse had to take the Civil Service Examination to enter government service. With the passage of R.A.
1080 those who passed the bar and board examinations were declared to be civil service eligibles. Nurses need not apply
to the Civil Service Commission for the conversion of the passed board examination. They just presented a photostatic
copy of their board rating and their professional license to the government agency where they were applying.
R.A. 7392 amended R.A. 2644 known as Midwifery Law, on June 18, 1960. It provided that only those who were
licensed midwives could practice Midwifery. Nurses, according to this Act, should pass the Board Examination for
Midwives and be registered as such upon payment of the prescribed fee and submit to the Midwifery Board a certification
from the Chief of Hospital or the Municipal or Provincial or City Health Officer that they actually had attended at least

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 twenty (20) deliveries. They should pay the corresponding fees for examination and registration (Article III Section 19 & 20
Philippine midwifery Act, R.A. 7392).
If nurses want to become registered midwives also, then they should comply with these requirements.
Several arguments arose among nurses as a result of the passage of this Act.
1. Do nurses really have to register as midwives before they can attend to deliveries?
In Philippine Nursing Act of 2002, R.A. 9173, Rule V Nursing Practice, Sec. 28. Scope of Nursing Practice, it
is stated that "A person shall be deemed to be practicing nursing within the meaning of R.A. No. 9173 when he/she
singly or in collaboration with another, initiates and performs nursing services to individuals, families and
communities, in any healthcare setting."
It includes but not limited to nursing care during conception, labor, delivery, infancy, childhood, adulthood and
old age. It is repeated in Section 28 a.
Since the law specifies that nurses perform nursing care during delivery, then nurses have the legal right to do
so. In the Board of Nursing Resolution 425 series of 2003, Implementing Rules and Regulations, these duties and
responsibilities are repeated in Rule V Section 28. Scope of Nursing.
2. Should hilots or the unlicensed midwives from the barrios be allowed to continue to practice their
trade?
Section 28 Article IV of R.A. 2644 specifically allows them to do so. However, in the same Article and Section of
R.A. 7392 no mention is made about hilots. Strictly speaking therefore, they are not legally allowed to deliver babies.
In the far-flung barrios, however, they are still part of our culture or society. To ensure safety of both mothers and
newborns, many health centers offer training programs for hilots as part of their service to their communities.
3. Are the midwives properly trained in their schools to assume the roles provided for in R.A. 7392? Does
this law not infringe on the Philippine Medical Act or the Philippine Nursing Act?
To prepare midwives to give intravenous injection and suture perineal lacerations, these procedures are already
incorporated in the Midwifery curriculum. The implementing guidelines of both the Nursing Law and Midwifery Act clarified
some of these issues for competent, safe, and legal practice.

Republic Act 2382, known as the Philippine Medical Act, defines the practice of medicine in the Philippines.
SEC. 10. Act constituting the practice of medicine. A person shall be considered as engaged in the practice of
medicine who shall for compensation, fee, salary, or reward in any form paid to him directly or through another or
even without the same may physically examine any person, and diagnose, treat, operate or prescribe any remedy for
any human disease, injury, deformity, physical, mental, physical condition or ailment, real or imaginary, regardless of the
nature of the remedy or treatment administered, prescribed or recommended.

Republic Act 5181. This act prescribes permanent residence and reciprocity as qualifications for any examination or
registration for the practice of any profession in the Philippines.
SEC. 1. No person shall be allowed to practice any profession in the Philippines unless he has complied with the
existing laws and regulations, is a permanent resident therein for at least three years, and, if he is an alien, the
country of which he is a subject or citizen permits Filipinos to practice their respective professions within its territories.
Provided, that the practice of said profession is not limited by law to citizens of the Philippines: Provided, further, that
Filipinos become American nationals by reason of service in the Armed Forces of the United States during the Second
World War and aliens who were admitted to the practice of their profession before July 4, 1946, shall be exempted
from the restriction provided herein.

Presidential Decree 541 allows former Filipino professionals to practice their respective professions in the
Philippines. Balikbayans, therefore, although not residents of the Philippines anymore, may practice their profession
during the period of their stay in the country provided they register with the Professional Regulation Commission and pay
their income tax on all earnings while in the country.

In 1972, Republic Act 6425 known as the Dangerous Drugs Act was passed. Article II, Section 4 states that sale,
administration, delivery, distribution, and transportation of prohibited drugs are punishable by law. The penalty of
imprisonment ranging from twelve (12) years and one (1) day to twenty (20) years and a fine ranging from twelve
thousand to twenty thousand pesos shall be imposed upon any person who, unless authorized by law, shall sell,
administer, deliver, give way to another, distribute, dispatch in transit, or transport any prohibited drug, or shall act as a
broker in any of such transactions. In case of a practitioner, the maximum penalty herein prescribed and the additional
penalty of revocation of his/her license to practice his/her profession shall be imposed. If the victim of the offense is a
minor, the maximum penalty shall be imposed.
Should a prohibited drug involved in any offense under this section be the proximate cause of death of the victim
thereof, the penalty of life imprisonment to death and a fine ranging from twenty thousand to thirty thousand pesos
(P20,000.00 - P30,000.00) shall be imposed upon the pusher.

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 SEC. 8. Possession or Use of Prohibited Drugs. The penalty of imprisonment ranging from six (6) years and one (1)
day to twelve (12) years and a fine ranging from six thousand to twelve thousand pesos (P6,000.00 - P12,000.00)
shall be imposed upon any person, who unless authorized by law, shall possess any prohibited drug, except Indian
hemp as to which the next following paragraph shall apply.
The penalty of imprisonment ranging from six months and one day to six years and a fine ranging from six hundred to
six thousand pesos (P600.00 -P6,000.00) shall be imposed upon any person who, unless authorized by law, shall
possess or use Indian hemp.

SEC. 15. Sale, administration, dispensation, delivery, transportation, and distribution of regulated drugs.
The penalty of imprisonment ranging from six (6) years and one (1) day to twelve (12) years and a fine ranging from
six thousand to twelve thousand pesos (P6,000.00 - P12,000.00) shall be imposed upon any person, who, unless
authorized by law, shall sell, dispense, deliver, transport, or distribute any regulated drugs. In case of a practitioner,
the maximum penalty herein prescribed and the additional penalty of revocation of his license to practice his
profession shall be imposed.

SEC. 16. Possession or Use of Regulated Drugs.

The penalty of imprisonment ranging from six (6) months and one (1) day to four (4) years and a fine ranging from six
hundred to four thousand (P600.00 - P4,000.00) pesos shall be imposed upon any person who shall possess or use
any regulated drug without the corresponding license or prescription.

Act No. 3573 in 1929 declared that all communicable diseases shall be reported to the nearest health station, and
that any person may be inoculated, administered or injected with prophylactic preparations. No person shall refuse as to
hinder or obstruct these protective measures deemed advisable by the Secretary of Health or the authorized
representatives.

Republic Act 1082 which was approved on June 1954 and amended by R.A. 1891 on June 22, 1957 provided for the
creation of rural health units. Public health nursing in the Philippines was in great demand particularly in the rural areas.
For this reason and to provide these areas with competent public health nursing service the government established rural
health units staffed with technical personnel, including public health nurses. The creation of rural health units all over the
Philippines was authorized by R.A. 1082, which was approved on June 15, 1954.
As amended by R.A. 1891 in June 22, 1957 the law provided for the creation of rural health units of eight different
categories corresponding to eight population groups of municipalities to be served. R.A. 4405, approved on June 16, 1965
enlarged the staff by integrating into these units the provincial, city, and municipal sanitary inspectors, nurses and
midwives covered by the act.

Republic Act 4073 liberalizes the treatment of leprosy.' Except when the disease requires institutional treatment, no
person afflicted with leprosy shall be confined in a leprosarium. Patients shall be treated in a government skin clinic, rural
health unit or by a duly licensed physician.

Presidential Decree 996 requires compulsory immunization for all children below eight years of age against
communicable diseases. Circular No. 14 of 1965 requires health examination and immunization of all prospective Grade I
pupils against smallpox, diphtheria and tuberculosis as a pre-requisite for enrolment.

Presidential Decree 825 provides penalty for improper disposal of garbage and other forms of uncleanliness.

Presidential Decree 856, the Code of Sanitation, provides for control of all factors in man's environment that affect
health including the quality of water, food, milk, control of insects, animal carriers, transmitters of disease, sanitary and
recreation facilities, noise, unpleasant odors and control of nuisance.

Presidential Decree No. 148 amending R.A. 679 (Woman and Child Labor Law), states that the employable age
shall be 16 years. This decree provides for the minimum employable age and for privileges of working women.

Republic Act 6365 established a National Policy on Population and created the Commission on Population
(POPCOM).

Presidential Decree No. 791 is the revised Population Act. It defines the objectives, duties and functions of the
POPCOM. Among others, it empowers nurses and midwives to provide, dispense and administer acceptable methods of
contraception after having undergone training and having been granted authorization by the POPCOM in consultation with
the appropriate licensing bodies.

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 Presidential Decree No. 166 amending Presidential Decree No. 791. This decree strengthens family planning
programs through participation of private organizations and individuals in the formulation and implementation of the
program planning policies.

General Order No. 18 enjoins all citizens of the Philippines, universities, colleges, schools, government offices, mass
media, voluntary and religious organizations of all creeds, business and industrial enterprises to promote the concept of
family welfare, responsible parenthood, and family planning.

Letter of Instruction No. 47 directs all schools of medicine, nursing, midwifery and allied medical professions and
social work to prepare, plan, and implement the integration of family planning in their curricula and to require from their
graduates sufficient appropriate licensing examination.

Department of Labor Order No. 7 requires all industrial establishments to provide family planning services.

Presidential Decree No. 48 limits paid maternity leave privileges to four children.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 20 minutes for this activity:

Multiple Choice

1. The first law that had to do with the practice of nursing was:
a. Act No. 2493 of 1915
b. Act 2808
c. RA 877
d. RA 4704
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The Philippine Nursing Law is also known as:

a. RA 7164
b. RA 9173
c. Act No. 2493 of 1915
d. RA 877
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Republic Act 7164 was introduced by:

a. Senator Heherson Alvarez
b. Senator Edgardo Angara
c. Pres. Corazon C. Aquino
d. Pres. Rodrigo Duterte
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Dangerous Drug Act is known as:

a. RA 2382
b. RA 5181
c. PD 541
d. RA 6425

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 ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. This act prescribes permanent residence and reciprocity as qualifications for any examination or registration for the
practice of any profession in the Philippines:
a. RA 2382
b. RA 5181
c. PD 541
d. RA 6425

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Provides penalty for improper disposal of garbage and other forms of uncleanliness:
a. PD 996
b. PD 825
c. PD 856
d. PD 148

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Requires compulsory immunization for all children below eight years of age against communicable diseases:
a. PD 996
b. PD 825
c. PD 856
d. PD 148
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. States that the employable age shall be 16 years:

a. PD 996
b. PD 825
c. PD 856
d. PD 148
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Provides penalty for improper disposal of garbage and other forms of uncleanliness:
a. PD 996
b. PD 825
c. PD 856
d. PD 148
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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 10. Limits paid maternity leave privileges to four children:
a. PD 791
b. PD 166
c. PD 148
d. PD 48

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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 LESSON WRAP-UP

Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This activity is to evaluate what the students learned after the discussion and the activity.
Three things you learned:
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________________
2. __________________________________________________________________________________________

One question you still have:

1. ___________________________________________________________________________________________

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 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 11

LESSON TITLE: LAWS GOVERNING THE PRACTICE OF Materials:

NURSING (PART 2)
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
References:
Upon completion of this lesson, the nursing student can:
Lydia M. Venzon RN, MAN, FPCHA
1. Define Law; Ronald M. Venzon RN MAN (2010), Professional
2. Enumerate the different Laws Governing the Practice of Nursing In The Philippines 11th Edition: C & E
Nursing; and, Publishing, Inc. 839 EDSA, South Triangle,
3. Recognize the Implementing Rules and Regulations of RA Quezon City
9173.

LESSON PREVIEW/REVIEW
Based on the previous lesson, enumerate 5 laws governing the practice of nursing.
1.
2.
3.
4.
5.

MAIN LESSON

Presidential Decree No. 69 limits the number of children to four (4) for tax exemption purposes.

Presidential Decree No. 965 requires that couples intending to get married must first undergo a family planning and
responsible parenthood instruction prior to the issuance of a marriage license.

Republic Act No. 1054 requires the owner, lessee or operator of any commercial, industrial or agricultural
establishment to furnish free emergency, medical and dental attendance to his employees and laborers.

Republic Act 4226, known as the Hospital Licensure Act, requires all hospitals in the Philippines to be licensed before
they can offer to serve the community. The licensing agency is the Office for Hospital and Medical Services, Department of
Health.
Nurses working in agencies with 100-bed capacity and/or above ' and are working in an area of one million population
are supposed to work only forty (40) hours a week per R.A. 5901.

Presidential Decree 442 known as the Labor Code of the Philippines provides workers the right to self-organization
and collective bargaining. It promotes the rights and welfare of workers.

Presidential Decree 603, Child and Youth Welfare Code, protects and promotes the rights and welfare of children and
youth. Employment of children below 16 years of age is limited to performing light work not harmful to their safety, health or
normal development and which is not prejudicial to their studies.

Presidential Decree 651 decrees the registration of birth of a child within 30 days with the Civil Registrar.

ILO Convention No. 149 provides for the improvement of life and work conditions of nursing personnel.

Employees insured with the GSIS and SSS are entitled to hospitalization privileges under Program I of the Philippine
Medical Care (MEDICARE) Act (R.A. 6111 of 1969). Medicare benefits of GSIS members or their legal dependents must be
filed with the GSIS Medicare Claims Department.

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 Following are the features of Medicare under Program I:
1. Benefits are extended only in cases of actual confinement in hospital due to illness or bodily injury.
2. There is freedom of choice of hospital or physician and drugstore concerned.
3. Benefits are paid directly to the hospital, attending physician and drugstore concerned.
4. The member is entitled to 45 days hospitalization per year while their legal dependents are entitled to a total of 45
days among them.
5. Hospitalization privileges include medical and surgical services. Vasectomy and caesarean section are included
while cosmetic surgery, optometric services, psychiatry, normal delivery and diagnostic services on an out-patient
basis are not included.
Dependent parents of single members are given Medicare benefits if they are 60 years old and above.

Presidential Decree 1519 gives Medicare benefits to all government employees regardless of status of appointment.
Retirees, regardless of age, are also entitled to Medicare privilege by virtue of their membership in the GSIS or SSS.
Effective January 1980, Presidential Decree No. 1636 requires compulsory membership in the GSIS or SSS
Retirement Fund.

Presidential Decree No. 626 or the Employee Compensation and State Insurance Fund provides benefits to
workers covered by SSS or GSIS for immediate injury, illness or disabilities.
Salient aspects in the Constitution of the Philippines affecting the practice of nursing include full respect for human
rights; recognition of the sanctity of family life; protection and promotion of the rights to form unions, associations or
societies; making health services available to the people at affordable cost; protection of working women; rights of people's
organizations; and recognition of the family as the foundation of the nation.

Republic Act 6675 or the Generics Act of 1988 is an act to promote, require and ensure the production of an adequate
supply, distribution, use and acceptance of drugs and medicines identified by their generic names. Medicines are prescribed
in generics.
Nurses are the patient's advocates. Their role is not only as drug administrators but also as educators by giving
information; as evaluators through monitoring, verifying and reporting of usage and problems encountered, and as
coordinators with physicians, pharmacists, dentists, and concerned groups.

Republic Act 6758 standardizes the salaries of government employees which include the nursing personnel." Their
new position titles, salary grades and schedules are found in Appendix V. However, these are still under negotiation so that
positions of equal importance will have the same salary grade levels and schedules.

Republic Act No. 6713, known as the "Code of Conduct and Ethical Standards for Public Officials and
Employees", upholds a time-honored principle that public office is a public trust. It is the policy of the State to promote a high
standard of ethics in public service. Public officials and employees shall discharge their duties with utmost responsibility,
integrity, competence and loyalty, and shall act with patriotism and justice. They must lead modest lives and uphold public
interest over personal interest.

Republic Act 7160 or the Local Government Code transfers responsibility for delivery of basic services and facilities of
the national government to local government units. This involves devolution of powers, functions and responsibilities to the
local government both provincial and municipal.

Another law approved by Pres. Corazon C. Aquino on March 26, 1992, and authored by Senator Edgardo Angara, is
R.A. 7305 entitled "Magna Carta for Public Health Workers". Its significant objectives are:
a. to promote and improve the social and economic well-being of health workers;
b. to develop their skills and capabilities; and
c. to encourage those qualified and with abilities to remain in government service.

Republic Act 7600 or the Rooming-in and Breastfeeding Act of 1992 provides that babies born in private and
government hospitals should be roomed-in with their mothers to promote breastfeeding and ensure safe and adequate
nutrition to children. This is enforced by the Milk Code (Executive Order No. 51).

Republic Act 7432 or the Senior Citizen's Act gives honor and justice to our people's long tradition of giving high
regard to our elderly. It entitles the elderly to a twenty percent (20%) discount in all public establishments such as
restaurants, pharmacies, public utility vehicles and hospitals. It also entitles the elderly to free medical and dental check-up
and hospitalization in all government hospitals.

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 Republic Act 9173 - Change in the Philippine Nursing Act of 2002 from R.A. 7164, The Philippine Nursing Act of 1998,
taken from the Implementing Rules and Regulations of RA 9173.
1. Composition of the Board of Nursing - The Board is now composed of a Chairman and six (6) members instead of
a Chairman and four (4) members.
2. Submission of names of qualified nominees by the Accredited Professional Organization (APO) to the
Commission, three (3) nominees per vacancy, not later than three months before the vacancy.
3. The Commission submits to the office of the President two (2) nominees per vacancy not later than two months
before the vacancy occurs. The appointment must be issued not later than thirty (30) days before the scheduled
licensure examination.
4. Qualifications of Board Members
4.1 Educational requirement for members of the Board is not limited to registered nurses with Master's degree in
nursing but also to registered nurses with master's degrees in education, or other allied medical profession
provided that the Chairperson and majority of the members are holders of a Master's degree in nursing.
4.2 Of the ten years of continuous practice of the profession prior to appointment, the last five (5) years must be in
the Philippines. This was not specified in RA 7164.
4.3 The section that states that the Board member must not be a green card holder (Art III Sec. 5e R.A. 7164) does
not appear in the new law.
5. Powers and Duties of the Board, Art. II Sec. 11 added:
5.1 Adopt and regulate a Code of Ethics and Code of Technical Standards for the practice of nursing within one
year from the effectivity of this Act.
5.2 Recognize specialty organizations in coordination with accredited professional organizations.
6. Licensure Examination and Registration
6.1 Specific Dates of examination has been deleted (RA 7164 Sec. 14). Specific dates of examination - not earlier
than one (1) month and not later than two months after the closing of each semestral term.
6.2 Specific age of applicants to take the examination to be at least eighteen years (18) of age has been deleted
(RA 7164 Sec. 13b).
7. Ratings, Sec. 15 RA 9173
7.1 Specific number of times an examinee may take the licensure examination has been deleted (RA 7164 Sec. 16
3rd paragraph).
7.2 Added: Removal examination shall be taken within two (2) years after the last failed examination.
8. Revocation and Suspension of Certificate of Registration
8.1 Added: Sec. 23f for violation of RA9173, the Implementing Rules and Regulations, the Code of Ethics, the
Code of Technical Standards for Nursing Practice, and policies of the Board and of the Commission.
8.2 Sec. 23g. Added: For practicing the profession during the period of suspension.
8.3 Period of suspension of the certificate of registration/ professional license not to exceed four (4) years.
9. Rule IV, Nursing Education
9.1 Sec. 26, Rule 1 - Added: requirement for inactive nurses returning to practice - Nurses who have not actively
practiced the profession shall undergo one (1) month of didactic training and three (3) months of practicum.
9.2 Sec. 27, Qualifications of Faculty — Requirement of clinical experience in a field of specification has been
reduced from three (3) years to one (1) year in a field of specialization.
9.3 The Dean of the College of Nursing must have at least five (5) years of experience in teaching and supervising
a nursing education program. Note: An increase from three (3) years as specified in RA 7164.
10. Rule V, Nursing Practice
10.1 Scope of Nursing — Duties and Responsibilities of the Nurse:
a. Deleted: Special training in intravenous injection
Note: Nursing Service Administrators still require formal training in this aspect for the safety of the
patient, the protection of the nurse and of the agency/institution where the patient is being treated or
confined.
b. Added: Special training for suturing the "Lacerated Perineum" Sec 25a
Note: This is being undertaken by the Association of Nursing Service Administrators of the Philippines
(ANSAP) with the Maternal and Child Association of the Philippines (MCNAP).
c. Added: Observe the Code of Ethics and the Code of Technical Standards for Nursing Practice. Maintain
competence through continual
professional education.
10.2 Qualification of Nursing Service Administrators.
a. Sec. 30. Priority in Appointment
a.1 For appointment as Chief Nurse in a Public Health Agency, priority shall be given to those who have
Master's degree in Public Health/ Community Nursing.
a.2 For appointment as Chief Nurse in Military Hospitals, shall be given to those who have a Master's
Degree in Nursing and completion of a General Staff Course (GSC).

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 11. Rule VI, Health Human Resource Production and Utilization Additions:
11.1 Sec. 32. Comprehensive Nursing Specialty Program. The Board is mandated to formulate and develop a
comprehensive nursing specialty program that would upgrade the level of skills and competency of specialty nurse
clinicians in the country.
11.2 Sec. 33. Salary. Minimum base pay of nurses in public health institutions shall not be lower than the first step
or hiring rate prescribed for Salary Grade 15 pursuant to RA 6758, otherwise known as the "Compensation and
Classification Act of 1989". For nurses working in Local Government units, adjustments in salaries shall be in
accordance with Sec. 10 of the same Act.
11.3 Sec. 34. Funding for the Comprehensive Nursing Specialty Program. The annual financial requirement to
train at least ten (10) percent of the nursing staff of the participating hospital shall be chargeable against the
incomes of the Philippine Charity Sweepstakes.
11.4 Sec. 35. Incentives and Benefits. Incentives and benefits shall be limited to non-cash benefits such as free
hospital care for nurses and their dependents, and scholarship grants. As part of the improved working condition of
nurses, the government and private hospitals are mandated to maintain the standard nurse-patient ratio set by the
Department of Health.
12. Rule VII. Penal and Miscellaneous Provisions
12.1 Penalty for violation of this Act in fines has been increased (from not less than ten (10) thousand pesos
(P10,000) nor more than forty thousand pesos (P40,000) as specified in RA 7164) to not less than fifty thousand
pesos (P50,000) nor more than one hundred thousand pesos (P100,000).
Imprisonment of not less than one (1) year nor more than five (5) years from RA 7164 increased from not less
than one (1) year or more than six (6) years, or both fine and imprisonment upon the discretion of the Board.
Penalty and fine are not only for those who practice nursing under circumstances prohibited by the Act but also for
persons or employers of nurses of judicial entities who undertake review classes for foreign or local examination
without permit from the Board; or violate the minimum base pay of nurses, incentives and benefits; or any provision of
this Act as implemented by its IRR.

PRC Resolution No. 2004-17 Series of 2004 re-implemented continuing Professional Education requiring sixty
(60) credit units for three (3) years for professionals with bachelor's degree. Any excess unit earned cannot be carried
on to the next three-year period except for units earned for doctoral and master's degrees.
The total CPE units for registered professionals without baccalaureate degrees shall be thirty (30) units for three
(3) years Any excess shall not be carried on to the next three-year period.

PRC Board of Nursing Resolution No. 14 Feb. 8, 1999 promulgated the guidelines for the implementation of a
Specialty Certification.

PRC Board Resolution No. 2003-166 amended the filing of application of various licensure examinations in the
regional offices from twenty (20) days to thirty (30) days before the first day of examination to give sufficient time for the
Boards in Charge in the Central Office to tally the report, review the qualifications, check the completeness and
accuracy of the documents thereby ensuring strict compliance with the "no deferent" policy.

PRC Board of Nursing Resolution No. 2004-200 series of 2004 - requires applicants in the licensure
examination to submit transcript of records with scanned pictures and with the remarks "For Board Examination
Purposes only."

PRC Resolution No. 2004-189 series of 2004 - forfeits the examination fees paid by the examinee who failed to
report and take the scheduled examination.
Executive Order No. 566 Sept. 8, 2006 directs the Commission on Higher Education to regulate the
establishment and operation of review centers and similar entities.

CHED Memorandum Order No. 49 series of 2006 implements the rules and regulations governing the operation
of review centers pursuant to Executive Order 266.

CHED Memorandum Order No. 13 - series prohibits higher education institutions from forcing their students and
graduating students to enrol in their own review centers and/or review centers of their own preferences.

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 CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Limits the number of children to four (4) for tax exemption purposes:
a. PD 69
b. PD 965
c. RA 1054
d. RA 4226

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Requires the owner, lessee or operator of any commercial, industrial or agricultural establishment to furnish free
emergency, medical and dental attendance to his employees and laborers:
a. PD 69
b. PD 965
c. RA 1054
d. RA 4226

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Requires that couples intending to get married must first undergo a family planning and responsible parenthood
instruction prior to the issuance of a marriage license:
a. PD 69
b. PD 965
c. RA 1054
d. RA 4226

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Known as the Hospital Licensure Act:

a. PD 69
b. PD 965
c. RA 1054
d. RA 4226

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Promulgated the guidelines for the implementation of a Specialty Certification:

a. PRC Board of Nursing Resolution No. 14
b. PRC Board Resolution No. 2003-166
c. PRC Board of Nursing Resolution No. 2004-200 series of 2004
d. PRC Resolution No. 2004-189 series of 2004

ANSWER: ________

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 RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Amended the filing of application of various licensure examinations in the regional offices from twenty (20) days to thirty
(30) days before the first day of examination:
a. PRC Board of Nursing Resolution No. 14
b. PRC Board Resolution No. 2003-166
c. PRC Board of Nursing Resolution No. 2004-200 series of 2004
d. PRC Resolution No. 2004-189 series of 2004

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Re-implemented continuing Professional Education requiring sixty (60) credit units for three (3) years for professionals
with bachelor's degree:
a. PRC Board of Nursing Resolution No. 14
b. PRC Board Resolution No. 2003-166
c. PRC Board of Nursing Resolution No. 2004-200 series of 2004
d. PRC Resolution No. 2004-17 series of 2004

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Forfeits the examination fees paid by the examinee who failed to report and take the scheduled examination:
a. PRC Board of Nursing Resolution No. 14
b. PRC Board Resolution No. 2003-166
c. PRC Board of Nursing Resolution No. 2004-200 series of 2004
d. PRC Resolution No. 2004-189 series of 2004

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Series prohibits higher education institutions from forcing their students and graduating students to enrol in their own
review centers and/or review centers of their own preferences:
a. PRC Resolution No. 2004-189 series of 2004
b. Executive Order No. 566 Sept. 8, 2006
c. CHED Memorandum Order No. 49 series of 2006
d. CHED Memorandum Order No. 13

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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 10. Implements the rules and regulations governing the operation of review centers pursuant to Executive Order 266:
a. PRC Resolution No. 2004-189 series of 2004
b. Executive Order No. 566 Sept. 8, 2006
c. CHED Memorandum Order No. 49 series of 2006
d. CHED Memorandum Order No. 13

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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 LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Do Now Strategy

This activity is to evaluate what the students learned after the discussion and the activity.
Give the changes from RA 7164 to RA 9173.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 12

Materials:
LESSON TITLE: LEGAL ASPECTS AND THE NURSE (PART Book, pen and notebook, and index card/class list
1)
References:
LEARNING OUTCOMES:
Lydia M. Venzon RN, MAN, FPCHA
Upon completion of this lesson, the nursing student can: Ronald M. Venzon RN MAN (2010), Professional
Nursing In The Philippines 11th Edition: C & E
1. Define Professional Negligence;
Publishing, Inc. 839 EDSA, South Triangle,
2. Enumerate legal aspects that a nurse can encounter; and,
Quezon City
3. Recognize legal responsibilities of a nurse.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give the name of the following laws:

1. Republic Act 4226 -

2. Presidential Decree 442 -
3. Presidential Decree 603 -
4. Presidential Decree No. 626 -
5. Republic Act 6675 -
6. Republic Act No. 6713 -
7. Republic Act 7160 -
8. Republic Act 7600 -
9. Republic Act 7432 -
10. R.A. 7164 -

MAIN LESSON

AS NURSES BEGIN their professional obligations, their legal responsibilities begin as well. Their license to practice
attests that they are qualified under the law to practice their profession.
The Philippine Nursing Act of 2002 is the best guide the nurse can utilize as it defines the scope of nursing practice.
There are also standards of care that may be used as criteria in evaluating their work. Nurses are enjoined to be familiar with
the Philippine Nursing Law, the standards of nursing care, and other laws which affect nursing practice and their code of
ethics.
Nurses need not be afraid of laws. These should be understood so that their scope and limitations may be defined and
identified. When these are clarified, performance of daily tasks are assumed with more confidence and safety.

RESPONSIBILITY AND ACCOUNTABILITY FOR THE PRACTICE OF PROFESSIONAL NURSING

When nurses undertake to practice their profession, they are held responsible and accountable for the quality of
performance of their duties. Nurses employed in an agency, institution, or hospital are directly responsible to their immediate
supervisors. Private duty nurses, being independent practitioners, are held to a standard of conduct that is expected of
reasonably prudent nurses. A standard is the desired and achievable level of performance against which actual practice is
compared. Standards serve as benchmark against which to plan, to implement and assess quality of services and to show
that nursing is accountable to society, to consumers of nursing services and to governments as well as to the profession of
nursing itself and individual members.

PROFESSIONAL NEGLIGENCE
The term "negligence" refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent
person in the same or similar circumstance would or would not do, and acting or the non-acting of which is the proximate
cause of injury to another person or his property.

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Education (Department of Nursing) 1 of 11
 If a person charged with negligence shows that she meets or even surpasses this standard then there is no negligence
or carelessness. But if the defendant's actions fail to meet the standard, then there has been negligence.
The elements of professional negligence therefore are (1) existence of a duty on the part of the person charged to use
due care under circumstances, (2) failure to meet the standard of due care, (3) the foreseeability of harm resulting from
failure to meet the standard, and (4) the fact that the breach of this standard resulted in an injury to the plaintiff.
Failure to foresee harm to the person injured, following from ignorance of the admonition born of the provisions,
constitutes in fact a negligence. Article 19 of the Civil Code states that one shall act with justice, give every man his due,
observe honesty and good faith.
Article 20 states that those who, in the performance of their obligations through negligence cause any injury to another,
are liable for damages.
Liability for negligence therefore shall be imposed upon a nurse who has failed to behave as a reasonable, prudent
nurse would act in the particular circumstance.
Common acts of negligence are burns resulting from hot water bags, heat lamps, vaporizers, sitz bath; objects left inside
the patient's body such as sponges, suctions tips, loose dentures lodged in the patient's trachea; falls of the elderly,
confused, unconscious, sedated patients, or those who are not fully recovered from anesthesia; falls of children whose side
rails of beds were not pulled up and locked; and failure to observe and take appropriate action as needed. Incident reports
clarify cause and preventive actions, and are used for medico-legal purposes.
Nurses employed in government agencies are covered by the rules and regulations of the Civil Service Commission.
Administrative offenses and their corresponding penalties are found in Appendix U.

SPECIFIC EXAMPLES OF NEGLIGENCE

1. Failure to report observations to attending physicians, A nurse observed that the toes of a patient with leg
cast was cyanotic and cold to touch, but she failed to report this to the physician. The leg became gangrenous and
had to be amputated below the knee. The court found the nurse negligent in failing to inform the attending
physician of the patient's condition, and to advise the hospital authorities so that appropriate action could have
been taken.
2. Failure to exercise the degree of diligence which the circumstances of the particular case demands.' In
1975 a community health nurse attended the delivery of a patient who had no prenatal care. Although she was
reluctant to attend to the patient, she was informed that this was an emergency. The baby was born spontaneously
but the placenta was not expelled after 30 minutes. She advised that the mother be brought to the hospital. The
family left without the nurse who was attending to the baby. The patient died. The nurse was found guilty of
negligence.
3. Mistaken identity. Drugs could be given to the wrong person especially if the latter is confused or unconscious
and could not respond to the nurse's verification of identity.
4. Wrong medicine, wrong concentration, wrong route, wrong dose. There are many reported cases where
patients are inadvertently given the wrong medications or wrong doses simply because the nurse did not take time
to check the order.
5. Defects in the equipment such as stretchers and wheelchairs may lead to falls thus injuring the patients.
6. Errors due to family assistance. Suppose a nurse asked a relative to apply hot water bag to the body of a chilling
child and the latter suffered burns. The nurse would be held liable for failure to test the temperature of the water
and/or for failure to check whether the mother knew what was expected of her during such assistance.
7. Administration of medicine without a doctor's prescription. A case of negligence was filed against a
puericulture center nurse in 1979 for injecting Penstrep to a boy who had a swollen foot. The nurse informed the
parents that she was not a doctor. Upon insistence of the parents to have their child treated, she informed them
that the doctor usually gave Penstrep injections in such cases. She injected the medicine without a doctor's
prescription. The boy died of cardiorespiratory failure secondary to anaphylactic shock due to the injection of the
drug. The nurse was found guilty as charged.'

THE DOCTRINE OF RES IPSA LOQUITUR

Res Ipsa Loquitur means "the thing speaks for itself”. This means that the injury could not have happened if someone
was not negligent that no further proof is required.
Three conditions are required to establish a defendant's negligence without proving specific conduct. These are:
1. that the injury was of such nature that it would not normally occur unless there was a negligent act on the part of
someone;
2. that the injury was caused by an agency within control of the defendant; and
3. that the plaintiff himself did not engage in any manner that would tend to bring about the injury.

Proof of the plaintiff that each of these factors exists in a given situation permits the courts to conclude that the
defendant is negligent. No further proof is required.
Following are examples of such cases:

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Education (Department of Nursing) 2 of 11
 1. A patient came in walking to the out-patient clinic for injection. Upon administering the injection to his buttocks, the
patient experienced extreme pain. His leg felt weak and he was subsequently paralyzed. His sciatic nerve was
injured.
2. The presence of sponges in the patient's abdomen after an operation.
3. Fracture on a newly-delivered baby born by breech presentation.

MALPRACTICE
Malpractice in the usual sense implies the idea of improper or unskillful care of a patient by a nurse. Malpractice also
denotes stepping beyond one's authority with serious consequences.
Malpractice is the term for negligence or carelessness of professional personnel. To determine what is and what is not
careless, the law has developed a standard of care which can be determined by deciding what a reasonably prudent person
would do under similar circumstances.
Lesnik (1962) also states that the term malpractice is used properly only when it refers to a negligent act committed in
the course of professional performance.
An example of malpractice is the giving of anesthesia by a nurse or prescribing medicines. Under the Philippine Medical
Act, this will be classified as within the purview of the medical practice.
It is best to remember that if you become involved in a malpractice suit, either as a defendant or as a witness, a lawyer
should be consulted in order that you will know what to do. Do not accept any invitation by an adverse party to informally
discuss the case. Remember that the malpractice case may continue for an extended period of time.

DOCTRINE OF FORCE MAJEURE

The term "force majeure" means an irresistible force, one that is unforeseen or inevitable. Under the Civil Code of the
Philippines, no person shall be responsible for those events which cannot be foreseen, or which, though foreseen, are
inevitable, except in cases expressly specified by law.
Circumstances such as floods, fire, earthquakes and accidents fall under this doctrine and nurses who fail to render
service during these circumstances are not held negligent. However, habitual tardiness due to heavy traffic is not
considered an excuse for force majeure.

DOCTRINE OF RESPONDEAT SUPERIOR

The term means "let the master answer for the acts of the subordinate." Under this doctrine, the liability is expanded to
include the master as well as the employee and not a shift of liability from the subordinate to the master. Therefore, when a
person, through his negligence, injures another, he remains fully responsible. This doctrine applies only to those actions
performed by the employee within the scope of his employment.
Following are some examples:
1. The hospital will be held liable, if, in an effort to cut down on expenses it decides to hire underboard nurses or
midwives in place of professional nurses, and these persons prove to be incompetent.
2. The surgeon will be held responsible in case a laparatomy pack is left in a patient's abdomen.

Private duty nurses, however, are considered independent contractors. They are liable for their own negligent actions.

INCOMPETENCE
Incompetence is the lack of ability, or legal qualifications and being unfit to discharge the required duty. Although a nurse
is registered, if in the performance of her duty she manifests incompetency, there is ground for revocation or suspension of
her certificate of regisration.

LIABILITY FOR WORK OF NURSE TRAINEES AND NURSE VOLUNTEERS

There are thousands of nursing graduates each year. Ironically, there are not enough vacancies both in public and
private sectors to accomodate them. They flock to hospitals to work as "volunteers" or as "trainees." These volunteers pay a
minimum of P1,000 monthly as training fees. They are rotated in the various clinical areas and are under the direct
supervision of the nursing staff in the unit for basic nursing care to patients.
They go on training for at least three months to one year then apply again as "casual" or part-time nurses and if lucky,
they are taken in as regular staff nurses. Opportunities for work abroad often require experience of at least one year in
hospitals, hence their willingness to volunteer.
Many hospitals take advantage of the situation though. Instead of hiring replacements for staff who have resigned, they
take in volunteers to save money. If the volunteers have no experience at all then the quality of service to the patients suffer.
There are tertiary specialty hospitals that offer specialty training such as Philippine Heart Center for Critical Care
Nursing; the National Kidney and Transplant Institute for Renal Nursing, the Lung Center of the Philippines for Respiratory
Nursing. Other training hospitals offer Emergency or Trauma Nursing, Operating Room Nursing and the General Basic
Training Program for new or novice nurses. However, training in specialty hospitals are costly and rigorous. At least four to
six months of training is required.

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Education (Department of Nursing) 3 of 11
 Since nurses are responsible and accountable for their practice, nurse volunteers should exercise utmost caution,
critical thinking and independent judgment to prevent incurring liabilities which may be hard to get out of.

LIABILITY OF NURSES FOR THE WORK OF NURSING AIDES

Nursing aides perform selected nursing activities under the direct supervision of nurses. They are usually given
on-the-job training by the Training Staff. Their responsibilities usually pertain to the routine care of chronically ill patients.
They are therefore responsible for their own actions.
Nurses should not delegate their functions to nursing aides since the Philippine Nursing Act specifies the scope of
nursing practice of professional nurses. If a nurse delegates her functions to a nursing aide and the latter commits a mistake
then the person responsible is the nurse.
Nurses are enjoined to supervise their subordinates and see to it that they perform only those which they have been
taught to do and those which they are capable of doing.

LIABILITY FOR THE WORK OF NURSING STUDENTS

Under the Philippine Nursing Act of 2002 R.A. 9173, nursing students do not perform professional nursing duties. They
are to be supervised by their Clinical Instructors. In order that the errors committed by nursing students will be avoided and
or minimized, the following measures should be taken:
1. Nursing students should always be under the supervision of their Clinical Instructors.
2. They should be given assignments that are at their level of training, experience, and competency.
3. They should be advised to seek guidance especially if they are performing a procedure for the first time.
4. They should be oriented to the policies of the nursing unit where they are assigned.
5. Their performance should be assessed frequently to determine their strengths and weaknesses.
6. Frequent conferences with the students will reveal their problems which they may want to bring to the attention of
their instructors or vice-versa. Discussion of these problems will iron out doubts and possible solutions may be
provided.

However, it must be emphasized that although nursing students are not employees of the hospital they are entrusted
with the responsibility of providing supervised nursing care to the patients. The patients can expect that the care given by
these students will be in a manner consistent with that which a reasonably prudent person will give.
Both the clinical instructor and the staff nurse in the clinical area where nursing students are assigned should coordinate
in assessing the competence of nursing students before they are allowed to give care to patients so that the risks of injury to
the same will be avoided.

LEGAL DEFENSE IN NEGLIGENCE

The most common defense in a negligent action is when nurses know and attain that standard of care in giving service
and that they have documented the care they give in a concise and accurate manner.
However, if the patient's careless conduct contributes to his own injury, the patient cannot bring suit against the nurse.
On the other hand, if the nurse has expressly given advanced consent in performing a duty that involves risk, such as caring
for a psychiatric patient or a patient with communicable disease, the nurse cannot bring suit against the patient if she gets
hurt or contracts the disease since upon accepting the case, the nurse agreed to assume the risk of harm or infection
thereby relieving the patient or his relatives from legal obligations. This is termed as "assumption of risk".
Nurses therefore shall exercise their sound judgment and utilize standards of care in order to prevent lawsuits or harm to
themselves.

MEDICAL ORDERS, DRUGS, AND MEDICATIONS

Republic Act 6675 states that only validly registered medical, dental and veterinary practitioners, whether in private
institution/ corporation or in the government, are authorized to prescribe drugs. Prescriptions made by unauthorized persons
constitute illegal practice of medicine, dentistry or veterinary medicine and is punishable under R.A. 2832 or the Medical Act
of 1959, R.A. 4419 or the Dental Act, and R.A. 382 or the Veterinary Act.
In accordance with R.A. 5921,19 or the Pharmacy Act as amended, all prescriptions must contain the following
information: name of the prescriber, office address, professional registration number, professional tax receipt number,
patient's/client's name, age and sex, and date of prescription. R.A. 6675 requires that the drugs be written in their generic
names.
The dependent and coordinated function of the nurse pertains to the application and execution of written legal orders of
physicians concerning treatment and medications. Only when these orders are legal in writing and bear the doctor's
signature does the nurse have the legal right to follow them. Written orders are better understood and chances of error are
minimized if they are clear, specific, complete and legible.
Verbal orders can be minimized if the nurse seeks a clear understanding from the physicians in establishing a policy
concerning the importance of written orders.

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Education (Department of Nursing) 4 of 11
 The general rule requiring a nurse to execute all lawful orders of a physician is tempered by common sense. The nurse
must not execute an order if she is reasonably certain it will result in harm to the patient. In such case she must speak out
and risk incurring the physician's resentment or ire rather than a lawsuit.
It is preferable to raise the matter of carrying out the procedure as a point of clarification in a tactful, acceptable manner
such as "The patient is three years old, did you mean 500 or 100 mg?" or "Doctor, I will now give your order of 1 gram" and
state the name of the drug. Reminders, as in this case, the age of the child or the dose, may provide cues to possible errors.
It is on occasions such as these, that the nurse must demonstrate courage and determination in verifying orders which
are not clear or which, to her, seem erroneous. Good judgment and common sense will help avoid legal problems and
protect patients from harm.
The case of Norton vs. Argonaut Insurance Co. involved an ambiguous order of a physician when he ordered, "Give 3.0
cc Lanoxin today for 1 dose only." The nurse in the case was familiar with the injectable form of Lanoxin and was not aware
of the elixir form which was what the doctor meant. She believed the order was incorrect and asked two physicians present
in the unit whether the order could be given. The physicians did not interpret the order as the nurse did, and therefore
advised her to follow the attending physician's order. She did not contact the attending physician. Instead she administered
the medication according to her interpretation. The patient later died as a result of an overdose of the drug administered by
injection.
The most discussed case in Philippine nursing history in relation to following doctor's order is the Somera case. Miss
Lorenza Somera was condemned in May 1929 in Manila to one (1) year imprisonment in connection with the death of a
young girl in the Operating Room. She was accused of homicide through reckless imprudence.
The facts of the case in condensed form from the International Nursing Review published in 1930 read as follows:

Several days prior to May 26, 1929 Pedro Clemente took his daughter, Anastacia Clemente, to Dr. Gregorio Favis at
Manila. The latter decided to perform a tonsillectomy and instructed the father and daughter to go to St. Paul's Hospital
where he would perform the operation at 7:00 a.m. on May 26, 1929.

Assisting Lorenza Somera, a Head Nurse, were student nurses Valentina Andaya and Consolacion Montinola. The
assistant surgeon was Dr. Bartolome.

During the operation, Dr. Favis asked Dr. Bartolome for novocaine solution. Miss Montinola handed Dr. Bartolome a
syringe of solution which was handed in turn to Dr. Favis who injected the same to the patient. After a few minutes, Dr.
Bartolome noticed that the patient was becoming pale and acting as if dying. He called the attention of Dr. Favis to this
but the latter said that it was not unusual. A third syringe of solution was injected and a few minutes later, the patient
convulsed. Adrenalin was injected twice but the patient died in a few minutes.

Dr. Favis asked if the novocaine was fresh. Miss Somera replied that the solution was not novocaine but 10% cocaine.

In court, Miss Montinola testified she heard Dr. Favis order cocaine with adrenalin for injection and heard Miss Somera
to have verified the order. The autopsy report and testimony of the Medico-legal Officer showed that the patient was
suffering from status lymphaticus and that such patients were known to die even with so slight an injury as a
needle-prick.

Facts not brought in the trial were 1) that Miss Somera had finished her training only on May 20, 1929; 2) that she had
not received her registration certificate and was not an experienced graduate as stated in the prosecution; 3) that Dr.
Favis had performed tonsillectomy but once previously in St. Paul's Hospital. During that time Miss Somera was not on
duty at the Operating Room and that no order from Dr. Favis was given before his arrival.

The two accused doctors were absolved of the crime but Lorenza Somera was condemned to suffer one year and one
day imprisonment and to indemnify the heirs of Anastacia Clemente the sum of P1,000.00 with subsidiary
imprisonment in case of insolvency and to pay one-third of costs.

In view of the recommendation of two of the Justices of the Supreme Court who reviewed the case upon the appeal of
the counsel for the defense, the unanimous recommendation of the Board of Pardons, and the petition of the Philippine
Nurses Association for executive clemency, the Governor-General remitted the part of the sentence which called for
prison confinement provided that Lorenza Somera would not, in the future, violate any of the penal laws of the
Philippines.

Discussions of this case among nurses and nursing students led to remarks that the incident should not have happened
had Miss Somera asked, "Doctor, did you ask for cocaine or novocaine?" and if the doctor insisted on cocaine, she should
have directed the nursing student to dip a cotton pledget in cocaine and give such to the doctor since she knew that cocaine
was administered topically.

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Education (Department of Nursing) 5 of 11
 A nurse must see to it that she understands the action of a drug, its minimum and maximum dosages, route of
administration, and untoward effects so that she may skillfully, safely, and effectively carry them out. She should be able to
report and record the effects on the patient so that the doctor can judge its therapeutic value and know when to discontinue
its use.
Tests and treatments should be explained to the patient in accordance with the general plan of his care so that the
patient can give full consent and cooperate in its implementation. Any unfavorable psychologic or physical reaction should
be likewise reported so that the proper action may be taken. Sometimes, however, refusal may be due to inaccurate
presentation of facts. Patients must receive special sympathetic attention from the nurses. Every effort should be made to
correct inaccurate views and modify superficially-held beliefs.

INTRAVENOUS THERAPY AND LEGAL IMPLICATIONS

Nurses now participate in complex intravenous therapy procedures that were once performed only by doctors. Because
of this change, nurses must remember that their legal right to give intravenous injection is based on the Philippine Nursing
Act of 1991 Section 28 which states that "in the administration of intravenous injections, special training shall be required
according to protocol established.
Therefore nurses have to undertake a certified training course on intravenous therapy. Nurses should use the
Intravenous Nursing Standards of Practice developed by the Association of Nursing Service Administrators of the
Philippines.
In giving intravenous injections, nurses should also follow the policies of their agencies. Even if nurses have formal
training on intravenous therapy, if the hospital does not allow them to do so, then they may not do the procedure.
Board of Nursing Resolution No. 8 states that any registered nurse without such training and who administers
intravenous injections to patients, shall be held liable, either criminally under Sec. 30 (c) Art. VII of said law or
administratively under Sec. 21 Art. III or both (whether causing or not an injury or death to the patient).

SCOPE OF DUTIES AND RESPONSIBILITIES IN INTRAVENOUS THERAPY

The duties and responsibilities of nurses in intravenous therapy include the following:
1. interpretation of the doctor's orders for intravenous therapy;
2. performance of venipuncture, insertion of needles, cannulas except TPN and cutdown;
3. preparation, administration, monitoring and termination of intravenous solution such as additives, intravenous
medications, and intravenous push;
4. administration of blood/blood products as ordered by physicians;
5. recognition of solution and medicine incompatibilities;
6. maintenance and replacement of sites, tubings, dressings, in accordance with established procedures;
7. establishment of flow rates of solutions, medicines, blood and blood components;
8. utilization of thorough knowledge and proficient technical ability in the use/care, maintenance, and evaluation of
intravenous equipment;
9. nursing management of Total Parenteral Nutrition, out-patient intravenous care;
10. maintenance of established infection control and aseptic nursing interventions; and
11. maintenance of appropriate documentation, associated with the preparation, administration and termination of all
forms of intravenous therapy.

There are reported cases wherein wrong types of blood were infused to some patients, there were wrong intravenous
solutions, infiltrations causing ulcerations, or too rapid administration of these fluids causing deaths or serious injuries to the
patients. Nurses should remember that if they have not been taught venipuncture, they may refuse to carry out the
procedure until after they have received proper training. The law will not excuse the negligence of nurses because they
carried out a doctor's order. If they give intravenous injections without prior training, they may be criminally or
administratively charged even if no harm has happened to the patient.
Before the administration of blood transfusion, the Resident on Duty, the Head Nurse or Senior Nurse, and the Staff
Nurse should check that the blood is of the correct type and is properly crossmatched. They should sign their names as they
attest to these.
Proper documentation provides protection for nurses and the hospitals. The intravenous therapy may be documented
on the progress notes, a special I.V. therapy sheet or flow sheet or nursing care plan on the patient's chart.
Although this requirement is not mentioned anymore in RA 9173, most Nursing Service Administrators still require their
nurses to undergo this training program for the legal protection of the patients, the nurses, and the agencies.

TELEPHONE ORDERS
There are legal risks in telephone orders. These may be misunderstood or misinterpreted by the receiving nurse.
Sometimes, messages from telephones may sound unclear or garbled because of some trouble in the telephone lines or

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Education (Department of Nursing) 6 of 11
mispronunciation of words by the caller. Most importantly the handwriting of the nursing physician may be illegible, his
signature is not present and this order may later be denied in case errors happen or court litigations arise.
Doctors should limit telephone orders to extreme emergency situations where there is no alternative. The use of a
telephone in a non-emergency as a substitute for the physician himself can lead to serious errors and may border on
malpractice.
Only in an extreme emergency and when no other resident or intern is available should a nurse receive telephone
orders. The nurse should read back such order to the physician to make certain the order has been correctly received and
written on the patients' chart. Such order should be signed by the physician on his/her next visit within 24 hours. The nurse
should sign the name of physician per her own and note the time the order was received. Should any problem arise, the
order should be referred back to the ordering physician. It is safer that when a telephone order is given, another resident
physician or intern in the same service receive it since the latter can discuss with the former the actual condition of the
patient.
It is in the interest of safety that only those who have more experience and a greater knowledge of drugs should receive
the order. In this connection, there should be a clear hospital policy that is within the bounds of the medical and the nursing
laws regarding telephone orders to avoid misunderstanding not only for the individuals concerned but also for the hospital as
well.

CONSENT TO MEDICAL AND SURGICAL PROCEDURES

Consent is defined as a "free and rational act that presupposes knowledge of the thing to which consent is being given
by a person who is legally capable to give consent." The consent signed by the patient or his authorized representative/legal
guardian upon admission is for the initial diagnosis and treatment. Subsequent treatments/operations require individual,
informed consent. Before any medical or surgical procedure can be performed on a patient, consent must be obtained from
the patient or his authorized representative who may be his parent or guardian. It is only in case of emergency where the
consent requirement does not apply.
The physician should give as much information about a contemplated procedure and the patient should receive enough
information to allow him to give an informed consent for such procedure or treatment. The intentional touching or unlawful
beating of another person without authorization to do so is a legal wrong called battery.

Nature of Consent. Consent is an authorization, by a patient or a person authorized by law to give the consent on the
patient's behalf, that changes touching, for example, from non-consensual to consensual.
It is the nurse who actually secures the consent of the patient upon admission. This consent is usually for diagnostic
procedures and initial treatment deemed necessary by the medical staff. To substantiate the patient's consent, a written
authorization is needed as proof against any liability that may arise due to an alleged unlawful touching of a patient.

Informed Consent. Hayt and Hayt state that "it is established principle of law that every human being of adult years and
sound mind has the right to determine what shall be done with his own body. He may choose whether to be treated or not
and to what extent, no matter how necessary the medical care, or how imminent the danger to his life or health if he fails to
submit to treatment."
The essential elements of informed consent include (1) the diagnosis and explanation of the condition; (2) a fair
explanation of the procedures to be done and used and the consequences; (3) a description of alternative treatments or
procedures; (4) a description of the benefits to be expected; (5) material rights if any; and (6) the prognosis, if the
recommended care, procedure, is refused.

Proof of Consent. A written consent should be signed to show that the procedure is the one consented to and that the
person understands the nature of the procedure, the risks involved and the possible consequences.
A signed special consent is necessary before any medical or surgical treatment is done such as x-rays, special
laboratory tests, blood transfusions, operations, cobalt therapy or chemotherapy, and the like.

Who Must Consent. Ordinarily, the patient is the one who gives the consent in his own behalf. However, if he is
incompetent (such as in the case of minors or the mentally ill) or physically unable and is not an emergency case, consent
must be taken from another who is authorized to give it in his behalf.

Consent of Minors. Parents, or someone standing in their behalf, give the consent to medical or surgical treatment of a
minor. Parental consent is not needed, however, if the minor is married or otherwise emancipated.
Consent of Mentally Ill. A mentally incompetent person cannot legally consent to medical or surgical treatment. The consent
must be taken from the parents or legal guardian.

Emergency Situation. When an emergency situation exists, no consent is necessary because inaction at such time
may cause greater injury. A mother, who is on the advanced stage of labor, or a patient, who goes to the emergency room,

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Education (Department of Nursing) 7 of 11
gives an implied consent to an immediate treatment or attendance. However, if time is available and an informed consent is
possible, it is best that this be taken for the protection of all the parties concerned.
Refusal to Consent. A patient who is mentally and legally competent (sane mind and of legal age) has the right to
refuse the touching of his body or to submit to a medical or surgical procedure no matter how necessary, nor how imminent
the danger to his life or health if he fails to submit to treatment. Examples are patients who, because of their religious beliefs,
may refuse blood transfusion as in the case of Jehovah's witnesses.
As stated earlier a patient may refuse to consent due to inadequate information regarding the procedure to be done. If
after the explanation, he still refuses to sign the consent form he should be made to fill out the release form to protect the
hospital and/or agency and its personnel from any liability that may result from his refusal. If he refuses to sign the release
form, this should be noted in his chart. The competent person has a legal and ethical right to refuse treatment, and this right
is formally established.

Consent for Sterilization. Sterilization is the termination of the ability to produce offsprings. The husband and the wife must
consent to the procedure if the operation is primarily to accomplish sterilization. When the sterilization is medically
necessary and the sterilization is an incidental result such as in cases of abruptio placentae, ectopic pregnancies or ruptured
uterus, the patient's consent alone is sufficient.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. The elements of professional negligence are the following. SATA

a. existence of a duty on the part of the person charged to use due care under circumstances
b. failure to meet the standard of due care
c. the foreseeability of harm resulting from failure to meet the standard
d. the fact that the breach of this standard did not result in an injury to the plaintiff.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is not an example of negligence?

a. Failure to report observations to attending physicians.
b. Mistaken identity.
c. Errors due to family assistance.
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The doctrine that means “the thing speaks for itself”.

a. Res Ipsa Loquitur
b. Res Ipsa Loquitor
c. Respondeat Superior
d. Force Majeure
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. The term for negligence or carelessness of professional personnel.

a. Negligence
b. Incompetence
c. Malpractice
d. None of the above

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Education (Department of Nursing) 8 of 11
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. This means an irresistible force, one that is unforeseen or inevitable.

a. Res Ipsa Loquitur
b. Res Ipsa Loquitor
c. Respondeat Superior
d. Force Majeure
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. The term means "let the master answer for the acts of the subordinate."
a. Res Ipsa Loquitur
b. Res Ipsa Loquitor
c. Respondeat Superior
d. Force Majeure
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. This is the lack of ability, or legal qualifications and being unfit to discharge the required duty."
a. Negligence
b. Incompetence
c. Malpractice
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. What law states that "in the administration of intravenous injections, special training shall be required according to
protocol established."
a. Philippine Nursing Act of 1991 Section 21
b. Philippine Nursing Act of 1991 Section 30
c. Philippine Nursing Act of 1991 Section 28
d. Philippine Nursing Act of 1991 Section 20

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. When taking a telephone order, which of the following if the least helpful?
a. The nurse should read back the physician’s order.
b. The physician must sign the order on his/her next visit within 48 hours.
c. The nurse should sign the name of physician per her own and note the time the order was received.
d. When a telephone order is being given there should be another resident physician or intern in the same
service to receive it.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The essential elements of informed consent include the following. SATA
a. the diagnosis and explanation of the condition

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Education (Department of Nursing) 9 of 11
 b. a fair explanation of the procedures to be done and used and the consequences
c. a description of alternative treatments or procedures
d. a description of the benefits to be expected
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 10 of 11
LESSON WRAP-UP
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what the students learned after the discussion and the activity.

1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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Education (Department of Nursing) 11 of 11
 Nursing Leadership and Management
STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR
Session # 13

Materials:
LESSON TITLE: LEGAL ASPECTS AND THE NURSE Book, pen and notebook, and index card/class list
(PART 2)
References:
LEARNING OUTCOMES:
Lydia M. Venzon RN, MAN, FPCHA
Upon completion of this lesson, the nursing student can: Ronald M. Venzon RN MAN (2010), Professional
Nursing In The Philippines 11th Edition: C & E
1. Define Professional Negligence;
Publishing, Inc. 839 EDSA, South Triangle,
2. Enumerate legal aspects that a nurse can encounter; and,
Quezon City
3. Recognize legal responsibilities of a nurse.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give examples of professional negligence:

MAIN LESSON

MEDICAL RECORDS
The value of medical records is both scientific and legal. As a record of illness and treatment, it saves duplication in
future cases and aids in prompt treatment. The record supplies rich material for medical and nursing research. It serves
as a legal protection for the hospital, doctor, and nurse by reflecting the disease or condition of the patient and his
management. Nurses must remember the rule, "If it was not charted, it was not observed or done."
In the performance of their duties, nurses are expected to record fully, accurately, legibly, and promptly their
observations from admission to the time of the patient's discharge. Daily notes should include not only medications and
treatments given or rendered but also the physical and emotional symptoms exhibited by the patient. The nurses' notes
are aids to medical diagnosis and in understanding the patient's behavior.
Since patients have the right to confidentiality of these records, nurses are legally and ethically bound to protect the
patient's chart from unauthorized persons. Permission has to be taken from the hospital authorities for authorization to
secure any information from the patient's chart.
Nurses are responsible for safeguarding the patient's record from loss or destruction or from access by persons who
are not legally authorized to read such.

CHARTING DONE BY NURSING STUDENTS

When a nurse or a clinical instructor countersigns the charting of a nursing student, he/she attests that he/she has
personal knowledge of information and that such is accurate and authentic. Anyone who countersigns without verification
commits herself to possible legal risks.

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Education (Department of Nursing) 1 of 14
 A SAMPLE CONSENT FORM

Name of Hospital
Address

Patient's Name __________________________________________________________________________________

(Last) (First) (Middle)

Age: ________ Sex: ____________ CS: ___________

Room No: _________ Bed No: ___________ Hospital Unit No: _____________

1. I, the undersigned, hereby authorize Dr/s_________________________________________________________

_____________________________________________________________________________________________

to administer/perform upon myself/my ____________________________________________________________

_____________________________________________________________________________________________

(State the Name of Treatment/Procedure/Operation)

2. The nature and purpose of the treatment/operation/procedure and/or risks involved and the possibility of
complications have been explained to me. I acknowledge that no guarantee or assurance has been made as to the
results that may be obtained there from.

3. It is further expressly agreed that I hereby release the hospital, its personnel and Medical Staff from all
responsibility and liability for consequences, if any, resulting from the above-mentioned treatment/operation and
procedure(s).

__________________________ ___________________________

Signature of Witness Signature of Patient

__________________________

Date and Time

Patient is a minor: _____________ years of age

Patient is unable to sign because _____________________________________

__________________________ _____________________________

Signature of Witness Signature of Patient's Representative

__________________________ ______________________________

Date and Time Relationship to Patient

MEDICAL RECORDS IN LEGAL PROCEEDINGS

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 Medical records are usually used to give important evidence in legal proceedings such as police investigations,
determining cause of death, extent of injury incurred by the patient, among others. It is usually the medical records
librarian, by virtue of a subpoena duces tecum, who testifies that the patients' records are kept and protected from
unauthorized handling and change. Only complete accurate records are accepted in court.

LEGAL RISKS FOR DEFECTIVE EQUIPMENT

One important duty of the nurse is to make sure that the equipment used in procedures and treatments is not
defective. While the nurse may or may not be responsible for inspecting the equipment for optimum functioning, she
should see to it that all pieces of equipment are regularly inspected, maintained and are functioning properly. She should
document the times she requested these to show that she was able to foresee the improper functioning of equipment
which might cause possible injury to patients. Such equipment includes wheelchairs, stretchers, suction machines,
anesthesia apparatus, x-ray tables, among others.

INTENTIONAL WRONGS
A nurse may be held liable for intentional wrongs. Intentional tortuous acts may arise in the performance of her duties.

TORTS
A tort is a legal wrong, committed against a person or property independent of a contract which renders the person
who commits it liable for damages in a civil action. The person who has been wronged seeks compensation for the injury
or wrong he has suffered from the wrongdoer.
Examples of torts are:
1. Assault and Battery. Assault is the imminent threat of harmful or offensive bodily contact. It is unjustifiable to
touch another person, or to threaten to do so in such circumstances as to cause the other to reasonably believe
that it will be carried out.
Battery is an intentional, unconsented touching of another person. It is, therefore, important that before a patient
can be touched, examined, treated or subjected to medical/surgical procedures, he must have given a consent to this
effect. If consent has not been secured, the person performing the procedure may be liable for battery.
When a person comes to the hospital, it is implied that he consents to be treated. However, he may refuse
certain contacts. If he refuses an injection and the nurse gives it anyway, the latter can be charged for battery.
A patient who gets injured while being restrained may cause the attendant or the nurse to be liable for assault
and battery.
2. False Imprisonment or Illegal Detention. False imprisonment means the unjustifiable detention of a person
without a legal warrant within boundaries fixed by the defendant by an act or violation of duty intended to result
in such confinement.
If the patient has a communicable disease, however, the hospital cannot be charged for false imprisonment
if it compels the patient to stay in the hospital. Mentally-ill patients may also be kept in the hospital if there is
danger that they may take their own lives or jeopardize the lives and property of others.
Patients insisting on leaving the hospital cannot be detained, instead, the probable consequences of their
actions must be explained by a competent doctor or medical staff. Notation in their chart should be made and a
release form should be signed by the patient and/or his guardian.
3. Invasion of Right to Privacy and Breach of Confidentiality. The right to privacy is the right to be left alone,
the right to be free from unwarranted publicity and exposure to public view as well as the right to live one's life
without having anyone's name, picture or private affairs made public against one's will. Nurses may become
liable for invasion of right to privacy if they divulge information from a patient's chart to improper sources or
unauthorized persons.
Publication of an picture of a patient or a malformed baby without the consent of the parents or revelation of
the contents of the records of the patient without his consent constitute tort. Another example is when a nurse
permits a non-professional person (usually a male helper) to view a woman in labor inside the delivery room.
4. Defamation. In general, character assassination, be it written or spoken, constitutes defamation. Slander is oral
defamation of a person by speaking unprivileged or false words by which his reputation is damaged. Libel is
defamation by written words, cartoons or such representations that cause a person to be avoided, ridiculed or
held in contempt or tend to injure him in his work.
The exchange of remarks between two persons does not constitute defamation. There must be a third
person who hears or reads the comment before it can be considered defamation. Nurses should be careful in
their statements especially regarding their patients and their co-workers. If the statements are, however, for a
justifiable and not a malicious purpose, truth is an available defense. An example is when a head nurse tells the
chief nurse her opinion regarding the inefficiency of one of the staff nurses who has not been doing well in her
job.

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CRIMES, MISDEMEANORS, AND FELONIES
Crime is defined as an act committed or omitted in violation of the law. Criminal offenses are composed of two
elements: (1) criminal act and (2) evil/criminal intent. In criminal action, the state seeks the punishment of the
wrongdoers.
Conspiracy to commit a crime. A conspiracy to commit a crime exists when two or more persons agree to
commit a felony and decide to do it. Persons who commit felonies are either principals, accomplices or accessories.
Principals are those who take a direct part in the execution of the act; who directly force or induce others to
commit it; or who cooperate in the commission of the offense by another act without which it would not have been
accomplished.
Accomplices are those persons who, not being principals, cooperate in the execution of the offense by previous
or simultaneous act. To hold the person liable as an accomplice, it must be shown that he had knowledge of the
criminal intention of the principal. This may be demonstrated by previous or simultaneous acts that contribute to the
commission of the offense as aid thereto, whether physical or moral.
Accessories are those who, having knowledge of the commission of the crime, either as principals or
accomplices, take part subsequent to its commission by profiting themselves or assisting the offender to profit from
the effects of the crime by concealing or destroying the body of the crime, or the effects or instruments thereof, in
order to prevent its discovery or by harboring, concealing, or assisting in the escape of the principal of the crime,
provided the accessories act with abuse of their public functions or are known to be habitually guilty of some other
crimes.

Criminal Actions. Criminal actions deal with acts or offenses against public welfare. These vary from minor
offenses and misdemeanors to felonies. A misdemeanor is a general name for a criminal offense which does not in
law amount to felony. Punishment is usually a fine or imprisonment for a term of less than one year. A felony is a
public offense for which a convicted person is liable to be sentenced to death or to be imprisoned in a penitentiary or
prison. It is far more atrocious in nature than misdemeanor.
A felony is committed with deceit and fault. A deceit exists when the act is performed with deliberate intent and
there is fault when the wrongful acts result from imprudence, negligence, or lack of skill or foresight.

Criminal negligence may be classified into reckless imprudence and simple imprudence. It is reckless
imprudence when a person does an act or fails to do it voluntarily but without malice, from which material damage
results immediately. Simple imprudence means that the person or nurse did not use precaution and the damage was
not immediate or the impending danger was not evident or manifest.

Criminal intent is the state of mind of a person at the time the criminal act is committed, that is, he/she knows
that an act is not lawful and still decided to do it anyway. To be criminal, an act must be defined as a crime.
Deliberate intent includes two other elements without which there can be no crime. These are freedom and
intelligence. However, when a person accused of the crime offers evidence showing insanity, necessity, compulsion,
accident, or infancy the court will decide if he did not commit a criminal offense and will declare the person not guilty.

Classes of Felonies. Felonies are classified according to the degree of the acts of execution which produces
the felony into consummated, frustrated, and attempted felonies. A felony is consummated when all the elements
necessary for its execution and accomplishment are present. It is frustrated when the offender performs all the acts
or execution which will produce the felony as a consequence but which nevertheless, do not produce it by reason of
causes independent of the will of the perpetrator. There is an attempt to commit a felony when the offender
commences the commission of the same directly by overt (open or manifest) acts, and does not perform all the acts
or execution which shall produce the felony, by reason of some cause or accident other than his own spontaneous
desistance. Consummated felonies, as well as those which are frustrated and attempted, are punishable.
Felonies are also classified according to the degree of punishment attached to the felony whether grave, less
grave, or light felony. Grave felonies are those to which the law attaches the capital punishment (death) or penalties
which in any of their periods are afflictive (imprisonment ranging from six (6) years and one (1) day to life
imprisonment or a fine not exceeding P6,000.00). Less grave felonies are those which the law punishes with
penalties which in their maximum period are correctional (imprisonment ranging from one month and one day to six
(6) years, or a fine not exceeding P6,000.00 but not less than P200.00). Light felonies are those infractions of law for
the commission of which the penalty of arresto menor (imprisonment for one (1) day to thirty (30) days or a fine not
exceeding P200.00 or both of which are imposed). Light felonies are punishable only when they have been
consummated, with the exception of those committed against a person or property.

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CIRCUMSTANCES AFFECTING CRIMINAL LIABILITY
1. Justifying Circumstances. A person may not incur criminal liability under the following circumstances:
1.1. when he/she acts in defense of his/her person or rights provided that
a. there is an unlawful aggression on the part of the offended or injured party;
b. there is reasonable necessity for the means employed by the person defending himself/herself to prevent
such aggression; and
c. there is lack of sufficient provocation on the part of the person defending himself.
1.2. when he/she acts in defense of the person or the rights of his/her spouse, ascendants, descendants, or legitimate
or natural or adopted brothers or sisters, or relatives by affinity in the same degrees and those by consanguinity within
the fourth civil degree, provided that the first and second requisites prescribed in the next preceding circumstance are
present, and further requisite, in the case of provocation was given by the person attacked, that the one making
defense had no part therein.
1.3. when he/she acts in defense of the person or rights of a stranger provided that the first and second requisites
mentioned in the first circumstance and that the person defending is not induced by revenge, resentment or other evil
motives.
1.4. when any person who, in order to avoid an evil or injury, does an act which causes damage to another provided
that the evil sought to be avoided actually exists, the injury feared is greater than that done to avoid it and there is no
other practical and less harmful means to prevent it.
1.5. when he/she acts in the fulfilment of a duty or in lawful exercise of a right or office.

Anyone who acts in defense of the person or the rights of his/her spouse does not likewise incur any criminal
liability.
Any person who acts in the fulfillment of a duty or in the lawful exercise or right of office shall not also incur any
criminal liability where such acts result in the commission of a crime." When a nurse is under an order from his/her
superior, he/she shall be able to discern whether the order is lawful or not, because if such order will result in the
commission of a crime, he/she shall be criminally liable.

2. Exempting Circumstances. There are certain circumstances under which the law exempts a person from criminal
liability for the commission of a crime. The following persons under the circumstances stated are expressly exempted
by law from criminal liability for the crime they may have committed:
a. an imbecile or an insane person, unless the latter has acted during a lucid interval;
b. a person under nine years of age;
c. a person over nine years of age and under fifteen unless he/she acted with discernment;
d. any person who, while performing a lawful act with due care, causes an injury which is merely an accident without
fault or intention of causing it;
e. any person who acts under the compulsion of an irresistible force;
f. any person who acts under the impulse of an uncontrollable fear of an equal or greater injury; and
g. any person who fails to perform an act required by law, when prevented by some lawful or insuperable cause.

3. Mitigating Circumstances are those which do not constitute justification or excuse of the offense in question, but
which, in fairness and mercy, may be considered as extenuating or reducing the degree of moral culpability.
Following are some of the circumstances considered by law to be mitigating and, as such, lessen the criminal liability
of the offenders.
a. Circumstances which are otherwise justifying or exempting were it not for the fact that all requisites necessary to
justify the act or to exempt the offender from criminal liability in the respective cases are not attendant.
b. When the offender has no intention to commit so grave a wrong as the one committed.
c. When the offender is under eighteen years of age or over seventy years old.
d. When sufficient provocation or threat on the part of the offended party immediately precedes the act.
e. When the act is committed in the immediate vindication of a grave offense to the one committing the felony, his/ her
spouse, ascendants, descendants, legitimate, natural or adopted brothers or sisters, or relative by affinity within the
same degree.
f. When a person acts upon an impulse so powerful as naturally to have produced an obfuscation.
g. When the offender voluntarily surrenders himself to a person in authority or his agents, or that he/she voluntarily
confesses his/her guilt before the court prior to the presentation of the evidence for the prosecution.
h. When the defender is deaf and dumb, blind or otherwise suffering from some physical defect which thus restricts
his/her means of action, defense or communication with his/her fellow beings.
i. When the offender is suffering from such illness as would diminish the exercise of his/her willpower without,
however, depriving him/her of consciousness of his/her acts.

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4. Aggravating Circumstances are those attending the commission of a crime and which increase the criminal liability
of the offender or make his guilt more severe. Some of the circumstances considered by law as aggravating the guilt
of the offender are the following:
a. when an offender takes advantage of his public position;
b. when the crime is committed in contempt of or with insult to public authorities;
c. when the act is committed with insult or in disregard of the respect of the offended party on account of his/her rank,
age, or sex or that it is committed in the dwelling of the offended party, if the latter has not given provocation;
d. when the act is committed with abuse or confidence or obvious ungratefulness;
e. when the crime is committed in a place of worship;
f. when the crime is committed on the occasion of a conflagration, shipwreck, earthquake, epidemic or other calamity
or misfortune;
g. when the crime is committed in consideration of a price, reward, or promise;
h. when the crime is committed by means of inundation, fire, poison, explosion, standings of a vessel or intentional
damage thereto, derailment of a locomotive, or the use of any other artifice involving great waste and ruin;
i. when the act is committed with evident premeditation or after an unlawful entry;
j. when craft, fraud, or disguise is employed; and
k. when the wrong done in the commission of the crime is deliberately augmented by causing other wrongs not
necessary for its commission.

5. Alternative Circumstances are those which must be taken into consideration as aggravating or mitigating according
to the nature and effects of the crime and other conditions attending its commission. These are the relationship,
intoxication and degree of instruction and education of the offender.

The alternative circumstance of relationship shall be taken into consideration when the offended party is the spouse,
ascendant or descendant, legitimate, natural or adopted brother or sister, or relative by affinity in the same degree of the
offender.
Relationship is aggravating in physical injuries inflicted by a descendant upon an ascendant. It is mitigating when an
accused aided his/her brother in the fight against the offended party. Relationship is inherent in parricide or infanticide.
The intoxication of the offender shall be taken into consideration as a mitigating circumstance when the offender has
committed a felony in a state of intoxication, if the same is not habitual or subsequent plan to commit said felony. When
the intoxication is habitual or intentional, it shall be considered as an aggravating circumstance.
Illiteracy is not in itself sufficient to be considered mitigating. There must be lack of sufficient intelligence and
knowledge of the full significance of one's act.

LACK OF EDUCATION IS NOT MITIGATING IN:

1) rape;
2) forcible abduction;
3) arson;
4) treason;
5) in crimes against chastity like seduction and acts of lasciviousness; and
6) those acts committed in a merciless or heinous manner.

Moral Turpitude is an act of baseness, vileness or depravity in social or private duties which a man owes to his fellow
man or to society in general, an act contrary to the accepted and customary rule of right and duty between men.

Murder is the unlawful killing of a human being with intent to kill. It is a very serious crime. Nurses should keep in
mind that death resulting from a criminal abortion is murder. Euthanasia is also considered murder.

Homicide. Homicide is the killing of a human being by another. It may be committed without criminal intent, by any
person who kills another, other than his father, mother, or child or any of his ascendants or descendants, or his spouse,
without any of the circumstances attendant the crime of murder enumerated above being present.

Abortion. The term abortion means the expulsion of the product of conception before the age of viability. In law, any
person who, with the intention of prematurely ending a pregnancy, wilfully and unlawfully does any act to cause the same
is guilty of procuring abortion.
The Constitution of the Philippines protects the life of the unborn from conception (Art. II Sec. 15). In the United States
legal abortion is practiced under certain conditions, but not in the Philippines which considers abortion as illegal.

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 Infanticide. Infanticide is the killing of a child less than three (3) days of age. The mother of the child who commits
this crime shall suffer the penalty of imprisonment ranging from two (2) years, four (4) months and one (1) day to six (6)
years.

Parricide. Parricide is a crime committed by one who kills his/her father, mother or child whether legitimate or
illegitimate, or any of his/her ascendants or descendants or his/her spouse. A person who is convicted of this crime shall
be imposed a penalty of from life imprisonment (reclusion perpetua) to death.

Robbery. Robbery is a crime against a person or property. The taking of personal property of another person from
him or in his presence constitutes robbery. An example would be when a nurse takes the patient's cash or jewelry while
the latter is sleeping.

Controlled Substances. Republic Act 6425 known as the Dangerous Drugs Act of 1972 covers the administration
and regulation of the manufacture, distribution, and dispensing of controlled drugs. Persons authorized to prescribe or
dispense these drugs are required to register and have a special license for this purpose. Doctors with such license
prescribe these drugs in a yellow form. Nurses may administer these drugs only upon the written order of a physician duly
licensed to prescribe such.
Controlled drugs are kept locked in cabinets and only authorized persons shall have access to them. These are
counted and endorsed every shift. A safer method is to order in unit doses from the pharmacy so that there is no danger
of these drugs being pilfered. Nurses who violate this law are in danger of having their licenses revoked aside from the
imposed fine and/or imprisonment.

Simulation of Birth, Substitution of One Child For Another, or Abandonment of a Legitimate Child
Simulation of birth is a crime committed by one who enters in a birth certificate a birth that did not occur. It is a crime
against the civil status of a person. Substitution of one child for another or concealing or abandoning any legitimate child
with intent to cause such child to lose his/her civil status shall be punishable for simulation of birth, by prison mayor and a
fine not exceeding one thousand pesos.

POINTS TO OBSERVE IN ORDER TO AVOID CRIMINAL LIABILITY

This chapter is intended to acquaint the nurse with the criminal liabilities he/she may incur and how to avoid them.
Court litigation is not only expensive, it is also time-consuming and emotionally exhausting. Following are some points to
remember in avoiding criminal liability:
1. Be very familiar with the Philippine Nursing Law. It is your guide in practicing nursing. It specifies the scope of
nursing practice.
2. Be aware of laws that affect nursing practice. Ignorance of the law excuses no one.
3. At the start of employment, get a copy of your job description, the agency's rules, regulations and policies.
Know your place in the organizational structure so that you will know your relationship with the various positions and
departments to whom you are responsible and the people you are responsible for.
4. Upgrade your skills and competence. Be sure that these are always on a high level. Such will enable you not
only to give the best nursing care but will also give you the satisfaction of a job well done.
5. Accept only such responsibility that is within the scope of your employment and your job description.
Determine whether you are competent to do the job assigned to you. If you are not, be honest in admitting so and try
your best to learn it.
6. Do not delegate your responsibility to others. You are accountable for them. If the person to whom you
delegated the responsibility makes a mistake, you are legally liable.
7. Determine whether your subordinates are competent in the work you are assigning them. This will show
whether an in-service training is needed. Supervise them well so that the danger of committing mistakes will be
avoided.
8. Develop good interpersonal relationships with your co-workers, whether they be your supervisors, peers or
subordinates. Good interpersonal relationships breed good working relationships and many problems are easily
detected, solved or eliminated.
9. Consult your superiors for problems that may be too big for you to handle. Just like a fire, problems are best
put out in the early stages before they become too big to handle.
10. Verify orders that are not clear to you or those that seem to be erroneous. Physicians' orders should be
clearly written to avoid misunderstanding. It is better to be safe than to be sorry.
11. The doctors should be informed about the patient's conditions, the effects of medications and treatments, or
the patient's lack of progress.
12. Keep in mind the value and necessity of keeping accurate and adequate records. These will show the quality
of care that you give.

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 13. Patients are entitled to an informed consent. The initial consent on admission is usually for the initial diagnosis
and laboratory work-up and treatment. Should an operation or a special procedure be needed or done, the patient and
his family are entitled to know what it is for and the consequences of such actions on his health. This will guide them
in making an intelligent and shared decision. Another consent is needed.

WILLS
A will is a legal declaration of a person's intentions upon death. It is called a testamentary document because it takes
effect after the death of its maker. It is an act whereby a person is permitted with the formalities prescribed by law, to
control to a certain degree the deposition of his estate, to take effect after his death.
A decedent is a person whose property is transmitted through succession whether or not he left a will. If he left a will,
he is also called a testator. If the person making a will is a woman she is called a testatrix.
An heir is a person called to succession either by the provision of a will or by operation of law.
A person who dies leaving a will is said to have died testate, while one who dies without a will is said to have died
intestate. Validation of a will in court is known as probate. One who administers the provision of the will is known as the
administrator .
A will which is written, dated and signed by the testator is called holographic will. It is subject to no other form and may
be made in or out of the Philippines and need not be witnessed. In the probate of a holographic will, it is necessary that at
least one witness who knows the handwriting and signature of the testator explicitly declares that the will and the
signature are in the handwriting of the testator.
An oral will is called a nuncupative will or nuncupation. Restrictions to the oral will are that such will be made during
the person's last illness, that it be done in the place in which he died, that he asked one or more witnesses to the will, that
the will be put in writing within a given number of days, and that it be offered for probate within a specified time.

TESTAMENTARY CAPACITY AND INTENT

Following are the essentials of will to meet legal requirements:
1. The testator must have the expressed intention of making a will. He must be of right age. A person under 18
years of age cannot make a will. He is required to be of sound mind and to have clear thinking ability at the time
of its execution. He must be free from undue influence.
2. The testator shall name the person who will be in charge of carrying out the provisions of the will.
3. Properties must be disposed in accordance with legal requirements.
4. The will must be signed by the testator, attested and signed by at least three witnesses in his presence and of
one another. It must be in a language or dialect known to the testators.
5. Every will must be acknowledged before a notary public by the testator and witnesses.
6. Witnesses to the wills shall be of sound mind, 18 years of age or more, not blind, deaf or dumb, and able to read
and write.
7. A married woman may make a will without the consent of her husband and without the authority of the court.
She may dispose by will all of her separate property as well as her share of the conjugal partnership or absolute
community property.

THE NURSE'S OBLIGATIONS IN THE EXECUTION OF A WILL

The nurse should note the soundness of the patient's mind (that he/she understood the act of making a will) and that
there was freedom from fraud or undue influence (he/she was not induced to make someone the beneficiary of the will)
and that the patient was above 18 years of age. He/She should note that the will was signed by the testator, that the
witnesses were all present at the same time and signed the will in the presence of the testator.
For protection of the nurse, she should make a notation on the patient's chart of the apparent mental and physical
condition of the patient at the time of making the will and also the fact of his making the will. Such records may be
important if the will is later contested. Obviously, she may then be asked to testify during the probate.

GIFTS
Another way of disposing property, aside from executing a will, is by gifts. Four legal requirements for a gift are:
1. the gift must consist of personal property;
2. there must be an intention to make the gifts;
3. there must be an indication of transfer of control over such property; and
4. there must be acceptance by the recipient.

Gifts made by a person because of anticipation of death or belief in approaching death are called gifts causa mortis or
donatio causa mortis. These are revocable and subject to the claims of the donor's creditors without proof of intent to
defraud them. Such gifts are the same as in the execution of will, that the person is of sound mind, of legal age, and is
not under undue influence. The nurse should make notes on the patient's chart and record the patient's condition and
reactions.

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Education (Department of Nursing) 8 of 14
LEGAL PROCEDURE AND TRIAL
In trial, the judicial procedure is to ascertain facts by hearing evidence, determine which facts are relevant, apply the
appropriate principle of law, and pass judgment. These procedures in a lawsuit can be divided into commencement,
pleading, pretrial, trial, and execution.

COMMENCEMENT OF THE ACTION

The first step in the trial process is to determine what kind of legal action to take. If the action relates to negligence,
the correct action would be in negligence; and if it relates to contract, the proper action would be for breach of contract.
The court, which has jurisdiction over the case and the geographic area where one of the parties resides or where the
action causing the complaint occurred, determines the venue where the case will be presented.

STATUTES OF LIMITATION
Complaint must be made within a specific time or the right to complain may be lost forever. There is a time limit in
filing cases because witnesses become less reliable after passage of time. It is more difficult to procure records that may
be important; death may intervene and prevent the presence of essential persons; parties may wait indeterminably until
an unfair advantage accrues by reason of death of an important witness or the destruction of documents. Claims for
negligence or malpractice vary from two (2) to three (3) years. In criminal cases, statutes of limitation vary from two (2) to
six (6) years except in cases where murder is committed in which there is no time limit.

COMMENCEMENT OF LEGAL PROCEEDINGS

The primary function of the court is to determine a controversy between two (2) disputants, technically called litigants.
The accuser is also known as the complainant or a plaintiff, whereas the accused is known as the respondent or
defendant.
The preliminary process will be taken care of by the attorney or counselor, who files an order with the court clerk to
issue a writ of summons to the sheriff to inform the defendants that they must appear before the court on a particular date.
The complaint is filed and served. The defendant's attorney will now study the case and prepare a strategy and defense.

PLEADING
Each party presents a statement of facts or pleading to the court. First pleading is generally known as a complaint or
petition. In less serious crimes known as misdemeanor, these pleadings are called complaints while in crimes of more
serious nature known as felonies, the pleadings are called indictments.
After the complaint is filed, the defendant must make some reply within a specific time. He must be aware of his
fundamental rights to due process of law.

FUNDAMENTAL REQUIREMENTS OF DUE PROCESS

The fundamental requirements of due process as per Article III, Bill of Rights of the New Constitution are as follows:

SEC. 12. (1) Any person under investigation for the commission of an offense shall have the right to be informed
of his right to remain silent and to have competent and independent counsel preferably of his own choice. If the
person cannot afford the services of a counsel, he must be provided with one. These rights cannot be waived except in
writing and in the presence of a counsel.
(2) No torture, force, violence, threat, intimidation, or any other means which vitiate the free will shall be used
against him. Secret detention places, solitary, incommunicable, or other similar forms of detention are prohibited.
(3) Any confession or admission obtained in violation of these or Section 17 hereof shall be inadmissible in
evidence against him.
(4) The law shall provide for penal and civil sanctions for violations of this section as well as compensation to
and rehabilitation of victims of torture or similar practices, and their families.

SEC. 13. All persons, except those charged with offenses punishable by reclusion perpetua when evidence of
guilt is strong, shall, before conviction, be bailable by sufficient sureties, or be released on recognizance as may be
provided by law. The right to bail shall be impaired even when the privilege of the writ of habeas corpus is suspended.
Excessive bail shall not be required.

SEC. 14. (1) No person shall be held to answer for a criminal offense without due process of law.
(2) In all criminal prosecutions, the accused shall be presumed innocent until the contrary is proved, and shall
enjoy the right to be heard by himself and counsel, to be informed of the nature and cause of the accusation against
him, to have a speedy, impartial and public trial, to meet the witnesses face to face, and to have production of
evidence in his behalf. However, after arraignment, trial may proceed notwithstanding the absence of the accused
provided that he has been duly notified and his failure to appear is justifiable.

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Education (Department of Nursing) 9 of 14
PRE-TRIAL PROCEDURES
This is an informal discussion between the judge and attorney to eliminate matters not in dispute, agree on issues and
settle procedural matters relating to the trial. Cases are often settled at this point.

TRIAL
At the trial, facts of the case are determine, the principles of law relating to those facts are applied and a conclusion
as to liability is reached. The judge determines the facts and applies the law.

WITNESS
The necessity of testimony by any person in a legal proceeding is determined by the attorneys for the parties. Thus, a
subpoena or a court summons is served directing a witness to appear and give testimony on the date and time ordered. A
subpoena duces tecum is served to a witness requiring him to bring records, papers and the like which may be in his
possession and which may help clarify the matter in issue.
Since a trial is a search for truth, it is the duty of a witness to aid in this. The nurse is trained to be thorough.
Therefore, when invited to become a witness, she should also seek the aid or counsel of a lawyer so that she may be
guided accordingly.
In the witness stand, she should face the judge or jury and speak clearly, adequately, and intelligently. She should
testify only on what she knows based on facts. This is called testimony of facts. Testimony of opinion may only be given
by expert witnesses. An expert witness is one who is qualified to testify based on special knowledge, skill, experience,
and training. She should use words and terms that the average person will understand. Since her testimony is under oath,
she should speak only the truth, otherwise, she will be liable for perjury or false swearing under oath. She should neither
hesitate to say she does not know, nor answer any question that might incriminate her. This is known as the privilege
against self-incrimination.
Hearsay evidence, or a repetition of what the witness has heard others say, is not admissible in court.
Privileged communications are statements uttered in good faith. These are not permitted to be divulged in a court of
justice. Examples of these are those made between man and his wife or vice-versa; between a lawyer and his client; a
physician and his patient; or a priest and the person who has made a confession.
Privileged communication between a patient and a doctor is based on the fact that a patient needs to give all the facts
regarding his ailment in order that the physician can arrive at a correct diagnosis and so that his plan of care may be
made accordingly.
If the purpose of the proceedings is to ascertain the truth, the purpose of evidence is to determine the truth or the
falsity of the facts at issue. Evidence may be established by records, documents, exhibits, objects, among others.
Testimony is one type of evidence.
Dying declarations or ante-mortem statements are considered hearsay evidence except when made by a victim of a
crime. If a nurse receives a dying declaration she should write down the person's actual words. She should repeat back
what she wrote to determine if it is correct. If possible, these statements are to be signed by the person making the
declaration.
The witness may be cross-examined to challenge or disprove the testimony. Evidence such as documents may also
be presented during the trial.
After all evidences have been presented, either party may ask the judge to rule that the claim has not been proven or
a defense has neither been proven nor has it been established. And the judge is directed to render a verdict to that effect.
The judge renders a judgment based on the verdict.
When the judgment is rendered, the losing party has an opportunity to move for a new trial, and if granted, the entire
process is repeated. If not, the judgment becomes final, subject to a review of the trial record by the appellate court.

APPEALS
An appellate court reviews the case, and when the case is decided by it, the final judgment results and the matter is
ended.

EXECUTION OF JUDGMENT
Generally, lawsuits against hospitals or physicians and nurses involve recovery of money damages. The defendant is
compelled to execute the judgment. Failure to obey will be regarded as contempt of court and will result in fine or
imprisonment. If the judgment is for payment of money, the plaintiff may cause the sheriff to sell so much of the
defendant's property as is necessary to pay the costs.

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Education (Department of Nursing) 10 of 14
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 20 minutes for this activity:

Multiple Choice

1. It serves as a legal protection for the hospital, doctor, and nurse by reflecting the disease or condition of the patient
and his management.
a. Medical Records
b. Consent
c. Advance Directives
d. Will
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Who testifies that the patients' records are kept and protected from unauthorized handling and change?
a. Physician
b. Nurse
c. Administrator
d. Medical Records Librarian
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. A legal wrong, committed against a person or property independent of a contract which renders the person who
commits it liable for damages in a civil action.
a. Crime
b. Tort
c. Malpractice
d. Negligence
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Is the imminent threat of harmful or offensive bodily contact.

a. Assault
b. Battery
c. False Imprisonment
d. Invasion of Right to Privacy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. An intentional, unconsented touching of another person.

a. Assault
b. Battery
c. False Imprisonment
d. Invasion of Right to Privacy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 11 of 14
6. This means the unjustifiable detention of a person without a legal warrant within boundaries fixed by the defendant by
an act or violation of duty intended to result in such confinement.
a. Assault
b. Battery
c. False Imprisonment
d. Invasion of Right to Privacy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The right to privacy is the right to be left alone, the right to be free from unwarranted publicity and exposure to public
view as well as the right to live one's life without having anyone's name, picture or private affairs made public against
one's will.
a. Assault
b. Battery
c. False Imprisonment
d. Invasion of Right to Privacy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. This is oral defamation of a person by speaking unprivileged or false words by which his reputation is damaged.
a. Grapevine
b. Libel
c. Slander
d. Bullying
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Is the defamation by written words, cartoons or such representations that cause a person to be avoided, ridiculed or
held in contempt or tend to injure him in his work.
a. Grapevine
b. Libel
c. Slander
d. Bullying
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Lack of education is not mitigating in which of the following?

a. Cyberbullying
b. Theft
c. Rape
d. Drunk driving

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 12 of 14
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 13 of 14
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Sentence Summary

This activity is to evaluate what the students learned after the discussion and the activity.

Give one-sentence summary on the punishment of someone who is guilty of Simulation of Birth, Substitution of One Child
For Another, or Abandonment of a Legitimate Child,

_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 14 of 14
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 14

LESSONTITLE: INTRODUCTION OF NURSING

MANAGEMENT & LEADERSHIP (LEADING, MANAGING, Materials:
FOLLOWING) (PART 1)
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can: References:
Sullivan, E. J. (2009), Effective Leadership and
1. Explain why every nurse is a manager & can be a leader; Management in Nursing (7th edition). Singapore:
2. Differentiate between leaders & managers; Pearson Education South Asia Pte Ltd.
3. Discuss how different theories explain leadership &
management;
4. Describe what management roles nurses fill in practice;
5. Discuss how followership is essential to leadership; and,
6. Describe what makes a leadership successful.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give some points to remember in avoiding criminal liability:

MAIN LESSON

MANAGEMENT
l Process by which a cooperative group directs actions towards common goals.
l Involves techniques by which a distinguished group of people coordinates the services of people
l Process of accomplishing goals of the group through efficiency and effective use of resources
l Management PROCESS is universal.
l Management is a task, a discipline. But it is also PEOPLE.
l Management is a PRACTICE rather than a science or a profession. (Peter Drucker)

MAJOR FUNCTIONS
1. Planning
2. Organizing
3. Directing
4. Controlling

NURSING MANAGEMENT
The process of working through staff members to be able to provide comprehensive care to the patient.

LEADERSHIP
l Process of influencing others to achieve organizational goal
l Interpersonal process that involves motivating and guiding others to achieve goals

TOOLS / ELEMENTS
1. MANPOWER
- people that operate an organization
- makes use of financial & material resources of an organization.
2. MACHINES
- devices that help the organization by either performing tasks faster or doing work that humans cannot.

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Education (Department of Nursing) 1 of 11
 3. MONEY
- refers to a budget allocated for an undertaking or activity.
4. METHODS
- refers to the body of technique for investigating phenomena, acquiring new knowledge, or correcting and
integrating previous knowledge.
5. MATERIALS
- physical resources used as inputs in the nursing process.
6. MOMENT
- refers to time as a resource.
7. MANAGER
- person responsible for planning & directing the work of group of individuals, monitoring their work, and taking
corrective action when necessary

LEVELS OF MANAGEMENT (MANAGER ORGANIZATIONAL LEVEL)

I. First-Line / First Level Manager (Frontline Manager)

l Manager functions in a role closely identified with the actual delivery of client care.
l Manager coordinates the activity of all staff who provide client care and supervises team members.
l Responsible for the daily management of line workers.
l Make the decisions with the help of few guidelines.
II. Middle Manager
l Responsibilities:
ü Managing staff
ü Preparing budget & work schedules
ü Writing & implementing policies that guide client care and unit operations
l Responsible for carrying out the goals set by top management
l Communicates upward and downward
III. Top Manager / Upper Level Manager (Nurse Executive Level)
l Supervises multiple departments & works closely with the administrative team of organization.
l Ensures that all clients provided by nurses is carries out in keeping with the objectives of health care
organization.
l Responsible for making wide decisions and establishing goals and plans that affect the entire organization.

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Education (Department of Nursing) 2 of 11
THEORIES OF MANAGEMENT

SCIENTIFIC MANAGEMENT
l Frederick Winslow Taylor - “Father of Scientific Management”
l Focuses on productivity and profit, & efficiency
l Programs/Principles:
1. Reduced waste efforts
- Determined the most scientific way to accomplish a task through the use of time & motion studies.
- Production is efficient in shortest time possible.
2. Set standards for performance
- Working conditions & methods had to be standardized.
- Management selects & trains workers to maximize production.
3. Encourage specialization
- Developed mastery on one area by training workers well.
- Developed an incentive plan whereby workers where paid according to their rates of production.
4. Stressed the selection of qualified workers who could be developed for a particular job
- The most productive are hired.

l Henry Laurence Gantt - “Father of Scientific Management”

- concerned with problems of efficiency.
- contributed to scientific management by refining previous work rather than introducing new concepts.
- forerunner of PERT chart.
ü PERT: Program Evaluation and Review Technique
ü PERT Chart - Depicts the relationship between work & time needed to perform a task.
- Developed task & bonus remuneration plan.
- Workers received a day’s wage plus a bonus for production above the standard to stimulate higher
performance
- Argued for a more humanitarian approach, placing emphasis on service rather than profit objectives,
recognizing useful non-monetary incentives.
- Recommended that workers be selected scientifically and provided with detailed instructions for their task.

CLASSIC ORGANIZATION
l Henri Fayol - “Father of the Management Process School”
- Studied the functions of managers.
- Conceptualized the Principles of Management.
l This viewed the organization as a whole rather than focusing solely on production.
l Has a inductive approach
l Also looks to facilities, employees, policies, structures (physical environment)
l AKA: FAYOLISM
-- we owe a lot from him in terms of management.

Principles of Management
1. DIVISION OF LABOR
- Task must be grouped & assigned to a group of people who are specially trained to efficiently perform the
job.
2. AUTHORITY
- Managers should possess the ability to give orders for work to be accomplished.
3. DISCIPLINE
- Rules and regulations need to be formulated and imposed.
4. UNITY OF COMMAND
- An employee should report to only one supervisor.
5. UNITY OF DIRECTION
- Only one manager should give directions regarding operations in an organization or generate a single plan
& all play their part in that plan.
6. SUBORDINATION OF INDIVIDUAL INTEREST TO GENERAL INTEREST
- Employee should give primary importance to the organization’s interest.
7. REMUNERATION
- Equal work for equal pay.
8. CENTRALIZATION
- Decision-making lies on the manager only.

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Education (Department of Nursing) 3 of 11
 DECENTRALIZATION
- Decision-making is shared with the employees.
9. SCALAR CHAIN (HIERARCHY OF COMMANDS)
- Line of authority of people within the organization flows from top to the bottom.
10. ORDER
- Things & people are in right place at the right time.
11. EQUITY
- Fair & just treatment of employees.
12. STABILITY OF TENURE
- Employees are secure in their jobs
- Grant security of tenure or permanent status after a satisfactory performance.
13. INITIATIVE
- Employees are given freedom to determine how to do the work.
14. ESPRIT DE CORPS
- Unity, team work, team spirit, harmony, camaraderie among all members of organization.

l Max Weber - “Father of Organization Theory”

- Conceptualized bureaucracy with emphasis on rules instead of individuals and on competence over favoritism
as the most efficient basis for organization.
ü BASES OF AUTHORITY under Max Weber
1. Traditional Authority - you already have the power (monarchy)
2. Charisma - sacred/ outstanding characteristics (Erap, Bong Revilla)
3. Rational Legal Authority - based on knowledge, skills, ability

HUMAN RELATIONS
u Chief concerns: individuals, group process, interpersonal relations, leadership & communication.
u Focused on the effect individuals have on the success or failure of an organization.
u Instead of concentrating on the organization's structure, managers encourage workers to develop their potential
and help them meet their needs for recognition, accomplishment and sense of belongingness.

Leadership is not defined by

the exercise of power but by
the capacity to increase the
sense of power among those
led. The most essential work
of the leader is to create
more leaders.

u Elton Mayo - With Fritz Roethlisberger, tested the assumption of the scientific management theory through studies
call the HAWTHORNE EFFECT.

HAWTHORNE EFFECT
l Refers to a momentary change of behavior or performance in response to a change in a worker’s environment,
the response usually being an improvement.
l Productivity was affected by both physical & social environment.
ü Ability or opportunity to participate in decision making with administration
ü Recognition from the administration
ü Brighter workplace, cleaner work areas, relocation

BEHAVIORAL SCIENCE APPROACH IN MANAGEMENT

l Stressed the importance of maintaining:

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Education (Department of Nursing) 4 of 11
 ü Positive attitude toward people
ü Training managers
ü Fitting supervisory actions to the situation
ü Meeting employees’ needs
ü Promoting employees’ sense of achievement
ü Participative leadership

l Abraham Maslow
- Developed the Hierarchy of Needs
- Used as a management process/tool knowing what drives people to work

l Douglas McGregor
- Conceptualized Theory X and Y.
THEORY X and Y
ü Theory X
- assumes that people dislike work
- actions: directed, controlled, led, coerced & threatened.
- will avoid work
- do the actions so that organizational goals can be met.
ü Theory Y
- assumes that workers have the self-direction & self-control necessary for meeting the objectives and
will respond to rewards for the accomplishment of goals.

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Education (Department of Nursing) 5 of 11
 l THEORY Z
ü Dr. William Ouchi
- focused on increasing employee loyalty to the company by providing a job for life with a strong focus on the
well-being of the employee, both on and off the job.

LEADERSHIP
l Process of influencing others to achieve organizational goals.
ü Motivate
ü Guide
ü Lead
l Types:
ü Formal Leadership
ü Informal Leadership
Leadership may be formal or informal. Leadership is formal when practiced by a nurse with legitimate authority
conferred by the organization and described in a job description (e.g., nurse manager, supervisor, coordinator, case
manager). Formal leadership also depends on personal skills, but it may be reinforced by organizational authority and
position. Insightful formal leaders recognize the importance of their own informal leadership activities and the informal
leadership of others who affect the work in their areas of responsibility.
Leadership is informal when exercised by a staff member who does not have a specified management role. A nurse
whose thoughtful and convincing ideas substantially influence the efficiency of work flow is exercising leadership skills.
Informal leadership depends primarily on one's knowledge, status (e.g., advanced practice nurse, quality improvement
coordinator, education specialist, medical director), and personal skills in persuading and guiding others.

LEADERSHIP THEORIES
Research on leadership has a long history, but the focus has shifted over time from personal traits to behavior and
style, to the leadership situation, to change agency (the capacity to transform), and to other aspects of leadership. Each
phase and focus of research has contributed to managers' insights and understandings about leadership and its
development. This chapter discusses four categories of leadership theories: trait theories, behavioral theories, contingency
theories, and contemporary theories.

TRAIT THEORIES
In the earliest studies researchers sought to identify in-born traits of successful leaders. Stogdill (1974) developed a
profile of successful leaders and traits. Bass (1990) added more traits, which he classified into three categories:
intelligence, personality, abilities. Gilbert (1975), in examining the personalities of nursing graduate students, found that
potential leaders were more likely to exhibit traits such as dominance, aggressiveness, ambition, high capacity to attain
status, poise, self-confidence, tolerance for others' views, high need to achieve, orderly thinking, sensitivity to others, and
flexibility. Although inconclusive, these early attempts to specify unique leadership traits provided benchmarks by which
most leaders continue to be judged.
BEHAVIORAL THEORIES
Research on leadership in the early 1930s focused on what leaders do. In the behavioral view of leadership, personal
traits provide only a foundation for leadership; real leaders are made through education, training, and life experiences.

Leadership Styles
Behavior-based theories assume that effective leaders acquire a pattern of learned behaviors. Initial studies
of teams of teenage boys identified three patterns or styles of leadership: autocratic, democratic, and laissez-faire
(Lewin & Lippit, 1938; Lewin, Lippit, & White, 1939). The autocratic leadership style assumes that individuals
are motivated by external forces, such as power, authority, and need for approval; the leader makes all the
decisions and uses coercion, punishment, and direction to change followers' behavior and achieve results.
The democratic leadership style assumes that individuals are motivated by internal drives and impulses,
want active participation in decisions, and want to get the task done; the leader uses participation and majority
rule in setting goals and working toward achievement. The laissez-faire leadership style also assumes that
individuals are motivated by internal drives and impulses and that they need to be left alone to make decisions
about how to complete the work; the leader provides no direction or facilitation.
Jenkins and Henderson (1984) added a fourth style, the bureaucratic leadership style. The bureaucrat of
assumes that employees are motivated by external forces. This leader trusts neither followers nor self to make
decisions and therefore relies on organizational policies and rules to identify goals and direct work processes.
By the early 1950s, leadership styles in work settings began to be explored (Katz & Kahn, 1952; Stogdill
Coons, 1957). Two major dimensions of behavioral style were identified: initiating structure and

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Education (Department of Nursing) 6 of 11
 consideration. Initiating structure refers to the behaviors that managers use to organize and define the goals of
work, work patterns and methods, channels of communication, and roles. For example, administration develops a
manual of job descriptions, personnel policies, and procedures for granting time off, implementing a new policy
on intravenous tubing changes, or family visiting. Consideration, the employee-centered dimension, refers to
behavior that conveys mutual trust, respect, friendship; warmth, and rapport between the manager and the staff.
When the leader is considerate, the employee learns to expect that the manager will hear a concern openly and
without reprisal, will involve employees in decision making, and will attend to the needs of the work group as a
whole. The manager is alert to employees' responses to stress, the effects of personal crises on their work, and
the social dynamics of the work group.
Followers' and managers' perceptions of managers' leadership style often differ; attempts to enhance a
manager's style in one area or the other do not necessarily result in higher employee performance or improved
goal achievement; equally effective leaders might possess strength in consideration or structure or both.
With the realization that different combinations of leader exclude leader behaviors might produce different
effects, researchers began searching for an optimal mix of behaviors that would produce optimal employee
performance. As these models evolved, researchers began to recognize the complexity and range of the
approaches managers use to produce results in organizations.

Comparison of Leadership Styles

ASSUMED EMPLOYEE
LEADERSHIP STYLE LEADER CHARACHTERISTICS
MOTIVATORS
Concerned with task accomplishment
rather than relationships
Uses directive behavior
Makes decisions alone
External forces, e.g., power and Expects respect and obedience of staff
Authoritarian (Autocratic)
authority, needs for approval Lacks group support generated by
participation
Exercises power with coercion
Proves useful (even necessary) in
crisis situations
Is primarily concerned with human
relations and teamwork
Fosters communication that is open
Democratic (Participative) Internal drives and impulses and usually two-way
Creates a spirit of collaboration and
joint effort that results in staff
satisfaction
Tends to have few established policies;
abstains from leading
Permissive (Laissez-faire) Internal drives and impulses Is not generally useful in highly
structured organizations (e.g., health
care institutions)
Lacks a sense of security and depends
on established policies and rules
Exercises power by applying fixed,
Bureaucratic External forces relatively inflexible rules tends to relate
impersonally to staff
Avoids decision making without
standards or norms for guidance

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Education (Department of Nursing) 7 of 11
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. This is defined as the process by which a cooperative group directs actions towards common goals:
a. Nursing
b. Management
c. Leadership
d. Power

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is not a major function of management?

a. Planning
b. Organizing
c. Directing
d. Communication

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The process of working through staff members to be able to provide comprehensive care to the patient:
a. Nursing
b. Management
c. Nursing Management
d. Leadership
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. It is an interpersonal process that involves motivating and guiding others to achieve goals:
a. Leadership
b. Management
c. Nursing
d. Power
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. The College of Nursing Dean belongs to what level of management?

a. First line
b. Middle manager
c. Top Manager
d. Frontline
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 8 of 11
6. Henry Laurence Gantt is the forerunner of PERT chart, which means:
a. Program Evaluation and Review Technique
b. Program Equation and Review Technique
c. Program Evaluation and Revision Technique
d. Program Evaluation and Recycle Technique
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. A leader that uses participation and majority rule in setting goals and working towards achievement:
a. Autocratic
b. Democratic
c. Laissez-faire
d. Bureaucratic
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The leader that makes all the decisions & uses coercion, punishment, & direction to change followers’ behavior &
achieve results:
a. Autocratic
b. Democratic
c. Laissez-faire
d. Bureaucratic
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The type of leader that trusts neither followers not self to make decisions and therefore relies on organizational policies
and rules:
a. Autocratic
b. Democratic
c. Laissez-faire
d. Bureaucratic
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. This leader acts as facilitator:

a. Autocratic
b. Democratic
c. Laissez-faire
d. Bureaucratic
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 9 of 11
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
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Education (Department of Nursing) 10 of 11
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT Muddiest Point

This activity is to evaluate what the students learned after the discussion and the activity.
In today’s session, what was least clear to you?
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Education (Department of Nursing) 11 of 11
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 15

LESSONTITLE: INTRODUCTION OF NURSING

MANAGEMENT & LEADERSHIP (LEADING, MANAGING, Materials:
FOLLOWING) (PART 2)
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can: References:
Sullivan, E. J. (2009), Effective Leadership and
1. Explain why every nurse is a manager & can be a leader; Management in Nursing (7th edition). Singapore:
2. Differentiate between leaders & managers; Pearson Education South Asia Pte Ltd.
3. Discuss how different theories explain leadership &
management;
4. Describe what management roles nurses fill in practice;
5. Discuss how followership is essential to leadership;
6. Define power;
7. Describe how power is used;
8. Discuss how image is a source of power;
9. Develop a plan to increase your power;
10. Discuss how politics influence policy; and,
11. Explain how to be politically savvy.

LESSON PREVIEW/REVIEW
Based on the previous lesson, enumerate the theories of management and types of leadership:

MAIN LESSON (60 minutes)

System 4 Management
Likert (1967) developed the System 4 model of management based on the premise that involving
employees in decisions about work is central to effective leadership. The model is composed of four dimensions
based on increasing levels of employee involvement. Autocratic leaders have little trust in employees and
systematically If exclude them from decision making. Benevolent leaders are kind to employees but still do not
involve them in decision making. Consultative leaders seek employees' advice about decisions. Participative
or democratic leaders value employee involvement, teamwork, and team building; they also have high levels of
confidence in employees and seek consensus in decision making. In doing so, the participative leader
shares power.

The Managerial Grid

Another model for depicting leadership along a continuum is the managerial grid. Five leadership styles are
plotted in four quadrants of a two-dimensional grid. The grid depicts various degrees of leader concern for
production (structure) and concern for people (consideration). Leadership styles are labelled "impoverished" (low
concern for both production and people), "authority compliance" (high concern for production, low concern for
people), "country club" (high concern for people, low concern for production), "middle of the road" (moderate
concern for both production and people), and "team" (high concern for both production and people).

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The Managerial Grid

STYLE PRODUCTION PEOPLE

IMPOVERISHED LOW LOW

AUTHORITY COMPLIANCE HIGH LOW
COUNTRY CLUB LOW HIGH
MIDDLE OF THE ROAD MOD MOD
TEAM HIGH HIGH

Continuum of Leadership Behavior

Leadership behavior also is depicted as occurring along a continuum. This model focuses specifically on the
decision-making style of managers. As displayed in the Figure, the left end of the continuum reflects a

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Education (Department of Nursing) 2 of 17
 manager-centered style. Managers are autocratic and directive and simply make and announce decisions. At
the right end of the continuum, managers are a employee-centered; they use a laissez-faire style and permit
employees to set their own goals and function within established parameters. No single leadership style is
correct or appropriate for every management situation.
Sellgren, Ekvall, and Tomson (2006) suggest that leaders must use more authority with less experienced
followers but that as followers become more accomplished, the need for leaders to exert authority diminishes.
The numerous variations of the multidimensional, behavioral approach have contributed significantly to our
understanding of managers' performance and effectiveness. Nurses may use these perspectives as a basis for
analyzing the leadership styles of others and analyzing and developing their own styles.

Continuum of Leadership Behavior

CONTINGENCY THEORIES
Contingency approaches suggest that managers adapt their leadership styles in relation to changing situations. According
to contingency theory, leadership behaviors range from authoritarian to permissive and vary in relation to current needs
and future probabilities. A nurse manager may use an authoritarian style when responding to an emergency situation such
as a cardiac arrest but use a participative style to encourage development of a team strategy to care for patients with
multiple system failure. The manager might delegate to a highly competent and eager follower group decision making and
task completion in designing a new patient intake form. The most effective leadership style for a nurse manager is the one
that best complements the organizational environment, the tasks to be accomplished, and the personal characteristics of
the people involved in each situation. Numerous contingency models have been developed. Four are discussed in this
chapter: Fiedler's contingency theory, Vroom—Yetton expectancy model, and House—Mitchell path—goal theory.

Fiedler's Contingency Theory

Fiedler (1967) proposed that a leader is most effective when he or she matches leadership style (relationship-oriented
or task-oriented) to situational factors. Fiedler described three situational factors of leadership, which are listed in
decreasing order of importance:
l Manager—follower relationship (good to poor)
l Task structure (high to low)
l Manager power (strong to weak).
Manager—follower relations reflect the degree to which the leader enjoys the loyalty and support of subordinates.

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Task structure is the degree to which the task or result is clearly described and/or standard operating procedures
guarantee successful completion and evaluation of the quality of the task. Position power is the degree to which leaders
are able to administer rewards and punishment by virtue of their positions (that is, legitimate power).
The figure below illustrates how the task-motivated leader will be more effective under high and low structures and the
relationship-motivated leader will have greater effectiveness under in-between situations.

Situational Leadership Theory

Hersey, Blanchard, and Johnson (2007) expanded Fiedler's contingency model by considering the followers' readiness
and willingness to perform the assigned tasks.
Leaders use a telling style (S1—high task, low relationship) with followers who are unable and unwilling or insecure
about performing the task (RI). Leaders use a selling style (S2—high task, high relationship) with followers who are unable
but are willing or confident in performing-the task (R2). Leaders use a participating style (S3—low task, high relationship)
with followers who are able but unwilling or lacking in confidence in performing the task (R3). Finally, leaders use a
delegating style (S4—low task, low relationship) with followers who are both able and willing and have confidence in
performing the task (R4).

TELLING (S1) Provide specific instructions & closely supervise performance.

SELLING (S2) Explain your decisions & provide opportunity for clarification.

PARTICIPATING (S3) Share ideas & facilitate in making decisions.

DELEGATING (S4) Turn over responsibility for decisions & implementations.

TELLING (S1) HIGH TASK LOW RELATIONSHIP

SELLING (S2) HIGH TASK HIGH RELATIONSHIP

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PARTICIPATING (S3) LOW TASK HIGH RELATIONSHIP

DELEGATING (S4) LOW TASK LOW RELATIONSHIP

Vroom —Yetton Expectancy Model

Vroom and Yetton (1973) developed a prescriptive of model for determining the amount of participation leaders should
seek from employees in decision making. This model, depicted in the figure below, helps managers decide how to make a
decision contingent on the task to be accomplished and needs of both managers and employees.
Three questions guide the manager's selection of an appropriate leadership style and the extent of participation
employees should have in decision making.
1. Is all the information available to make the decision?
2. Is the staff's acceptance of the decision required for effective implementation?
3. Would the group make a decision the leader could live with?
Vroom and Yetton (1973) identified five leadership styles: tell, sell, consult, join, and delegate. Here are their guidelines
to decide which leadership style cons to use:
Use a telling style to assess a problem, make a decision independently, and inform followers.
Use a selling style to gather information from followers about a problem, make a decision independently, and persuade
followers to implement it.
Use a consultative style to seek advice from followers individually, make the decision independently, and inform
followers.
Use a joining style to join the group, seek suggestions, independently make a decision, and inform followers.
Use a delegation style to work with followers in developing solutions to the problem and facilitate consensus-building
toward a group solution, which generally is accepted and implemented as the group wishes.
The manner in which managers make decisions directly reflects their leadership style. A model or framework that
addresses the many contingencies in a decision-making situation helps managers analyze how to make decisions
successfully. It also helps managers demonstrate a consistent, predictable decision-making style, which enables co
workers to anticipate the manager's expectations and perform accordingly.

House—Mitchell Path—Goal Theory

Path—goal theory applies a theory of human motivation and task performance to leadership effectiveness (House &
Mitchell, 1974). Because a primary function of leadership is to motivate others to attain goals, path—goal theory proposes

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that removing obstacles to goal attainment, coaching, and providing personal rewards for achievement will result in high
levels of performance and productivity. The leader affects performance by influencing employees' perceptions of their work
and personal goals and facilitating the process by which employees achieve goals.
The motivational functions of leadership derive directly from the expectancy theory of motivation (Porter & Lawler,
1968; Vroom, 1964; also see Chapter 19). Employees work for rewards they find attractive and that result from successful
performance.
Three concepts are central to expectancy theory:
Expectancy is the perceived probability that effort will result in successful performance.
Instrumentality is the perceived probability that performance will lead to desired outcomes.
Valence is the perceived value of an outcome.
The manager exercises leadership by defining and clarifying expectancies, instrumentalities, and valences associated
with specific tasks and employees' personal goals.
Path—goal theory specifies four leader behaviors (House, 1971):

Directive leadership involves telling employees what is expected, giving specific guidance, ensuring adherence to
rules and procedures, and scheduling and coordinating work efforts. This type of leadership is most effective for employees
who are marginally trained or prepared and are performing partially routine and ambiguous tasks.
Supportive leadership focuses on the needs of employees, displays concern for their well-being, and creates a
friendly climate in the work environment. Supportive leadership behavior is most effective for employees who are
performing routine work or are very experienced with the work.
Participative leadership involves consultation with subordinates and requests for opinions and suggestions, which
the leader takes into consideration when making decisions. This style works best for employees who have moderate skill
levels and are performing somewhat ambiguous work. Involvement of employees encourages mutual clarification of
objectives and specification of mutually helpful work processes.
Achievement-oriented leadership includes setting challenging goals, seeking performance improvements,
emphasizing excellence in performance, and showing confidence that employees will attain high levels of performance. It is
indicated for employees who are skilled and perform highly innovative and ambiguous work. By setting challenging goals
and pointing out valued rewards, managers fulfill a strong motivating role.
Staff members interpret and respond to leader behavior in different ways, depending on personal characteristics and
characteristics of the task and environment. Specifically, employees' needs for achievement, affiliation, power,
competence, autonomy, and personality traits form a context within which leaders function. As in situational leadership, the
effect of leadership behavior on employee satisfaction and effort depends on the task and the work situation.
Path—goal theory is interesting because it suggests that there are substitutes for direct leader—follower interaction.
On the one hand, the manager can influence employee performance directly by clarifying the route to desired goals. On the
other hand, actions that clarify objectives, specify roles, increase the value of rewards, provide needed support to complete
tasks successfully, and facilitate performance might be viewed as substitutes for direct leadership activity.
The application of any contingency theory to leadership practice requires continuous monitoring of employees'
expectancies, abilities, and motivations and an understanding of the task and options for completing it. Managers must
also thoroughly consider the consequences of their actions on employee performance. For every leader's action, a
predictable employee reaction is likely to occur. A nurse manager must care-fully observe the cause-and-effect
relationships that exist between leader behavior and employee response and continuously take into account the multitude
of environmental factors that influence leader—employee interactions.

CONTEMPORARY THEORIES
Leaders in today's health care environment place increasing value on collaboration and teamwork in all aspects of the
organization. They recognize that as health systems become more complex and require integration, personnel who
perform the managerial clinical work must cooperate, coordinate their efforts, and produce joint results. Leaders must use
additional skills, especially group and political leadership skills, to create collegial work environments.

QUANTUM LEADERSHIP
Trait, behavioral, and contingency theories represent conventional approaches to leadership and have provided
important foundations for leadership. Current views of leadership are neither complete reformulations nor simple
refinements of conventional perspectives. Evolved from the principles of quantum mechanics, effective leadership today
reflects a remarkable fusion of trait, behavior, and contingency approaches.
Quantum leadership is based on the concepts of chaos theory.
CHAOS THEORY
Suggests that the drive to create permanent organizational structure is doomed to fail.
Set of rules that guide the organization must be discarded & newer principles that ensure flexibility, speed of
adaptability, cultural sensitivity & fluidity must emerge.

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Reality is constantly shifting, and levels of complexity are constantly changing. Movement in one part of the system
reverberates throughout the system. Roles are fluid and outcome oriented. It matters little what you did; it only matters what
outcome you produced. Within this framework, employees become directly involved in decision making as equitable and
accountable partners, and managers assume more of an influential facilitative role, rather than one of control
(Porter-O'Grady & Malloch, 2002).
Quantum leadership demands a different way of thinking about work and leadership. Change is expected. In fact, the
leader's role is to encourage employees to per "close the door on receding practices and challenge them to simply turn
around and squarely confront the opportunities and challenges of emerging practice" (Porter-O'Grady, 2003,).
Informational power, previously the purview of the leader, is now available to all. Patients and staff alike can access
untold amounts of information. The challenge, however, is to assist patients, uneducated about health care, how to
evaluate and use the information they have. Because staff have access to information only the leader had in the past,
leadership becomes a shared activity, requiring the leader to possess excellent interpersonal skills.

CHARISMATIC LEADERSHIP
Charismatic leadership is based on personal qualities such as charm, persuasiveness, personal power,
self-confidence, extraordinary ideas, and strong (often unconventional) convictions. The leader's personality arouses great
affection and emotional commitment, first to the leader and secondarily to the beliefs and causes the leader espouses. Few
leaders possess genuine charisma. Those who do often use their powerful personalities to advance revolutionary goals.

TRANSACTIONAL LEADERSHIP
Transactional leadership is based on the principles of social exchange theory (Homans, 1958; Thibaut & Kelley,
1959). The primary premise of social exchange theory is that individuals engage in social interactions expecting to give and
receive social, political and psychological benefits or rewards. The exchange process between leaders and followers is
viewed as essentially economic. Once initiated, a sequence of exchange behavior continues until one or both parties finds
that the exchange of performance and rewards is no longer valuable. The nature of these transactions is determined by the
participating parties' assessments of what is in their best interests; for example; staff respond affirmatively to a nurse
manager's request to work overtime in exchange for granting special requests for time off. Leaders are successful to the
extent that they understand and meet the needs of followers and use incentives to enhance employee loyalty and
performance. Transactional leadership is aimed at maintaining equilibrium, or the status quo, by performing work according
to policy and procedures, maximizing self-interests and personal rewards, emphasizing interpersonal dependence, and
routinizing performance.

TRANSFORMATIONAL LEADERSHIP
Transformational leadership goes beyond transactional leadership to inspire and motivate followers (Aarons, 2006).
Transformational leadership emphasizes the importance of interpersonal relationships (Ward, 2002). Transformational
leadership is not concerned with the status quo, but with effecting revolutionary change in organizations and human
service. Whereas traditional views of leadership emphasize the differences between employees and managers,
transformational leadership focuses on merging the motives, desires, values, and goals of leaders and followers into a
common cause. The goal of the transformational leader is to generate employees' commitment to the vision or ideal rather
than to themselves.
Transformational leaders appeal to individuals' better selves rather than these individuals' self-interests. They foster
followers' inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes. Transformational
leaders also encourage others to exercise leadership. The transformational leader inspires followers and uses power to
instill a belief that followers also have the ability to do exceptional things. McGuire and Kennerly (2006) found that
transformational leaders were more likely than transactional leaders to have committed followers willing to put extra effort
into their work, thus enhancing the organization's overall performance.
Transformational leadership may be a natural model for nursing managers, because nursing has traditionally been
driven by its social mandate and its ethic of human service. Transformational leadership can be used effectively by nurses
with clients or co-workers at the bed-side, in the home, in the community health center, and in the health care organization.

RELATIONAL LEADERSHIP
Relational leadership, also known as relationship-oriented leadership or connective leadership, recognizes that today
we are all connected and that relationships form the cornerstone of contemporary leadership. Klakovich (1994) proposed a
connective leadership paradigm for nursing. This paradigm acknowledges the need for more flexible systems in health care
that empower employees, their interdisciplinary . colleagues, clients, and families. Klakovich explains that contemporary
nursing leadership skills should include the ability to create interconnections between and across caregiving settings and
among multiple constituencies.
The purpose of relational leadership is to better coordinate and integrate patient care services in a caring,
noncompetitive manner. The focus is to link professionals, communities, governing groups, and voluntary agencies to
improve patient-centered care. Connective leaders use their interpersonal skills to broker alliances, encourage

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collaboration, and integrate systems. Klakovich stresses the importance of collegiality among health care professionals in
achieving patient care and organizational goals.
The nurse manager applies relational leadership principles when convening a group of physicians, administrators,
nursing staff, and representatives of other disciplines to plan a new patient care program, for example, or bring nursing
staff members together to develop a staff orientation program or seek the assistance of an external expert to help in the
professional development of the nursing staff. Hierarchical relationships break down and leadership develops at all levels
in the organization.
Relational leadership requires both content and res process skills (such as the task and relationship skills discussed
earlier). Both power and political tactics may be needed. The ability to manage the groups and team interactions is
essential. In addition, leaders must recognize that integrating the activities of diverse participants in health care involves
creating connections that extend beyond well-defined groups.
The process of developing relationships and creating connections requires the leader to:
l Identify actual and potential collaborators
l Communicate and sell a potential shared vision to those in varied settings and under disparate conditions
l Describe the value each collaborator could bring to the endeavor, both to the individual and others
l Facilitate communication by sharing information, preparing for interactions, and following up on communications
exchanges
l Build and maintain social interaction and comfort
l Define and sell roles and assignments
l Track and reward contributions
l Formalize an integrated effort at the right time.

SHARED LEADERSHIP
Reorganization, decentralization, and the increasing complexity of problem solving in health care have forced
administrators to recognize the value of shared leadership, which is based on the empowerment principles of participative
and transformational leadership. Essential elements of shared leadership are relationships, dialogues, partnerships, and
understanding boundaries. The application of shared leadership assumes that a well-educated, highly professional,
dedicated workforce is comprised of many leaders. It also assumes that the notion of a single nurse as the wise and heroic
leader is unrealistic and that many individuals at various levels in the organization must be responsible for the
organization's fate and performance.
Different issues call for different leaders, or experts, to guide the problem-solving process. A single leader is not
expected always to have knowledge and ability beyond that of other members of the work group. Appropriate leadership
emerges in relation to the current challenges of the work unit or the organization. Individuals in formal leadership positions
and their colleagues are expected to participate in a pattern of reciprocal influence processes. Examples of shared
leadership in nursing include:
l Self-directed work teams. Work groups manage their own planning, organizing, scheduling, and day-to-day
work activities.
l Shared governance. The nursing staff are formally organized at the service area and organizational levels to
make key decisions about clinical practice standards, quality assurance and improvement, staff development,
professional development, aspects of unit operations, and research. Decision making is conducted by
representatives of the nursing staff who have been authorized by the administrative hierarchy and their
colleagues to make decisions about important matters.
l Co-leadership. Two people work together to execute a leadership role. This kind of leadership has become more
common in service-line management, where the skills of both a clinical and administrative leader are needed to
successfully direct the operations of a multidisciplinary service. For example, a nurse manager provides
administrative leadership in collaboration with a clinical nurse specialist, who provides clinical leadership.
The development of co-leadership roles depends on the flexibility and maturity of both individuals, and such
arrangements usually require a third party to provide ongoing consultation and guidance to the pair.

SERVANT LEADERSHIP
Servant leadership is based on the premise that leadership originates from a desire to serve and that in the course of
serving, one may be called to lead. According to Greenleaf (1991), servant leadership occurs when other people's needs
take priority, when those being served "become healthier, wiser, freer, more autonomous, and more likely themselves to
become servants". The servant leader must address the question of whether the least advantaged in society benefit from
the leader's service.
Campbell and Rudisill (2005) suggest that servant leaders must have these skills:
l Listening—the most important skill
l Awareness—of a situation or individual need
l Persuasion—to convince, do, or believe
l Foresight—a visionary to create change

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Education (Department of Nursing) 8 of 17
 l Stewardship—take responsibility and be accountable
l Commitment—to the growth of individuals.
Servant leadership appeals to nurses for two reasons. First, our profession is founded on principles of caring, service,
and the growth and health of others. Second, nurses serve many constituencies, often quite selflessly, and consequently
bring about change in individuals, systems, and organizations.
Health care environments require innovations in care delivery and therefore innovative leadership approaches.
Quantum, charismatic, transactional, transformational, relational, shared, and servant leadership comprise a new
generation of leadership styles that have emerged in response to the need to humanize working environments and improve
organizational performance. In practice, leaders tap a variety of styles culled from diverse leadership theories.

WHY POWER?
Power emerges in every human encounter, whether you choose to acknowledge it or not. Often, the content, meaning, and
purpose of power use or abuse are misunderstood or ignored. Power needs to be your ally, and you must seek to
understand its dynamic qualities.
Power is the potential ability to influence (Hersey, Blanchard, & Johnson, 2007). Power also is defined as the potential
to achieve goals.
It is also important to understand why power is used. The most common reasons are to gain a competitive advantage,
acquire information, motivate, communicate, improve performance, and improve processes. By developing a power base,
you gain the potential for maximum influence. The willingness to use power increases a nurse's ability to acquire the
resources needed to improve patient care.
Regardless of when, why, and where care takes place, power centers around an individual's ability to influence others
or the behavior of others. To acquire power, maintain it effectively, and use it skillfully, nurses must be aware of the sources
and types of power that they will use to influence and transform patient care.

POWER AND LEADERSHIP

Real power—principle-centered power—is based on honor, respect, loyalty, and commitment. Principle-centered power is
not forced; it is invited (Covey, 1992). It is defined by the capacity to act and to make choices and decisions. How you
choose and what you choose is based on deeply held values. If you choose to live up to your own values and potential, you
have an infinite amount of power available. By recognizing your power and the capacity to use it, you can influence and
lead others in promoting and creating changes in health care and in your community.
Leadership power then becomes the capacity to create order from conflict, contradictions, and chaos. Leadership
power comes from the ability to sustain proactive influence because followers trust and respect the leader to do the right
thing for the right reason. As leaders in health care, nurses must understand and select behaviors that activate
principle-centered leadership:
l Get to know people. Understanding what other people want is not always simple.
l Be open. Keep others informed. Trust, honor, and respect spread just as equally as fear, suspicion, and deceit.
l Know your values and visions. The power to define your goals is the power to choose.
l Sharpen your interpersonal competence. Actively listen to others, and learn to express your ideas well.
l Use your power to enable others. Be attentive to the dynamics of power, and give attention to ground rules,
such as encouraging dissenting voices and respecting disagreement.
l Enlarge your sphere of influence and connectedness. Power sometimes grows out of someone else's need.

HOW MANAGERS AND GIVER LEADERS GET THINGS DONE

Classically, managers in health care institutions relied on authority to rouse employees to perform tasks and accomplish
goals. In contemporary health care organizations, managers use persuasion, enticement, and inspiration to mobilize the
energy and talent of a work group and to overcome resistance to change.
A leader's use of power alters attitudes and behavior by addressing individual needs and motivations. There are seven
generally accepted types of interpersonal power used in organizations to influence others (French & ad Raven, 1959;
Hersey, Blanchard, & Natemeyer, 1979).
1. Reward power is based on the inducements the manager can offer group members in exchange for
cooperation and contributions that advance the manager's objectives. The degree of compliance depends on
how much the follower values the expected benefits. For example, a nurse manager may grant paid educational
leave as a way of rewarding staff nurses for implementing a new patient database system. Reward power often is
used in relation to a manager's formal job responsibilities.
2. Punishment, or coercive, power is based on the penalties a manager might impose on an individual or a group.
Motivation to comply is based on fear of punishment or withholding of rewards. For example, the nurse manager
might make undesirable job assignments, mete out a formal reprimand, or recommend termination for a nurse
who engages in disruptive behavior. Punishment or coercion is used in relation to a manager's perceived
authority to determine employment status.

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 3. Legitimate power stems from the manager's right to make a request because of the authority associated with job
and rank in an organizational hierarchy. Followers comply because they accept a manager's prerogative to
impose requirements, sanctions, and rewards in keeping with the organization's mission and aims. For instance,
staff nurses will comply with a nurse manager's directive to take time off without pay when the workload has
dropped below projected levels because they know that the manager is charged with maintaining unit expenses
within budget limitations.
4. Expert power is based on possession of unique skills, knowledge, and competence. Nurse managers, by virtue
of experience and advanced education, often are the best qualified to determine what to do in a given situation.
Employees are motivated to comply because they respect the manager's expertise. Expert power relates to the
development of personal abilities through education and experience. Newly graduated nurses might ask the
nurse manager for advice in learning clinical procedures or how to resolve conflicts with coworkers or other health
professionals.
5. Referent power is based on admiration and respect for an individual. Followers comply because they like and
identify with the manager. Referent power relates to the manager's likeability and success. For example, a new
graduate might ask the advice of a more experienced and admired nurse about career planning.
6. Information power is based on access to valued the data. Followers comply because they are motivated by for a
desire for information that will meet personal needs the and facilitate decision making. Information power
depends on a manager's organizational position, connections, and communication skills. For example, the nurse
manager is frequently privy to information obtained at meetings with administrators about pending organizational
changes that affect employees' work situations. A nurse manager may exercise information power by sharing
significant information the at staff meetings, thereby improving attendance.
7. Connection power is based on an individual's formal and informal links to influential or prestigious persons
within and outside an area or organization. Followers comply because they want to be linked to influential
individuals. Connection power also relates to the status and visibility of the individual is as well as the position. In
some cases, nurse managers have personal relationships with an organization's board members that followers
believe will protect or advance their work situation.

These power bases are available to managers and may be classified more simply as personal or position power.
Position power is determined by the job description, assigned responsibilities, recognition, advancement, authority, the
ability to withhold money, and decision making. Legitimate, coercive, and reward power are positional because they relate
to the "right" to influence others based on rank or role. The extent to which managers mete out rewards and punishment
usually is dictated by organizational policy. Information and legitimate power are directly related to the manager's role in the
organizational structure.
Expert, referent, information, and connection power are based, for the most part, on personal traits. Personal power
refers to one's credibility, reputation, a expertise, experience, control of resources or information, and ability to build trust.
The extent to which one may exercise expert, referent, information, and connection power relates to personal skills and
positive inter-personal relationships, as well as employees' needs and motivations. The box below illustrates that nurses
can learn to use power in organizations.

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 Guidelines for the Use of Power in Organizations

Guidelines for Using Legitimate Authority

• Make polite, clear requests.
• Explain the reasons for a request.
• Don't exceed your scope of authority.
• Verify authority if necessary.
• Follow proper channels.
• Follow up to verify compliance.
• Insist on compliance if appropriate.

Guidelines for Using Reward Power

• Offer the type of rewards that people desire.
• Offer rewards that are fair and ethical.
• Don't promise more than you can deliver.
• Explain the criteria for giving rewards and keep it simple.
• Provide rewards as promised if requirements are met.
• Use rewards symbolically (not in a manipulative way).

Guidelines for Using Coercive Power

• Explain rules and requirements, and ensure that people understand the serious consequences of violations.
• Respond to infractions promptly and consistently without showing any favoritism to particular individuals.
• Investigate to get the facts before using reprimands or punishment, and avoid jumping to conclusions or making
hasty accusations.
• Except for the most serious infractions, provide sufficient oral and written warnings before resorting to
punishment.
• Administer warnings and reprimands in private, and avoid making rash threats.
• Stay calm and avoid the appearance of hostility or personal rejection.
• Express a sincere desire to help the person comply with role expectations and thereby avoid punishment.
• Invite the person to suggest ways to correct the problem, and seek agreement on a concrete plan.
• Maintain credibility by administering punishment if noncompliance continues after threats and warnings have been
made.

Guidelines for Using Expert Power

• Explain the reasons for a request or proposal and why it is important.
• Provide evidence that a proposal will be successful.
• Don't make rash, careless, or inconsistent statements.
• Don't exaggerate or misrepresent the facts.
• Listen seriously to the person's concerns and suggestions.
• Act confidently and decisively in a crisis.

Ways to Acquire and Maintain Referent Power

• Show acceptance and positive regard.
• Act supportive and helpful.
• Use sincere forms of ingratiation.
• Defend and back up people when appropriate.
• Do unsolicited favors.
• Make self-sacrifices to show concern.
• Keep promises.

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Education (Department of Nursing) 11 of 17
USING POWER
Despite an increase in pride and self-esteem that comes with using power and influence, some nurses still consider power
unattractive. The association of power with aggression and coercion remains strong. In a profession that prides itself on
care and compassion, power is viewed as alien. How, then, can nurses bridge the disparity between power as good versus
power as bad?
Power grabbing, which has been the traditionally accepted means of relating to power for one's own self-interests and
use, is how nurses often think of power. Rather, nurses tend to be more comfortable with power sharing and
empowerment: power "with" rather than power "over" others. Although nurses need power to ensure that patients have
access to cost-effective quality nursing care, nurses can help transform health care organizations by using power that
embraces equality and caring.

IMAGE AS POWER
A major source of power for nurses is an image of power. Even if one does not have actual power from other sources,
the perception by others that one is powerful bestows a degree of power. The same is true for the profession as a whole. If
the public sees the profession of nursing as powerful, the profession's ability to achieve its goals and agendas is enhanced.
Images emerge from interactions and communications with others. If nurses present themselves as caring and
compassionate experts in health care through their interactions and communications with the public, then a strong,
favorable image develops for both the individual nurse and the profession. Nurses, as the ambassadors of care, must
understand the importance and benefit of positive therapeutic communications and image. Developing a positive image of
power is important for both the individual and the profession.
Individual nurses can promote an image of power by a variety of means.
1. Appropriately introducing yourself by saying your name, using eye contact, and shaking hands can immediately
establish you as a powerful person. If nurses introduce themselves by first name to the physician, Dr. Smith, they
have immediately set forth an unequal power relationship unless the physician also uses his or her first name.
Although women are not socialized to initiate handshakes, it is a power strategy in male-dominated circles,
including health care organizations. In Western cultures, eye contact conveys a sense of confidence and
connection to the individual to whom one is speaking. These seemingly minor behaviors can have a major impact
on whether the nurse is perceived as competent and powerful.
2. Appropriate attire can symbolize power and success. Although nurses may believe that they are limited in choice
of attire by uniform codes, it is in fact the presentation of the uniform that can hold the key to power. For example,
a nurse manager needs a powerful image both with unit staff and with administrators and other professionals who
are setting organizational policy. An astute nurse manager might wear a suit rather than a uniform to work on the
day of a high-level interdisciplinary committee meeting. Certainly, attention to details of grooming and uniform
selection can enhance the power of the staff nurse as well.
3. Conveying a positive and energetic attitude sends " the message that you are a doer" and someone to be sought
out for involvement in important issues. Chronic complaining conveys a sense of powerlessness, whereas solving
problems and being optimistic promote a "can do" attitude that suggests power and instills confidence in others.
4. Pay attention to how you speak and how you act when you speak. Nonverbal signs and signals say more about
you than words. Make sure your words are reflected in your body language. In other words, keep your facial
expression consistent with your message. Stand erect and move energetically. Speak with an even pace and
enunciate words clearly. Use only body movements and gestures necessary to make your point.
5. Use facts and figures when you need to demonstrate your point. Policy changes usually evolve from data
presented in a compelling story. To position yourself as a powerful player requires the ability to collect and
analyze data. Data can be obtained to describe nursing care issues, activities, or concerns. These include patient
acuity, daily census, length of stay, overtime budgets, or any data that reflect nursing's overall contribution.
Remember that power is a matter of perception; therefore, you must use whatever data are available to support
your judgment.
6. Knowing when to be at the right place at the right time is crucial to gain access to key personnel in the
organization. This means being invited to events, meetings, and parties not necessarily intended for nurses. It
means demanding to sit at the policy table when decisions affecting staffing and patient care are made. Influence
is more effective when it is based on personal relationships and when people see others in person: "If I don't see
you, I can't ask you for needed information, analysis, and alternative recommendations." Become visible. Be
avail-able. Offer assistance. You can be invaluable in providing policy makers with information, interpreting data,
and teaching them about the nursing side of health care.
7. In dealing with people outside of nursing, it is important to develop powerful partnerships. Be very careful to use
"we" instead of "they". Learn how to share both credit and blame. When working on collaborative projects, be
clear about what is needed. If something isn't working well, say so. Never accept another's opinion as fact. Facts
can be easily manipulated to fit one's personal agenda. Learn how to probe and obtain additional information.
Don't assume you have all the information. Beware of unsolicited commentary. Don't be fearful of giving strong
criticism, but always put criticisms in context. Before giving any criticism, give a compliment, if appropriate. Also,

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 make sure your partners are ready to hear all sides of the issue. It's never superfluous to ask, "Do you want to
talk about such and such right now?" Once an issue is decided—really decided—don't raise it again.
8. Make it a point to get to know the people who matter in your sphere of influence. Become a part of the power
network so that when people are discussing issues or seeking people for important appointments of leadership,
your name comes to mind. Be sure to deal with senior people. The more contact you have with the "power
brokers," the more support you can generate in the future should the need arise. The more power you use, the
more you get.
9. Know who holds the power. Identify the key power brokers. Develop a strategy for gaining access to power
brokers through joining alliances and coalitions. Learn how to question others and how to become part of the
organizational infrastructure. There is an art to determining when, what, and how much information is exchanged
and communicated at anytime and to determining who does so. Powerful people have a keen sense of timing. Be
sure to position yourself to be at the right place at the right time. Any strategy will involve a good deal of energy
and effort. Direct influence and efforts toward issues of highest priority or when greatest benefits are likely to
result.
10. Use power appropriately to promote consensus in mini organizational goals, develop common means to sever
achieve these goals, and enhance a common culture to bind organizational members together. As the health care
providers closest to the patient, nurses best understand patients' needs and wants. In the hospital, nurses are
present on the first patient contact and thereafter for 24 hours a day, 7 days a week. In the clinic, the nurse may
be the person the patient sees first and most frequently. By capitalizing on the special relationship that they have
with patients, nurses can use marketing principles to enhance their position and image as professional
caregivers.

Nursing as a profession must market its professional expertise and ability to achieve the objectives of health care
organizations. From a marketing perspective, nursing's goal is to ensure that identified markets (e.g., patients, physicians,
other health professionals, community members) have a clear understanding of what nursing is what it does, and what it is
going to do. In doing so, nursing is seen as a profession that gives expert care with a scientific knowledge base.
Nursing care often is seen as an indicator of an organization's overall quality. Regardless of the setting, quality
nursing care is something that is desired and valued. Through understanding patients' needs and preferences for programs
that promote wellness and maintain and restore health, nurses become the organization's competitive edge to enhancing
revenues. Marketing an image of expertise linked with quality and cost can position nursing powerfully and competitively in
the health care marketplace.

USING POWER APPROPRIATELY

Using power not only affects what happens at the time, but also has a lasting effect on your relationships. Therefore, it
is best to use the least amount of power necessary to accomplish your goals. Also, use power appropriate to the situation
(Sullivan, 2004). The box below lists rules for using power.

Rules for Using Power

1. Use the least amount of power you can to be effective in your interactions with others.
2. Use power appropriate to the situation.
3. Learn when not to use power.
4. Focus on the problem, not the person.
5. Make polite requests, never arrogant demands.
6. Use coercion only when other methods don't work.
7. Keep informed to retain your credibility when using your expert power.
8. Understand you may owe a return favor when you use your connection power.

Improper use of power can destroy a manager's effectiveness. Power can be overused or underused. Overusing
power occurs when you use excessive power relative to the situation. If you fail to use power when it is needed, you are
under using your power. In addition to the immediate loss of influence, you may lose credibility for the future. Power plays
are another way that power is used in-appropriately.
Power plays are attempts by others to diminish or demolish their opponents. The table below describes several
common power plays and their consequences. It is essential that nurses not accept these statements at face value. Often,
restating one's initial point in a firm manner is a useful strategy. It is not necessary to respond directly to statements such
as those shown in the table below.
Nursing must perceive power for what it really is—the ability to mobilize and focus energy and resources. What better
position can nurses be in but to assume power to face new problems and responsibilities in reshaping nursing practice to

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adapt to environmental changes? Power is the means, not the end, to seek new ways for doing things in this uncertain and
unsettling time in health care.

Power Plays
POWER PLAY RECIPIENT’S RESPONSE
"Let's be fair." Feelings of insecurity; insecure about choices because
power game is played by someone else's rules.
"Can you prove that?" Embarrassed by inability to defend self.
"Be specific." Feelings of incompetence if facts and figures cannot be
generated to support position.
"It's either this or that; which is it? Take your pick." Angered at being forced to choose between limited options.
"But you said . . . and now you say .. ." Confused about what was meant; believe your position is
illogical.

POWER PLUS VISION

The key to understanding and gaining power is to identify what you and other people really desire. Once you
have decided what you want, look at the total situation or encounter. Take into account, for example, the whole
organization, not just your workplace or unit. Rank your wants or needs in order of importance. Determine who controls
what you want and who or what stands in your way of achieving it. Identify there sources you control and the individuals
who might desire those resources. Power resides not in aggressiveness or assertiveness but in the ability to make a
conscious choice. Focus on the choice, not the action.
By making choices about what you want, you develop a strong sense of self-confidence and are aware of and feel
good about your true capabilities. Your self-respect depends not on maintaining your role or position of power, but rather
on your sense of purpose and direction. A clear vision pulls it all together by building consensus and support; identifying
present capabilities; determining success factors; and identifying resources of people, time, and money.
Once you understand how power influences what choices are made and how these choices affect behaviors and
feelings, you can appreciate its usefulness. In a constantly dynamic universe, power is a fundamental ingredient. You must
ask yourself: Are you willing to use your power to know yourself, set goals, ignite the imagination, direct nursing care, build
teams, and reach beyond the unknown into what could be? To use power to change and improve patient care is to recog-
nize that power is natural and desirable.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Who developed the system 4 management?

a. Likert
b. Ekvall
c. Tomson
d. Fiedler
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is not included among the 4 dimensions of system 4 management?
a. Autocratic leaders
b. Bureaucratic leaders
c. Consultative leaders
d. Participative leaders
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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3. The process of working through staff members to be able to provide comprehensive care to the patient:
a. Nursing
b. Management
c. Nursing Management
d. Leadership
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. This leadership style based on the managerial grid believes that adequate organization performance is possible through
balancing the necessity:
a. Impoverished
b. Middle of the Road
c. Authority compliance
d. Country Club
e. Team
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. In decreasing order of importance, arrange the 3 situational factors of leadership:

I. Manager-follower relationship
II. Manager power
III. Task structure

a. I,II, III
b. III,II, I
c. I,III,II
d. II,III,I
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Leaders should use what style if the followers are unable but willing or confident in performing the task?
a. S1
b. S2
c. S3
d. S4
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Leaders should use what leadership style with followers who are both able and willing and have confidence in
performing the task?
a. S1
b. S2
c. S3
d. S4
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 15 of 17
8. Leaders should use what type of leadership style with followers who are able but unwilling or lacking in confidence in
performing the task?
a. S1
b. S2
c. S3
d. S4
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Leaders should use what type of leadership style with followers who are unable and unwilling or insecure about
performing the task?
a. S1
b. S2
c. S3
d. S4
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. According to Fieldler's contingency theory, which of the following factors is most related to appropriate leader
behaviors?
a. leader-member relations
b. task structure
c. strength of leader position power
d. all of the above

ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________

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Education (Department of Nursing) 16 of 17
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what the students learned after the discussion and the activity.

1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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This document and the information thereon is the property of PHINMA
Education (Department of Nursing) 18 of 17
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 16

LESSON TITLE: PLANNING

LEARNING OUTCOMES: Materials:
Upon completion of this lesson, the nursing student can: Book, pen and notebook, and index card/class list

1. Define planning; References:

2. Describe the importance of planning;
Sullivan, E. J. (2009), Effective Leadership and
3. Enumerate the principles of planning; and,
Management in Nursing (7th edition). Singapore:
4. Identify the elements of planning.
Pearson Education South Asia Pte Ltd.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give the types of interpersonal power used in organizations to influence others:

MAIN LESSON

PLANNING
Planning is a four-stage process to:
l Establish objectives (goals)
l Evaluate the present situation and predict future trends and events
l Formulate a planning statement (means)
l 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. Numerous computer software programs and databases are available to help facilitate planning.
Organization-level plans, such as determining organizational structure and staffing or operational budgets, evolve from
the mission, philosophy, and goals of the organization. The nurse manager plans and develops specific goals and objectives
for her or his area of responsibility.

Antonio, the nurse manager of a home care agency, plans to establish an in-home phototherapy program, knowing that
part of the agency's mission is to meet the health care needs of the child-rearing family. To effectively implement this
program, he would need to address:
• How the program supports the organization's mission
• Why the service would benefit the community and the organization
• Who would be candidates for the program
• Who would provide the service
• How staffing would be accomplished
• How charges would be generated
• What those charges should be

PRINCIPLES OF PLANNING
1. Planning is always based & focused on the vision, mission, philosophy and clearly defined objectives of the
organization.
2. Planning is a continuous process.
3. Planning should be pervasive within entire organization.

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4. Planning utilized all available resources.
5. Planning must be precise/exact/ specific in its scope & nature.
6. Planning should be time-bound.
7. Projected plans must be documented/ recorded for proper dissemination to all concerned for implementation &
evaluation as to the extent of it achievement.

TYPES OF PLANNING
l Short-Term Plan
- achievable from 6 to 12 months
l Contingency Plan
- devised for an exceptional risk which is impractical or impossible to avoid
- systematic approach to identifying what can go wrong in the situation or while you are making your work done;
l Long-Term Plan
- more than a year to be achieved.

Why Managers Fail to Plan Effectively?

1. Lack knowledge of the philosophy, goals, & objectives of the agency.
2. Lack understanding of the significance of planning process
3. May not know how to manage their time to devote for planning.
4. Lack confidence in formulating plans or may fear that planning may bring about unwanted changes that they are
unwilling to undertake or are unable to cope with.

ELEMENTS OF PLANNING
I. Forecasting
II. Setting the Vision, Mission, Philosophy, Goals & Objectives
III. Developing & Scheduling Programs
IV. Preparing the Budget
V. Establishing Nursing Standards, Policies, and Procedures

FORECASTING
Helps managers look into the future and decide in advance where the agency would like to be and what is to be
done in order to get there.
Components:
ü Environment - where? Strategic location
ü Client - who?
ü Personnel - number & mix of staff
ü Resources - budget, facilities

SETTING THE VISION, MISSION, PHILOSOPHY, GOALS & OBJECTIVES

Ø VISION
- Describes the goal to which the organization aspires.
- “what the organization would like to achieve in the future”

To be the leading education company in the country – providing high quality education and training at affordable
fees, making it accessible to the greater majority.

Ø PHILOSOPHY
- Written statement that reflects the organizational values, vision & mission.

Ø GOAL
- More general & covers broad area
- May have 1 or more objectives

Ø OBJECTIVE
- Tends to be more specific, concrete
- Action commitments through which an organization’s mission & purpose will be achieved

DEVELOPING & SCHEDULING PROGRAMS

Ø PROGRAMS
- Activities put together to facilitate attainment of some desired goals

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 - Determined, developed & targeted within a time frame to reach the set goals & objectives
Ø TIME MANAGEMENT
- Technique for allocating one’s time through:
1. Setting of goals
ü Lifetime Goal - mission in life; needed to achieve for life (self-fulfillment)
ü Long Term Goal - a year beyond
ü Short Term Goal - set for 6 to 12 months
ü Job-Related Goal - all related to profession (promotion)
ü Personal Goal - ex: social life

Suggestions that may assist the nurse in planning work activities:

a. Gather all supply that will be needed.
b. Group activities that are in the same ward.
c. Use time estimates.
d. Document activities as much as possible.

Major Questions:
a. What specific objectives are to be achieved?
b. What specific activities are necessary to achieve these objectives?
c. How much time is required for each activity?
d. Which activities can be planned & scheduled for concurrent action, & which must be planned &
scheduled?
e. Which activities can be delegated to staff?

2. Assigning priorities

3. Identifying & eliminating wasted time

TIME WASTERS
- Something that prevents a person from accomplishing the job or achieving the goal.
COMMON TIME WASTERS
a. Interruptions (phone calls, drop-in visitors)
b. Meetings (scheduled or unscheduled)
c. Lack of clear-gut goals, objectives, & principles.
d. Lack of daily/weekly plans.
e. Lack of personal organization & self-discipline.
f. Lack of knowledge about how one spends one’s time.
g. Failure to delegate, working on routine tasks.
h. Ineffective communication.
i. Waiting for others, not using transition time effectively.
j. Inability to say NO.
4. Using managerial techniques to reach goal

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Education (Department of Nursing) 3 of 10
 TIME ANALYSIS
ü 1st step: analyze how time is being used
ü 2nd step: determine whether time used is appropriate to your role
DAILY PLANNING & SCHEDULING
- prepare a To-Do List each day.

TIME LOG
ü A diary of activities that reflect if time is properly spent or wasted.
ü Typically kept in intervals of 30 to 60 minutes.
Ex: A system to keep track of regularly scheduled meetings, regular events, and appointment is also
necessary.

PERSONAL ORGANIZATION & SELF-DISCIPLINE

a. Organize your workspace so it is functional.
b. Close your door when you need to concentrate.
c. Focus on one task at a time, making sure to start with high-priority task.
d. Break down large projects into smaller parts.

CONTROLLING INTERRUPTIONS
ü INTERRUPTION
- Occurs any time you are stopped in the middle of an activity to give attention to something
else.

ü INTERRUPTION LOG
- Shows who interrupted, when it occurred, how long it lasted, what topics were discussed, the
importance of topics, and time-saving actions to be taken.
a. Phone Calls
u Minimize socializing and small talks
u Plan calls
u Set a time for calls
u State and ask for preferred call times and the purpose of the call
b. E-mail
u Minimizes wasted time trying to contact individuals
u Enables to contact many people simultaneously
u Allows to code the urgency of messages
Turn off e-mail alert and set specific times of day to check email.
c. Drop-In Visitors
u Direct visit by identifying the issue/query
u Arranging an alternative meeting
u Referring the visitor to someone else
u Redirecting the visitor’s problem-solving efforts
u Open doors are open for interruptions
d. Paperwork
u Plan and schedule paperwork.
u Sort paperwork for effective processing.
u Send every communication electronically.
u Analyze paperwork frequently.
u Do not be a paper shuffler.
PAPER SHUFFLERS
- Those who continually move things around on their desks or accumulate unread e-mails.
- Delaying actions unreasonably, and the problem mounts.

RESPECTING TIME
- The key to using time-management techniques is to respect one’s own time as well as that of
others.

PRIORITY SETTING TRAPS

A. Whatever Hits First
ü “I will cross the bridge when I get there.”

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 ü Occurs when someone responds to a situation as it happens, rather than thinking first before acting
on it.
B. Path of Least Resistance
ü The individual erroneously thinks that he can accomplish mush if he himself will do the job.
ü Does not involve others.
C. Squeaky Wheel
ü The individual falls prey to those who are more vocal about their urgent request and tend to
manipulate.
D. Managing by Default
ü The individual feels obligated to take a task that no one else has gone forward to do.
E. Inspiration
ü The individual waits until he finally feels inspired to do the job.
ü Learn to say NO graciously.

APPROACHES TO BUDGETING
1. INCREMENTAL BUDGET
ü aka: Line-By-Line Budget
ü The finance department distributes a budget worksheet listing each expense item or category on a separate
expense line.
² Advantage: Preparation is simple.
² Disadvantage: Discourages cost-efficiency.
2. ZERO-BASED BUDGET
ü Assumes that base for projecting next year’s budget is zero.
ü Managers are required to justify ALL activities and programs as if they were being initiated for the first time.
² Advantage: Every expense is justified.
² Disadvantage: Time-consuming.
3. FIXED / VARIABLE BUDGET
ü Fixed – budgeted amounts are set without regard to changes that may occur during the year (patient volume,
program activities)
ü Variable – adjustments to the budget may be made during the year based on changes in revenues, patient census,
utilization of supplies, & other expenses.

BUDGET PROCESS
ü Ensure that resources necessary to achieve objectives are available at the appropriate time and that
operations are carried out within the resources available.
ü Budget Committee
² Governing Board
² Executive Management / Chief Nurse
- works with supervisors and the head nurses

OPERATING BUDGET
ü aka: ANNUAL BUDGET
ü The organization’s statement of expected revenues and expenses for the coming year.
ü Coincides with the fiscal year - 12-month period during which the operational and financial performance of the
organization is measured.

Three Components:
1. Revenue Budget
- Represents the patient care income expected for the budget period.
2. Expense Budget
- Describes the expected acuity in operational & financial terms for a given period
- Costs of providing services to clients
- Consists of salary / non-salary items
3. Capital Budget
- Intended for long term goals
- Limited to specified amount & decisions need to be made how best to allocate available funds.

EXPENSE BUDGET
ü Salary Expense Budget
- aka: Personnel Budget

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Education (Department of Nursing) 5 of 10
 - Projects the salary costs that will be paid & charged to the cost center in the budget period.
ü Supply & Non-Salary Expense Budget
- Identifies patient-related supplies needed to operate the nursing unit.
- Examples are office supplies, rental fees, maintenance costs, equipment service contracts.

Factors that Affects Salary Budget:

ü Benefits
- Vacation days, holidays, personal days, etc
ü Shift Differentials
- 10% (evenings); 20% (weekends)
ü Overtime Fee
- 1.5 times the hourly rate
ü On-Call Expenses
- Relievers; usually paid at a flat rate per hour.
ü Bonuses & Premiums
- For certifications & professional advancement
ü Salary Increases

Types of Expenditures
1. DIRECT COST
ü Expenses that directly affect patient care.
- ex: hands-on nursing personnel salary
2. INDIRECT COST
ü Expenditures that are necessary but do not affect patient care directly.
- ex: security guard & maintenance personnel salaries

Classification of Costs
1. FIXED COST
- Will remain the same for budget period regardless of the activity level of the organization (rental
payments, insurance)
2. VARIABLE COST
- Depend on and change in direct proportion to patient volume and patient acuity (patient care supply
expenses)

CAPITAL BUDGET
ü Identifies expensive / costly expenses that will lasts.
ü Planned within a specified time period.

VARIANCE ANALYSIS
ü A technique for controlling budgetary performance
ü To determine when a variance is favorable or unfavorable, it is important to relate the variance to its impact on the
organization in terms of revenues and expenses.

VARIANCE
- Difference between the amount that was budgeted for a specific revenue or cost and the actual revenue or cost
that resulted during the course of activities.

FAVORABLE UNFAVORABLE

≥ REVENUE < REVENUE

≤ EXPENSE > EXPENSE

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Education (Department of Nursing) 6 of 10
Budgeted Expenditure Actual Expenditure Variance Percent

$ 34, 560 $ 36, 958 $ 2, 398 6.9%

*Divide the Variance to the Budgeted and multiply to 100 to get the Percent

SALARY VARIANCES
1. VOLUME VARIANCES
- Result when there is a difference in the budgeted and actual workload requirements as would occur with
increases in patient days
2. EFFICIENCY VARIANCE
- aka: QUANTITY / USE VARIANCE
- Reflects the difference between budgeted and actual nursing care hours provided.
3. RATE VARIANCE
- aka: PRICE / SPENDING VARIANCE
- Reflects the difference in budgeted and actual hourly rates paid.

ESTABLISHING NURSING STANDARDS, POLICIES, AND PROCEDURES

Standards of Nursing Practice and Nursing Service Administration

ü Good reference for nursing standards
ü Formulated by ANSAP and PNA
ü Printed in 1981

POLICIES
ü Broad guidelines for the managerial decisions that is necessary in organizational departmental planning

General Areas in Nursing that Require Policy Formulation

1. Areas in which confusion about the locus of responsibility might result in neglect or malperformance of an act
necessary to patient’s welfare.
2. Areas pertaining to the protection of patients’ and families’ right.
3. Areas involving personnel management and welfare.

MANUAL
- Effective tool for orienting new employees; a reference when unexpected problems arise.

The Nursing Service Policy Manual

- consists of policies on admissions, discharge, death of clients, nursing care, etc.

Interdepartmental Policies
- developed in keeping with overall hospital policies, thus ensuring unity & harmonious relationships among
departments.

PROCEDURES
- Specific directions for implementing the written policies.

Areas where Procedures are Needed:

- Those that are related to job situations
- Those involving patient care

Nursing Procedure Manual

- should be available in each unit to familiarize nurses with the common nursing procedures utilized in that unit.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 7 of 10
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Defined as predetermined course of action in order to arrive at a desired result:

a. Planning
b. Organizing
c. Controlling
d. Evaluating
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The following are the four-stage process of planning, except?

a. Establish subjective (goals).
b. Evaluate the present situation & predict future trends & events.
c. Formulate a planning statement (means).
d. Convert the plan into an action statement.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The principles of planning are the following. SATA

a. Planning is always based & focused on the vision, mission, philosophy and clearly defined objectives of the
organization.
b. Planning is a continuous process.
c. Planning should be pervasive within entire organization.
d. Planning utilized all available resources.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. What type of planning is devised for an exceptional risk which is impractical or impossible to avoid:
a. Short term
b. Long term
c. Contingency
d. Middle range
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. This type of planning is achievable from 6 to 12 months:

a. Short term
b. Long term
c. Contingency
d. Middle range
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. A type of planning that take more than a year to be achieved:

a. Short term

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Education (Department of Nursing) 8 of 10
 b. Long term
c. Contingency
d. Middle range
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Which of the following is not an element of planning?

a. Forecasting
b. Setting the Vision, Mission, Philosophy, Goals & Objectives
c. Developing & Scheduling Operations
d. Preparing the Budget
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. This describes the goal to which the organization aspires:

a. Objective
b. Vision
c. Goal
d. Philosophy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. This is where action commitments through which an organization’s mission & purpose will be achieved is stated:
a. Objective
b. Vision
c. Goal
d. Philosophy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. A written statement that reflects the organizational values, vision & mission:
a. Objective
b. Vision
c. Goal
d. Philosophy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 9 of 10
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT Muddiest Point

This activity is to evaluate what the students learned after the discussion and the activity.

In today’s session, what was least clear to you?

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 10 of 10
 Nursing Leadership and Management
STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR
Session # 17

LESSON TITLE: ORGANIZING (PART 1) Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define organizing; Sullivan, E. J. (2009), Effective Leadership and
2. Describe the organizational chart; Management in Nursing (7th edition). Singapore:
3. Enumerate the elements of organizing; Pearson Education South Asia Pte Ltd.
4. Describe staffing;
5. Determine staffing needs; and,
6. Determine the appropriate staffing mix and distribution of
staff.

LESSON PREVIEW/REVIEW

Based on the previous lesson, give the approaches to budgeting:

MAIN LESSON

ORGANIZING
- The process of coordinating the work to be done within the organization.
- Ongoing process that systematically reviews the use of human and material resources.
l Involves:
ü identifying the work of the organization
ü dividing the labor
ü developing the chain of commands
ü assigning authority
l In healthcare, the basis of organization are:
ü Mission
ü Formal Organization Structure
ü Delivery systems
ü Job descriptions
ü Skill mix
ü Staffing Patterns

ORGANIZATION
- Refers to a body of persons, methods, policies and procedures arranged in a systematic process through the delegation
of functions and responsibilities for the accomplishment of purpose .
l AUTHORITY
- The right to act, empower or make decisions without approval of higher administrators.
l RESPONSIBILITY
- Obligation to perform or accomplish the assigned tasks.
l ACCOUNTABILITY
- Taking full responsibility for the quality of work and behavior while engaged in the practice of one’s profession.

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Education (Department of Nursing) 1 of 11
 ELEMENTS OF ORGANIZING
n Setting up the Organizational Structure
n Staffing
n Developing Job Descriptions
n Scheduling

Setting up the Organizational Structure

ORGANIZATIONAL STRUCTURE
- Refers to the way in which a group is formed, its lines of communication, and its means of challenging authority
and making decisions.
- Describes the arrangement of the work group
- Increases organizational efficiency.

ORGANIZATION CHART
- A line drawing that shows how the parts of an organization are linked.
- Depicts the formal organizational relationships, areas of responsibilities, persons to whom one is and channels
of communication.

PURPOSES OF ORGANIZATIONAL STRUCTURE

1. It informs members of their responsibilities so that they may carry them out.
2. It allows the manager and the individual workers to concentrate on his/her specific role and responsibilities.
3. It coordinates all organization activities so there is minimal duplication of effort or conflict.
4. It reduces the chances of doubt and confusion concerning assignments.
5. It avoids overlapping of functions because it pinpoints responsibilities.
6. It shows to whom and for whom employees are responsible.

TYPES OF ORGANIZATION
n Functional Structure
n Line Organization / Formal Structure
n Informal Structure
n Staff Organization

Functional Structure
- Employees are grouped in departments by specialty, with similar tasks being performed by the same group,
similar groups operating out the same department, and similar departments reporting to the same manager.
- Tends to centralize decision making because the functions converge at the top of the organization.
- UNCOMMON in today’s rapidly changing health care environments due to its weaknesses.
1. Coordination across functions is poor as the decision making can pile up at the top and overload senior
managers
2. General management training is limited because most employees move up the organization within the
functional departments only.

Line Organization
- Oldest, simplest and most direct type of organization in which each position has general authority over the
lower positions in the hierarchy
- Line positions are displayed by a ‘solid line’
- Vertical Line of Authority / Vertical Relationship

Informal Organization
- Refers to horizontal relationships rather than vertical.
- Composed of small groups of workers with similar interests, ideas, and responsibilities.

Staff Organization
- Purely advisory to the line structure with no authority to put recommendations into action.
- Staff positions are displayed as ‘broken line’.

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Education (Department of Nursing) 2 of 11
*Vertical line authority – Chief Nurse to Nurse Manager to Staff
*Horizontal –Acute nurse practitioner and Nurse manager
--- they collaborate to improve efficiency and productivity of unit but NOT responsible for the work of the other

CHARACTERISTICS OF AN ORGANIZATION CHART

1. Division of Work
- Each box represents the individual or sub-unit responsible for given task.
- reduces number of tasks that each employee must carry out
- managers can standardize the work to be done, which in turn provides greater control.
2. Chain of Command
- Lines indicate who reports to whom and by what authority.
- hierarchy of authority and responsibility within the organization.
3. Type of Work to be Performed
- Indicated by labels or descriptions for the boxes
4. Grouping of Work Segments
- Shown by clusters of group works (departments or single unit)
5. Levels of Management
- Indicate individual and entire management hierarchy

ORGANIZING PRINCIPLES
1. Unity of Command - one direction ONLY; under the 14 principles of management (Henri Fayol) -- An employee
should report to only one supervisor
2. Scalar Principle or Hierarchy - refers to a clearly defined line of authority that includes all employees in the
organization --- immediately report to the higher management
3. Homogenous Assignment / Departmentalization
4. Span of Control - number of people you can directly monitor; the higher the number, the lesser the possible
control.
- How many employees a manager can effectively supervise.
- Complex organization has tall structure due to numerous departments in which authority is
centralized
- Less complex organization has flat structure; authority is decentralized with several managers
supervising large work groups.
5. Exception - decision to your own department; on your own
6. Decentralization - proper delegation of authority; Decision-making is shared with the employees

STAFFING
- The process of determining and providing the accepted numbers and mix of nursing personnel to produce a desired
level of care to meet the patient’s demand.
- There is no single or perfect method to achieve the staffing.
- Variability in patient census requires continuous fine-tuning.

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Education (Department of Nursing) 3 of 11
 FACTORS AFFECTING STAFFING
1. Type, philosophy & objectives of the hospital & nursing services.
2. The population served or the kind of patients served whether pay or charity.
3. The number of patients, severity of illness & knowledge and ability of personnel are matched with the actual care
needs or patients.
4. Availability & characteristics of the nursing staff including education, level of preparation, mix of personnel,
number & position.
5. Administrative policies such as rotation, weekends and holiday off-duties.
6. Standards of care desired which should be available & clearly spelled-out. Institution may utilize the ANSAP’s
(Association of Nursing Service Administrators of the Philippines) standard of Nursing Practice.
7. Layout of various nursing units & resources available within the department such as adequate equipment,
supplies, & material.
8. Budget including the amount allotted to salaries, fringe benefits, supplies, materials & equipment.
9. Professional activities & priorities in non-patient activities like involvement in professional organizations, formal
educational development, participation in research & staff development.
10. Teaching program or extent of staff involvement in teaching activities.
11. Expected hours of work per annum of each employee, influenced by the 40-hr week law.
12. Pattern of work schedule:
ü 5 days/wk, 8 hrs/day, 2 days off/wk
ü 4 days/wk, 10 hrs/day, 3 days off/wk
ü 3 ½ days/ wk, 12 hrs/ day, 3 ½ days off/wk

PATIENT CARE CLASSIFICATION SYSTEM

- Sometimes referred to as PATIENT ACUITY SYSTEMS
- Method of grouping patients according to the amount and complexity of their nursing care requirements and the
nursing time and skill they require.
- 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 number and mix nursing staff.
- Use patient needs to determine workload requirements and staffing needs objectively.
- Ideally, this system would accurately predict the number and skill level of nurses needed for the next shift
- Reality, much can go amiss due to:
1. Nurses call in sick
2. Nurses schedule may not have the skill set necessary for a new admission (ex: patient condition may change)

TABLE 1: NCH/ Patient/ Day

*according to classification of patients by units.
*NCH – Nursing Care Hours

CLASSIFICATION CATEGORIES:
n LEVEL I – Self Care or Minimal Care
n LEVEL II – Moderate Care or Intermediate Care
n LEVEL III – Total, Complete or Intensive Care
n LEVEL IV – Highly Specialized Critical Care

LEVEL I
- Patient can take a bath on his own, feed himself, and perform his ADLs.
- Patients about to be discharged, those in non-emergency, newly admitted, don’t exhibit unusual s/sx & requires little
treatment.
² NCH: 1.5
² Ratio: 55:45 (Professional: Non-Professional)

LEVEL II
- Patients need some assistance in bathing, feeding & ambulating
- Extreme symptoms may have subsided, haven’t yet appeared
- May have slight emotional needs, with V/S ordered up to 3x/shift, IVF or BT, are semi-conscious
- Require periodic treatment
² NCH: 3
² Ratio: 60:40

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Education (Department of Nursing) 4 of 11
 LEVEL III
- Patients are completely dependent upon the staff
- Provided with complete bath, fed, may or may not be unconscious, may be on continuous O2 therapy, with chest or
abdominal tubes
- Require close observation at least 30 minutes
² NCH: 4.5
² Ratio: 65:35

LEVEL IV
- Patients need maximum nursing care
- Patient needs continuous treatment, with many medications, IV piggy backs, V/S every 15 to 30 minutes, hourly
output, with significant changes in doctor’s order
² NCH: 6 *NCH can go to 9
² Ratio: 70:30 *Ratio can go to 80:20

FORTY HOUR WEEK LAW

- Provides that employees working in hospitals with 100-bed capacity and up will work only 40 hours a week.
- This also applies to employees working in agencies with at least one million population.
- RA 5901 - an act prescribing 40 hrs a week of labor for government and private hospitals or clinic personnel

CIVIL SERVICE COMMISSION

- As per Memorandum Circular No. 6 Series of 1996
- 3-day special privilege to government employees, which may be spent for:
ü Birthday
ü Wedding
ü Anniversary
ü Funeral
ü Relocation
ü Enrolment / Graduation
ü Hospitalization
ü Accident Leaves

TABLE 2: Categories / Levels of Care of Patients, NCH needed/pt/day & Ratio of Professional to Non-
Professonal

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Education (Department of Nursing) 5 of 11
TABLE 3: Percentage of Patients at Various Levels of Care per Type of Hospital

TABLE 4: Total # of Working & Non-Working Days & Hrs of Nursing Personnel Per Year

* Standard: 365 days per year

* Standard reference
For the relievers:
33 days average number of days an employee is absent/yr
213 total number of working days/yr (40hrs)

0.15 per person who works 40 hrs/wk

33 ⁄265 = 0.12per person who works 48 hrs/wk

SHIFT DISTRIBUTIONS
n AM SHIFT – 45%
n PM SHIFT – 37%
n NIGHT SHIFT – 18%
* Whether it would be nurses or nursing attendants

STAFFING COMPUTATION
PROBLEM: Find the number of nursing personnel needed for 250 patients in a tertiary hospital.

1. Categorize the patients according to the levels of care needed. Refer to table 3

250 x .30 = 75 pts needing minimal care

250 x .45 = 112.5 pts needing moderate care
250 x .15 = 37.5 pts needing intensive care
250 x .10 = 25 pts needing highly specialized care

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Education (Department of Nursing) 6 of 11
 2. Find the number of Nursing Care Hours (NCH) needed by the patients at each level of care per day. Refer to table
2.
75 x 1.5 (NCH at Level I)= 112.5 NCH/day
112.5 x 3 (NCH at Level II)= 337.5 NCH/day
37.5 x 4.5 (NCH at Level III)= 168.75 NCH/day
25 x 6 (NCH at Level IV)= 150 NCH/day

TOTAL = 768.75 NCH/day

3. Find the total NCH needed by 250 patients.

768.75 NCH/day x 365 days/year = 280,593.75 NCH/yr

4. Find the actual working hours rendered by each nursing personnel per year.

8 hrs/day x 213 working days/year

= 1,704 working hours /yr

5. Find the total number of nursing personnel needed.

a. Total NCH per year

Working hrs/year

280,593.75 NCH/yr
1,704 = 165 nursing personnel

b. Relief x Nursing Personnel

0.15 (constant for 40 hrs) x 165 = 25 relievers

c. Total Nursing Personnel needed

165 nursing personnel + 25 relievers = 190

6. Categorize to professional and non-professional personnel. Ratio of pro to non-pro in a tertiary hospital is ______.

65:35 (Refer to table 2)

190 x .65 = 123.5

190 x .35 = 66.5

7. Distribute the shifts. (Refer to shifts distribution)

a. NURSES = 123.5
123.5 nurses x .45 (AM shift) = 56
123.5 nurses x .37 (PM shift) = 46
123.5nurses x .18 (NIGHT shift) = 22
TOTAL: 124

b. NURSING ATTENDANTS = 66.5

66.5 NA x .45 (AM shift) = 30
66.5 NA x .37 (PM shift) = 25
66.5 NA x .18 (NIGHT shift) = 12
TOTAL: 67

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Education (Department of Nursing) 7 of 11
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 20 minutes for this activity:

Multiple Choice

PROBLEM: Find the number of nursing personnel needed for 150 patients in a secondary hospital.

1. How many patients needs minimal care?

a. 45
b. 97.5
c. 105
d. 15
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. How many patients needs moderate care?

a. 45
b. 97.5
c. 105
d. 15
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. How many patients needs intensive care?

a. 22.5
b. 67.5
c. 7.5
d. 15
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Patients on level 1 care needs how much NCH?

a. 67.5
b. 146.25
c. 157.5
d. 22.5
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Patients on level 2 of care needs how much NCH?

a. 135
b. 292.5
c. 315
d. 45

ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 8 of 11
6. Patients on level 3 of care needs how much NCH?
a. 101.25
b. 303.75
c. 33.75
d. 67.5
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. What is the total number of NCH per year for 150 patients?
a. 168,356.25
b. 283,331.25
c. 49,275
d. 114,975
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. How many nursing personnel are needed?

a. 99
b. 166
c. 29
d. 67
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. How many relievers are needed?

a. 15
b. 25
c. 4
d. 10
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. How many TOTAL Nursing personnel are needed?

a. 114
b. 191
c. 33
d. 77
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 9 of 11
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 10 of 11
LESSON WRAP-UP (10 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This activity is to evaluate what your learned after the discussion and the activity.

Three things you learned:

1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
Two things that you’d like to learn more about:
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
One question you still have:
1. ___________________________________________________________________________________________

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Education (Department of Nursing) 11 of 11
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 18

LESSON TITLE: ORGANIZING (PART 2) Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Describe how to recruit and select staff; Sullivan, E. J. (2009), Effective Leadership and
2. Describe how to interview prospective candidates; Management in Nursing (7th edition). Singapore:
3. Distinguish between appropriate and inappropriate Pearson Education South Asia Pte Ltd.
questions to ask during an interview;
4. Describe the various ways to schedule staff; and,
5. Explain how to supplement staff when needed.

LESSON PREVIEW/REVIEW
Based on the previous lesson, enumerate the types of organization.
1.
2.
3.
4.

MAIN LESSON

THE RECRUITMENT AND SELECTION PROCESS

The purpose of the selection process is to match people to jobs. Responsibility for selecting nursing personnel in health care
organizations is usually shared by the human resource management (HRM) department, which may include a nurse
recruiter, and nursing management. First-line nursing managers are the most knowledgeable about job requirements and
can best describe the job to applicants. HRM performs the initial screening and monitors hiring practices to be sure they
adhere to legal stipulations.
Before recruiting or selecting new staff, those responsible for hiring must be familiar with the position description. The
position description describes the skills, abilities, and knowledge required to perform the job. The position description
should reflect current practice guidelines and include:
l Principal duties and responsibilities involved in a particular job
l Tasks inherent on those duties
l Personal qualifications (skills, abilities, knowledge, and traits) needed for the position
l May also include competency-based behaviors

These steps designed to acquire and retain personnel are:

1. Plan the number and types of personnel needed according to patient care delivery systems of the organization.
2. Determine the duties, requirements, tasks, and qualifications of each position.
3. Develop and implement a recruitment strategy to locate and attract enough qualified applicants to provide a pool of
potential employees.
4. Interview, evaluate, and select needed staff.
5. Orient staff to the job.
6. Enhance employee performance through staff development and management of job performance.
7. Evaluate performance to provide feedback to the employee.
8. Manage absenteeism and other personnel problems.
9. Develop and implement strategies to retain staff.
10. Providing career counseling.
11. Develop exit strategies, such as preretirement counseling and exit interviews.

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Education (Department of Nursing) 1 of 13
 The purpose of recruitment is to generate a pool of qualified applicants, whereas the purpose of the selection process is
to assess an applicant’s ability, skills, and motivation related to the requirements and rewards of the job. When candidates
are matched to the job, positive outcomes such as high job satisfaction, low turnover, and high-quality performance can
result.
The recruitment and selection process begins with job analysis, which is a careful determination of job duties and
requirements by nursing service, with technical assistance from HRM. Based on the job analysis subsequent job
descriptions, recruiting plans and selection systems are developed and implemented.
Once an applicant makes contact with the organization, HRM reviews the application and may conduct a preliminary
interview. If the applicant does not meet the basic needs of the open position or positions, he or she should be so informed.
Rejected applicants may be qualified for other positions or may refer friends to the organization and thus should be treated
with utmost courtesy.
The next three stages include the selection instruments used: tests, reference checks, and managerial interviews. In
most cases, the interview is last but practices may vary. Even if an applicant does poorly on the selection test or receives
poor references, it is prudent to carry out the interview so that the applicant is not aware that the test or reference checking
led to the negative decision. In addition, applicants may feel they have a right to “tell their story” and may spontaneously
provide information that explains poor references.
The nurse manager should participate in the interview process because the manager is:
l Best able to assess applicants’ technical competence, potential, and overall suitability
l Able to answer applicants’ technical, work-related questions more realistically. In some organizations, the
candidate’s future co-workers also participate in the interview process to assess compatibility.
After the managerial interview, the applicant is given a comprehensive medical examination to protect the organization
from legal actions. For example, individuals with back problems should not be hired to work on rehabilitation unit where a
great deal of lifting of patients is required. In addition, state boards of health and other regulatory bodies require rubella,
tetanus, and tuberculosis testing. The Occupational Safety and Health Administration (OSHA) requires that the hepatitis
immune series be offered to health care workers who are not immune to hepatitis.
Once the medical examination has been completed, the nurse manager reviews the information available on each
candidate and makes a job offer. The nurse manager must keep others involved in the selection process informed. The
nurse manager is usually the first to be aware of potential resignations, requests for transfer, and maternity or family medical
leaves that require replacement staff. The manager also is aware of changes in the work area that might necessitate a
redistribution of staff, such as the need for a night nurse instead of a day one. Communicating these needs to HRM promptly
and accurately help ensure effective coordination of the selection process.

RECRUITMENT
The purpose of recruitment is to locate and attract enough qualified applicants to provide a pool from which the required
number of individuals can be selected. Even though recruiting is primarily carried out by HRM staff and nurse recruiters,
nurse managers and nursing staff play an important role in the process. Recruiting is easier when current employees spread
the recruiting message, reducing the need for expensive advertising and reward methods.
The best recruitment strategy is the organization's reputation among its nurses. Brady-Schwartz (2005) found that
nurses in magnet hospitals demonstrated higher levels of job satisfaction than those in non-magnet hospitals. It follows that
satisfied nurses are more likely to speak highly of the organization.
Kerfoot (2001) suggested ways in which the organization can attract potential employees by oft-ignored messages it
sends.
Individual nurse managers also affect how well the unit is able to attract and retain staff. A nurse manager who is able to
create a positive work environment through leadership style and clinical expertise will have a positive impact on recruitment
efforts because potential staff members will hear about and be attracted to that area (e.g., hospital unit, home health team).
In contrast, an autocratic manager is more likely to have a higher turnover rate and is less likely to attract sufficient numbers
of high-quality nurses.
Any recruiting strategy includes essentially four elements:
1. Where to look
2. How to look
3. When to look
4. How to sell the organization to potential recruits
Each of these elements may be affected by market competition, nursing shortages, reputation, visibility, and location.

WHERE TO LOOK
For most health care organizations, the best place to look is in their own geographic area. During nursing shortages,
however, many organizations conduct national searches. This effort is frequently futile because most nurses look for jobs in
their local area. If the agency is in a major metropolitan area, a search may be relatively easy; if it is located in a rural area,
however, recruitment may need to be conducted in the nearest city. Organizations tend to recruit where past efforts have

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been the most successful. Most organizations adopt an incremental strategy whereby they recruit locally first and then
expand to larger and larger markets until a sufficient applicant pool is obtained.
Because proximity to home is a key factor in choosing a job, recruitment efforts should focus on nurses living nearby.
The state board of nursing can provide the names of registered nurses by zip code to allow organizations to target
recruitment efforts to surrounding areas. Also, personnel officers in large companies or other organizations in the area can
be asked to assist in recruiting nurse spouses of newly hired employees.
Collaborative arrangements with local schools of nursing offer opportunities for recruitment. Providing preceptors or
mentors for students during their clinical rotation or offering externships or residencies postgraduation encourages students
to consider employment in the organization. Nurses who work with students play a key role in recruitment. Students are
more likely to be attracted to the organization if they see nurses' work valued and appreciated and perceive a positive
impression of the work group.
Employing students as aides may provide another recruitment tool because it allows students to learn first-hand about
the organization and what it has to offer. In turn, the organization can evaluate the student as a potential employee
postgraduation. Some organizations provide assistance with student loan payments if the student continues to work after
graduation. Of major importance to new graduates is the orientation program. Graduates look for an orientation that
provides successful transition into professional practice. Other top factors they consider are the reputation of the agency,
benefits, promotional opportunities, specialty area and nurse-patient ratio.

HOW TO LOOK
Posting online on general job search sites (e.g., www. monster.com) or on nurse-specific job referral sites is a common
practice. Nurse.com is one (www.nurse.com). Professional associations such as Sigma Theta Tau International
(http://stti.monster.com) and the American Nurses Association (www.nursecareercenter.com) offer job search services.
Employee referrals, advertising in professional journals, attendance at professional conventions, job fairs, career days,
visits to educational institutions, employment agencies (both private and public), and temporary help agencies are all
recruiting sources. Advertising in professional journals or newspapers can be an effective recruiting tool, but it tends to be
expensive. Numerous websites target nurses and may be free. On others, ads can be purchased.
In recruiting, both the medium and the message must be considered. The medium is the agent of contact between the
organization and the potential applicant (e.g., online site, professional journal, newspaper). Obviously, it is desirable to find
a medium that gives the widest exposure. Unfortunately, these media tend to be inefficient and low in credibility. The more
influential media tend to be the more personal ones: present employees and recruiters. Acquaintances or friends of the
recruit have prior credibility and the ability to communicate more subtle aspects of the organization and the job.
During extreme nursing shortages, some organizations offer bonuses to staff members who refer candidates, as well as
bonuses to the recruits themselves. Direct applications and employee referrals are quick and relatively inexpensive ways of
recruiting people, but these methods also tend to perpetuate the current cultural or social mix of the workforce. It is both
legally and ethically necessary to recruit individuals without regard to their race, ethnicity, gender, or disability. In addition,
organizations can benefit from the diversity of a staff composed of persons from a wide variety of social, experiential,
cultural, generational, and educational backgrounds.
On the other hand, nurses referred by current employees are likely to have more realistic information about the job and
the organization and, therefore, their expectations more closely fit reality. Those who come to the job with unrealistic
expectations may experience dissatisfaction as a result. In an open labor market, these individuals may leave the
organization, creating high turnover. When nursing jobs are less plentiful, dissatisfied staff members tend to sty in the
organization because they need the job, but they are not likely to per-form as well as other employees. Consequently, even
where applicants are sought may have significant con-sequences later on.

WHEN TO LOOK
The time lag in recruiting is a concern to nursing because of the shortage. Positions in certain locations (e.g., rural
areas) or specialty areas (e.g., critical care) may be especially difficult to fill. Careful planning is necessary to ensure that
recruitment begins well in advance of anticipated needs.

HOW TO SELL THE ORGANIZATION

A critical component of any recruiting effort is marketing the organization and available positions to potential employees.
The nursing department and/or HRM should develop a comprehensive marketing plan. Generally, four strategies are
included in marketing plans and are called the 4 Ps of marketing:
1. Product
2. Place
3. Price
4. Promotion
The consumer is the key figure around which the four concepts are oriented, and in the recruiting process, the consumer
is the potential employee.

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 Product is the available position(s) within the organization. Consider several aspects of the position and organization,
such as
• Professionalism
• Standards of care
• Quality
• Service
• Respect

Place refers to the physical qualities and location, such as

• Accessibility
• Scheduling
• Parking
• Reputation
• Organizational culture

Price includes
• Pay and differentials
• Benefits
• Sign-on bonuses
• Insurance
• Retirement plans

Promotion includes
• Advertising
• Public relations
• Direct word of mouth
• Personal selling (e.g., job fairs, professional meetings)

Developing an effective marketing message is important. Sometimes the tendency is to use a "scatter-gun" approach,
sugarcoat the message, or make it very slick. A more balanced message, which includes honest communication and
personal contact, is preferable. Overselling the organization creates unrealistic expectations that may lead to later
dissatisfaction and turnover.
Realistically presenting the job requirements and re-wards improves job satisfaction, in that the new recruit learns what
the job is actually like. Promising a nurse every other weekend off and only a 25 percent rotation to nights on a severely
understaffed unit and then scheduling the nurse off only every third weekend with 75 percent night rotations is an example of
unrealistic job information. It is important to represent the situation honestly and describe the steps management is taking to
improve situations that the applicant might find undesirable. The candidate can then make an informed decision about the
job offer.

CROSS-TRAINING AS A RECRUITMENT STRATEGY

In today's rapidly changing health care environment, patient census fluctuates rapidly, and staffing requirements must
be adjusted appropriately. These conditions may bring about layoffs and daily cancellations and contribute to low morale.
Offering cross-training to potential employees may increase the applicant pool.
Cross-training has the benefits of increasing morale and job satisfaction, improving efficiency, increasing the flexibility of
the staff, and providing a means to manage fluctuations in census. It gives nurses, such as those in obstetrics and neonatal
areas, an opportunity to provide more holistic care. In addition, cross-training enhances the nurse's range of skills, adding
expertise useful for career planning.
If cross-training is used, care should be taken to provide a didactic knowledge base in addition to clinical training. How
broadly to cross-train is an important decision because training in too many areas may overload the nurse and reduce the
quality of care.

INTERVIEWING
The most common selection method, the interview, is an information-seeking mechanism between an individual applying for
a position and a member of an organization doing the hiring. After the applicant's initial screening with HRM, the nurse
manager usually conducts an interview.
The interview is used to clarify information gathered from the application form, evaluate the applicant's responses to
questions, and determine the fit of the applicant to the position, unit, and organization. In addition, the interviewer should
provide information about the job and the organization. Finally, the interview should create goodwill toward the employing
organization through good custom relations.

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 Research suggests that decision making is improved if the interviewer postpones reviewing information not needed for
the interview, such as test scores, until after the interview. Reviewing such information before the interview may lead to
ignoring data that disconfirm this information.
An effective interviewer must learn to solicit information efficiently and to gather relevant data. Interviews typically last
for 1 or 11/2 hours, and include an opening, an information-gathering and information-giving phase, and a closing. The
opening is important because it is an attempt to establish rapport with the applicant so she or he will provide relevant
information. Gathering information, however, is the core of the interview. Giving information also is important because it
allows the interviewer to create realistic expectations in the applicant and sell the organization if that is needed. However,
this portion of the interview should take place after the information has been gathered so that the applicant's answers will be
as candid as possible. The interviewer should answer any direct questions the candidate poses. Finally, the Closing is
intended to provide information to the candidate on the mechanics of possible employment.

PRINCIPLES FOR EFFECTIVE INTERVIEWING

Developing Structured Interview Guides
Unstructured interviews present problems; if interviewers fail to ask the same questions of every candidate, it is often
difficult to compare them. With any human skill or trait, no standard or true score exists that can serve as a basis on which to
compare applicants. People can only be compared to other people. Consequently, the interview is most effective, when the
information on the pool of interviewees is as comparable as possible. Comparability is maximized via a structured interview
supported by an interview guide. An interview guide is a written document containing questions, interviewer directions, and
other pertinent information so that the same process is followed and the same basic information is gathered from each
applicant. The guide should be specific to the job, or job category.
Instead of the traditional interview questions, such as "tell me about yourself, what are your strengths and weaknesses,
and why do you want to work for us," specific questions that target job-related behaviors are more common today.
Behavioral interviewing, also called competency-based interviewing, uses the candidate's past performance and
behaviors to predict behavior on the job (Simonsen & Smith, 2007). The questions are based on requirements of the
position. Examples of specific behaviors expected of staff nurses and related sample questions are found in the table below.
Examples of Behavioral Interview Questions
BEHAVIOR SAMPLE QUESTION
What was your most difficult decision in the last month and
Decision making
why was it difficult?
What do you think is the most important skill in successful
Communication
communication?
Describe a major change that affected you and how you
Adaptability
handled it.
How do you make a decision to delegate? Describe a
Delegation
specific situation.
What have you done in school or on a job that went beyond
Initiative
what was required?
Motivation What is your most significant professional accomplishment?
Negotiation Give an example of a negotiation situation and your role in it.
How do you schedule your time? What do you do when
Planning and organization
unexpected circumstances interfere with your schedule?
Describe a situation where you had to make a decision by
Critical thinking analyzing information, consider a range of alternatives, and
select the best one for the circumstances.
Conflict resolution Describe a situation where you had to help settle a conflict.

In addition, develop additional questions based on the specific job. For example, you may want to add questions on
teamwork and collaboration as they relate to position.
Interview guides reduce interviewer bias, provide a relevant and effective questions, minimize leading questions, and
facilitate comparison among applicants. Space left between the questions on the guide provides room for note taking, and
the guide also provides a written record of the interview.

Preparing for the Interview

Most managers do not adequately prepare for the interview, which should be planned just like any business
undertaking. All needed materials should be on hand, and the interview site should be quiet and pleasant. If others are
scheduled to see the applicant, their schedules should be checked to make sure they are available at the proper time. If
coffee or other refreshments are to be offered, advance arrangements need to be made. Lack of advance preparation may
lead to insufficient interviewing time, interruptions, or failure to gather Important information. Other problems include losing

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focus in the interview because of a desire to be courteous or because a particularly dominant interviewee is encountered.
This typically keeps the interviewer from obtaining the needed information.
In general, when time is limited, it is better to use part of it for planning rather than squander all of it on the interview itself.
This is preferable to spending more time later trying to correct the performance of a poor employee. Before the interview, the
interviewer should review job requirements, the application and résumé, and note specific questions to be asked. Planning
should be done on the morning of the interview or the evening before for an early morning interview. If you are sure that time
will be available, planning is best done immediately before an interview or between interviews. Unfortunately, a busy
manager may have to deal with unexpected minor crises between interviews and may not be able to use the time to plan the
next interview.
A cardinal rule is to review the application or résumé before beginning the interview. If the interviewee arrives with the
résumé or application in hand, ask him or her to wait for a few minutes while you review the material. In doing a quick review,
consider four things:
1. Are there clear discrepancies between the applicant's qualifications and the job specifications? If the answer is
yes, then only a brief interview may be necessary to explain why the applicant will not be considered. (If a
preliminary screening is per-formed by the HRM, such applicants should not be referred to nurse managers.)
2. Look for specific questions to ask the applicant during the interview.
3. Look for a rapport builder (something you have in common with the applicant) to break the ice at the beginning of
the interview.
4. Remember that the résumé is prepared by the applicant and is intended to market an applicant's assets to the
organization. It does not give a balanced view of strengths and weaknesses. So, examine the résumé critically and
make notes about areas where you need more information.

To provide a relaxed, informal atmosphere, the set-ting is important. Both you and the applicant should be in
comfortable chairs, as close as comfortably possible. No table or desk should separate you. If an office is used, arrange
chairs so that the applicant is at the side of the desk. There should be complete freedom from distracting phone calls and
other interruptions. If the view is distracting, do not seat the applicant so that she or he can look out a window.

Opening the Interview

The interview should start on time. Give a warm, friendly greeting, introduce yourself, and ask the applicant her or his
preferred name. Try to minimize status; do not patronize or dominate. The objective is to establish an open atmosphere so
applicants reveal as much as possible about themselves. Establish and maintain rapport throughout the interview by talking
about yourself, discussing mutual interests such as hobbies or sports, and using nonverbal cues, such as maintaining eye
contact. Finally, start the interview by outlining what will be dis-cussed and setting the time limits for the interview.
Be careful not to form hasty first impressions and make equally hasty decisions. Interviewers tend to be influenced by
first impressions of a candidate, and such judgments often lead to poor decisions. First impressions may degrade the quality
of the interview by coloring the search for information to justify their first impressions, good or bad. If the first impression is
negative and you decide not to hire a potentially successful candidate, you have wasted an hour or so and possibly lost a
good recruit. If, because of a positive first impression, you hire an unsuccessful candidate, problems may continue for
months. Conversely, your personal characteristics may influence the applicant's decisions. You create first impressions by
tone of voice, eye contact, personal appearance, grooming, posture, and gestures.
Using the structured interview guide, take notes, telling the candidate that this is being done to aid recall and that you
hope the candidate does not mind. There are various ways of asking questions, but only one question should be asked at a
time and, where possible, open-ended questions should be used. Open-ended questions cannot be found answered with a
single yes, no, or one-word answer and usually elicit more information about the applicant (Parrish, 2006). Closed questions
(e.g., what, where, why, when, how many) should only be used to elicit specific information.
Work sample questions are used to determine an applicant's knowledge about work tasks and ability to perform the
job. It is easy to ask a nurse whether she or he knows how to care for a patient who has a central intravenous line in place.
An answer of yes does not necessarily prove the ability, so you might ask some very specific questions about central lines.
Avoid leading questions, in which the answer is implied by the question (e.g., "We have lots of overtime. Do you mind
overtime?" ). You may also want to summarize what has been said use silence to elicit more information, reflect back the
applicant's feelings to clarify the issue, or indicate acceptance by urging the applicant to continue.

Giving Information
Before reaching the information-giving part of the interview, consider whether the candidate is promising enough to
warrant spending time in giving detailed job information. Unless the candidate is clearly unacceptable, be careful not to
communicate a negative impression, because evaluation of the candidate may change when the entire packet of material is
reviewed or more promising candidates decline a job offer. You also must know what information you should give and what
is to be provided by others. Detailed benefit or compensation questions are usually answered by HRM. If a promising
candidate's questions cannot be answered, arrange for someone to contact the candidate later with the desired information.

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 Closing the Interview
In closing the interview, you may want to summarize the applicant's strengths. Make sure to ask the applicant whether
she or he has anything to add or questions to ask related to the job and the organization. You may also want to mention the
candidate's weaknesses, particularly if they are objective and clearly related to the job, such as lack of experience in a
particular field. Mentioning a perception of a subjective weakness, such as poor supervisory skills, may lead to legal
problems. Thanking the applicant and completing any notes made during the interview conclude the interview process.

INVOLVING STAFF IN THE INTERVIEW PROCESS

Today's trend toward decentralization of decision making may lead to sharing interview responsibilities with staff.
Involving staff in interviews helps to strengthen teamwork, improves work-group effectiveness, increases staff involvement
in other unit activities, and increases the likelihood of selecting the best candidate for the position.
If staff are involved in interviews, several steps must be taken to protect the integrity of the interview process. An
organized orientation to interviewing should be given that includes:
• Federal, state, and local laws and regulations governing interviewing, as well as any collective-bargaining agreements
that may affect the process
• Tips on handling awkward interviewing situations
• Time for rehearsing interviewing skills. Just as the manager does, staff should follow a structured interview guide to
help standardize the process.
Graham Nelson is nurse manager of a dialysis center. Training a new renal dialysis nurse is an expensive process. To
reduce turnover among nursing staff, Graham includes peer interviews as part of the overall interview process. Peer
interviews can help ensure that Potential employees will interact well with existing staff and ensure a cultural fit with the
dialysis team. Additionally, an interviewee can gain a better under-standing of the day-to-day workflow of the center.

INTERVIEW RELIABILITY AND VALIDITY

Numerous research studies have been performed on the reliability and validity of employment interviews. In general,
agreement between two interviews of the same measure by the same interviewer (intrarater reliability) is fairly high,
agreement between two inter-views of the same measure by several interviewers (interrater reliability) is rather low, and
the ability to predict job performance (validity) of the typical inter-view is very low. Research also has shown that:
1. Structured interviews are more reliable and valid
2. Interviewers who are under pressure to hire in a short time or meet a recruitment quota are less accurate than other
interviewers
3. Interviewers who have detailed information about the job for which they are interviewing exhibit higher interrater
reliability and validity
4. The interviewer's experience does not seem to b related to reliability and validity
5. There is a decided tendency for interviewers to make quick decisions and therefore be less accurate
6. Interviewers develop stereotypes of ideal applicants against which interviewees are evaluated, and individual
interviewers may hold different stereo-types, thus decreasing interrater reliability and validity
7. Race and gender may influence interviewers' evaluations

Possibly the greatest weakness in the selection inter-view is the tendency for the interviewer to try to assess an
applicant's personality characteristics. Although it is difficult to eliminate such subjectivity, evaluations of applicants are often
more subjective than they need to be. Information collected during an interview should answer three fundamental questions:
1. Can the applicant perform the job?
2. Will the applicant perform the job?
3. Will the candidate fit into the culture of the unit and the organization?

The best predictor of the applicant's future behavior in these respects is past performance. Previous work and other
experience, previous education and training, and current job performance all should be considered, not personality
characteristics, which even psychologists cannot measure very accurately.

EDUCATION, EXPERIENCE, LICENSURE, AND PHYSICAL EXAMINATIONS

Education and experience requirements for nurses have long been important screening factors and bear a close
relationship to work sample tests. Educational requirements are a type of job knowledge sample because they tend to
ensure that applicants have at least a minimal amount of knowledge necessary for the job. For nurses, educational
preparation is particularly important. For example, nurses who are graduates of associate degree and diploma programs are
prepared to care for individuals in structured settings and use the nursing process, decision-making process, and
management skills in the care of those individuals. Baccalaureate graduates can provide nursing care for individuals,
families, groups, and communities using the nursing process and decision-making process. Baccalaureate graduates also
are prepared for beginning community health positions and possess the leadership and management skills needed for
entry-level management positions.

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 Making assumptions regarding the type and number of years of experience should be avoided. Factors such as job
requirements, patient acuity, clinic populations, autonomy, and degree of specialization vary from organization to
organization. Therefore, careful interviewing is needed to determine the individual applicant's knowledge and skill level.
References and letters of recommendation also are used to assess the applicant's past job experience, but there is little
evidence that these have any validity. Because few persons write unfavorable letters of recommendation, such letters do not
really predict job performance. Criticisms are likely to be mild and may be reflected by the lack of positive language. Letters
with any criticism should be verified with a telephone call, if possible, to avoid overreacting to an unusually honest author.
To avoid legal problems, many organizations include in letters of recommendation only employment dates, salary, and
whether the applicant is eligible for rehire. Many organizations do not allow supervisors to write letters of recommendation.
Negative references may be viewed as potential for slander or other legal recourse. Almost every organization will at least
verify position title and dates of employment, which helps to detect the occasional applicant who counterfeits an entire work
history. Unfortunately, omission of a position from the work history is more common than including a position not actually
held. The only way to detect such omissions is to ask that candidates list year and month of all educational and work
experiences. Caution is necessary when asking about time between jobs; be careful not to inquire about marital or family
status.
In almost every selection situation, an applicant fills out an application form that requests information regarding previous
experience, education, and references. Most applications also ask for the applicant's medical history and other personal
data. As application forms are reviewed, the critical question to be asked is whether the applicant has distorted responses,
either intentionally or unintentionally. Studies indicate that there is usually little distortion, at least not on the easily verifiable
information. Applicants may stretch the truth a bit, but rarely are there complete false-hoods. Relative to other predictors, the
application form may be one of the more valid predictors in a selection process.
Licensure status can be verified online with the state board of nursing, and most organizations obtain per-mission to do
criminal background checks as well. The computerized NCLEX-RN® examination changed hiring practices for new
graduates; because rapid notification (7 to 10 days) of licensure examination results are available, state boards no longer
issue interim permits to new graduate nurses. Organizations generally wait for new graduates to obtain a license before
starting employment.
Preemployment physical examinations can no longer be used to disqualify applicants for a job or benefits. Passage of
PL 101-336, the Americans with Disabilities Act of 1990, protects individuals with physical or mental disabilities from
discrimination. In fact, individual accommodations must be provided for an individual with disabilities. Regardless, disabled
employees may be held to the same standards for employment (i.e., they must possess the necessary skills and experience
to perform the job) as applicants without disabilities.

PLACEMENT
- Assigning employees to a position or area where they have very good chances for success.
l Factors to be considered:
1. Expertise - put your best on proper place
2. Past experience and Training
3. Culture of the Clientele - ex: more male nurses in surgical ward
more female nurses in OB and DR
4. Decision-Making Skills - mostly in ER and ICU
5. Communication Skills - good at speaking, conversant

Proper Placement
ü Foster personal growth
ü Provides motivating climate for employees
ü Maximizes productivity
ü Organizational goals have better chances of being met

Inappropriate Placement
ü Frustration
ü Poor quality of work
ü Reduced organizational efficiency
ü Rapid turn-over
ü Poor image for the agency
*Turnover rate is the percentage of employees in a workforce that leave during a certain period of time
Positive to achieve:
1. Increase knowledge from new environment
2. Increase skills also

SCHEDULING

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 Schedule
- A time table showing planned work days and shift for nursing personnel
- Objective: to assign working days & days-off to the nursing personnel so that there will be assurance of adequate
patient care, 24/7.

Factors to be Considered:
1. Different levels of nursing staff - distribute good nurses equally
2. Adequate coverage for 24 hrs, 7 days a week
3. Staggered vacations & holidays - duty, duty, off (preferred)
4. Weekends - at least 1 weekend OFF in a month; not applicable to Head Nurse & Supervisor (Commonly in AM
shift)
5. Long stretches of consecutive working days - avoid 4 – 5 consecutive days of working
6. Afternoon and night shifts
7. Floating/Relievers

Assessing a Schedule System

1. Ability to cover the needs of the unit
2. Quality to enhance the nursing personnel’s knowledge, training, & experience
3. Fairness to staff
4. Stability
ü you know your schedule in advance, about a week prior
5. Flexibility

Types of Scheduling
l CENTRALIZED SCHEDULE
- Schedule is made by one person, usually the chief nurse, or her designate, assigns the nursing personnel to the
various units of hospital.
- This includes the shifts on duty and off-duties.
l DECENTRALIZED SCHEDULE
- Schedule done by the supervisor or head nurse of a particular unit.
l CYCLICAL SCHEDULE
- Covers a designated number of weeks call the cycle length and is repeated thereon.
*cycle length usually one month period of shifting.
Advantages of Cyclical Schedule
1. It is fair to all.
2. It saves time.
3. It enables the employees to plan ahead for their personal needs preventing frequent changes in schedule.
4. Scheduled leave coverage such as vacation, holidays, and sick leaves are more stable.
5. Productivity is improved.

Points to Remember in Scheduling:

ü Mondays are usually busy days; minimal days off on these days are observed.
ü Avoid afternoon shift after a night shift.
ü Have 8 hours rest in between duties
ü Avoid 4 to 5 consecutive days of duty.

DEVELOPING JOB DESCRIPTIONS

JOB DESCRIPTION
- aka: POSITION DESCRIPTION
- Statement that sets duties and responsibilities of a specific job.
- Includes needed characteristics or qualifications of the individual to perform such duties successfully.
- Includes knowledge, skills, attitude to be possessed by the applicant.
Contents:
l Identifying Data
a. Position Title – staff nurse (Nurse I)
b. Department – Nursing
c. Supervisor’s Title – Senior Nurse

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Education (Department of Nursing) 9 of 13
 l Job Summary
ü Includes the essential features of the job

l Qualification Requirements
a. Education – BSN
b. License – Registered Nurse
c. Training – BLS & ACLS

l Job Relationships ► Source of workers

a. Promoted to – Senior Nurse / Nurse II
b. Responsible to – Senior Nurse / Nurse II

l Specific and Actual Functions and Activities

Uses:
ü For recruitment and selection
ü To orient new employees to their jobs
ü For job placement, transfer or dismissal
ü As an aid in evaluating the performance of employees
ü For budgetary purposes
ü For determining departmental functions & relationships to help define the organizational structure
ü For classifying levels of nursing functions accordingly to skill levels required
ü To identify training needs
ü As a basis for staffing
ü To serve as channel of communication

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. What is the purpose of recruitment?

a. To generate a pool of qualified applicants.
b. To generate a pool of unqualified applicants.
c. To match people to jobs;
d. To assess applicant’s ability, skills and motivation related to the requirements and rewards of the job
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The purpose of selection process is/are the following, except?

a. To match people to jobs;
b. To assess applicant’s ability, skills and motivation related to the requirements and rewards of the job
c. To generate a pool of qualified applicants.
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Selection process is the responsibility of which department?

a. Administrative department
b. Admission department
c. Human Resources Management (HRM) department
d. Medical records department
ANSWER: ________

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Education (Department of Nursing) 10 of 13
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. This describes the skills, abilities, & knowledge required to perform the job; must reflect current practice guidelines.
a. Organization’s description
b. Selection description
c. Employer description
d. Position description
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. Which of the following is not an instrument of the selection process?

a. Background check
b. Reference check
c. Tests
d. Managerial interviews
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. The best recruitment strategy is

a. Resume
b. Reputation
c. Records
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. In choosing a job, the best place to look is

a. Newspaper announcement
b. Online
c. Referral
d. Own geographic area
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The following are ways to look for a job. SATA

a. Posting Online on general job search / on nurse-specific referral sites
b. Employee Referrals
c. Advertising in Professional Journals
d. Attendance at Professional Conventions, Job Fairs, Career Days
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The 4P’s of marketing includes the following, except.

a. Product
b. Place
c. Peace
d. Promotion
ANSWER: ________

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Education (Department of Nursing) 11 of 13
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The following are the contents of job description. SATA

a. Contact information
b. Job summary
c. Qualification Requirements
d. Job Relationships
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 12 of 13
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT Muddiest Point

This activity is to evaluate what you learned after the discussion and the activity.
In today’s session, what was least clear to you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 13 of 13
 Nursing Leadership and Management

STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR

Session # 19

LESSON TITLE: DIRECTING/DELEGATION Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define directing; Sullivan, E. J. (2009), Effective Leadership and
2. Enumerate the elements of directing; Management in Nursing (7th edition). Singapore:
3. Describe how delegation involves responsibility, Pearson Education South Asia Pte Ltd.
accountability, and authority; and,
4. Describe how to be an effective delegator.

LESSON PREVIEW/REVIEW
Based on the previous lesson, give the 4 elements of recruiting strategy:
1.
2.
3.
4.

MAIN LESSON

DIRECTING
- Process of getting the organization’s work done.
- The issuance of orders, assignments, and instructions that enable the nursing personnel to understand what are expected
of them.
l 2 Types:
ü Written - memorandum
ü Verbal

Elements of Directing
1. Delegation
2. Supervision
3. Communication
4. Coordination
5. Staff Development
6. Decision Making

DEFINING DELEGATION
Delegation is the process by which responsibility and authority for performing a task (function, activity, or decision) is
transferred to another individual who accepts that authority and responsibility. Although the delegator remains accountable
for the task, the delegate is also accountable to the delegator for the responsibilities assumed. Delegation can help others to
develop or enhance their skills, promotes teamwork, and improves productivity. Delegation skills can be learned.

RESPONSIBILITY AND ACCOUNTABILITY

Although responsibility and accountability are often used synonymously, the two words represent different concepts that
go hand in hand. Responsibility denotes an obligation to accomplish a task, whereas accountability is accepting
ownership for the results or lack thereof. Responsibility can be transferred, but accountability is shared.
You can delegate only those tasks for which you are responsible. If you have no direct responsibility for the task, then
you can't delegate that task. For instance, if a manager is responsible for filling holes in the staffing schedule, the manager
can delegate this responsibility to another individual. However, if staffing is the responsibility of a central coordinator, the
manager can make suggestions or otherwise assist the staffing coordinator, but cannot delegate the task.

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 Likewise, if an orderly who is responsible for setting up traction is detained and a nurse asks a physical therapist on the
unit to assist with traction, this is not delegation, because setting up traction is not the responsibility of the nurse. However,
if the orderly (the person responsible for the task) had asked the physical therapist to help, this could be an act of delegation
if the other principles of delegation are met.

AUTHORITY
Along with responsibility, you must transfer authority. Authority is the right to act. Therefore, by transferring authority, the
delegator is empowering the delegate to accomplish the task. Too often this principle of delegation is neglected. Nurses
retain authority, crippling the delegate's abilities to accomplish the task, setting the individual up for failure, and minimizing
efficiency and productivity. This pitfall is discussed later in the chapter.

DIFFERENTIATING DELEGATION FROM ASSIGNMENT

Delegation is often confused with work allocation. Delegation involves transfer of responsibility and authority. In
assignment no transfer of authority occurs. Instead, assignments are a bureaucratic function that reflect job descriptions and
patient or organizational needs. Effective delegation benefits the delegator, the delegate, and the organization.

DELEGATION VERSUS DUMPING

You should delegate because it is the best use of time, both yours and the delegates, not to dump an undesirable task or
to reward a productive employee with even more work. Managers can role model this behavior, and they can teach their staff
to do likewise. One way is to have RNs and UAPs exchange part of a shift with each other (Cohen, 2004). Of course UAPs
cannot do RNs' work, but they can learn what all is involved when nurses give medications, for example. Similarly, RNs can
learn how UAPs handle delegation from several nurses, possibly simultaneously. Trying to accomplish those tasks could
bring a new-found appreciation for the work of UAPs. Role modeling delegation and giving staff opportunities to experience
delegation from another's point of view can improve the work of the team.

BENEFITS OF DELEGATION
BENEFITS TO THE NURSE
Nurses also benefit from delegation. If the nurse is able to delegate some tasks to UAPs, more time can be devoted to those
tasks that cannot be delegated, especially complex patient care. Thus, patient care is enhanced, the nurse's job satisfaction
increases, and retention is improved.
Nancy, RN, has three central line dressing changes to complete as well as transfer two patients to another unit before
the end of shift in 1 hour. Nancy delegates the transfer duties to Shelley, LPN, and completes the central line dressing
changes.

BENEFITS TO THE DELEGATE

The delegate also benefits from delegation. The delegate gains new skills and abilities that can facilitate upward mobility. In
addition, delegation can bring trust and sup-port, and thereby build self-esteem and confidence. Subsequently, job
satisfaction and motivation are enhanced as individuals feel stimulated by new challenges. Morale improves; a sense of
pride and belonging develops as well as greater awareness of responsibility. Individuals feel more appreciated and learn to
appreciate the roles and responsibilities of others, increasing cooperation and enhancing teamwork.

BENEFITS TO THE MANAGER

Delegation also yields benefits for the manager. First, if staff are using UAPs appropriately, the manager will have a better
functioning unit. Also the manager may be able to delegate some tasks to staff members and devote more time to
management tasks that cannot be delegated. With more time available, the manager can develop new skills and abilities,
facilitating the opportunity for career advancement.

BENEFITS TO THE ORGANIZATION

As teamwork improves, the organization benefits by achieving its goals more efficiently. Overtime and absences decrease.
Subsequently, productivity increases, and the organization's financial position may improve. As delegation increases
efficiency, the quality of care improves. As quality improves, patient satisfaction increases.

THE DELEGATION PROCESS

The delegation process has five steps:
1. Define the task. Delegate only an aspect of your own work for which you have responsibility and authority. These
include:
• Routine tasks
• Tasks for which you do not have time
• Tasks that have moved down in priority
Define the aspects of the task. Ask yourself:

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 • Does the task involve technical skills or cognitive abilities?
• Are specific qualifications necessary?
• Is performance restricted by practice acts, standards, or job descriptions?
• How complex is the task?
• Is training or education required?
• Are the steps well defined, or are creativity and problem solving required?
• Would a change in circumstances affect who 3 could perform the task?
While you are trying to define the complexity of the task and its components, it is important not to fall into the trap of
thinking no one else is capable of performing this task. Often others can be prepared to perform a task through education
and training. The time taken to prepare others can be recouped many times over. Also know well the task to be delegated.
An alternative would be to subdivide the task into component parts and delegate the components congruent with the
available delegate's capabilities. For example, developing a budget is a managerial responsibility that cannot be delegated,
but someone else could explore the types of tympanic thermometers on the market, their costs, advantages, and so on. A
committee of staff nurses could evaluate the options and make a recommendation that you could include in the budget
justification.
But how do you know what should not be delegated?
Before a task is delegated, determine what areas of authority and what resources you control to achieve the expected
results. A unit manager who is responsible for maintaining adequate supplies needs budget authority. The authority to
spend money on supplies, however, may be limited to a specific amount for specific supplies or may be allocated to supplies
in general.
Certain tasks should never be delegated. Discipline should not be delegated nor should a highly technical task. Also any
situation that involves confidentiality or controversy should not be delegated to others.
2. Decide on delegate. Match the task to the individual. Analyze individuals' skill levels and abilities to evaluate their
capability to perform the various tasks; also determine characteristics that might prevent them from accepting
responsibility for the task. Conversely experience and individual characteristics, such as initiative, intelligence, and
enthusiasm, can expand the individual's capabilities. A rule of thumb is to delegate to the lowest person in the
hierarchy who has the requisite capabilities and who is allowed to do the task legally and by organizational policy.
Next determine availability. For example, Su Ling might be the best candidate, but she leaves for vacation
tomorrow and won't be back before the project is due. Then ask who would be willing to assume responsibility.
Delegation is an agreement that is entered into voluntarily.
3. Determine the task. The next step in delegation is to clearly define your expectations for the delegate. Also plan
when to meet. Attempting to delegate in the middle of a crisis is not delegation; that is directing. Provide for enough
time to describe the task and your expectations and to entertain questions. Also, meet in an environment as devoid
of distractions as possible.
Key behaviors in delegating tasks are:
a. Describe the task using "I" statements, such as "I would like . . ." and appropriate nonverbal behaviors—open body
language, face-to-face positioning, and eye contact. The delegate needs to know what is expected, when the task
should be completed, and where and how, if that is appropriate. The more experienced delegates may be able to
define for themselves the where and how. Decide whether written reports are necessary or if brief oral reports are
sufficient. If written reports are required, indicate whether tables, charts, or other graphics are necessary. Be
specific about reporting times. Identify critical events or milestones that might be reached and brought to your
attention. In patient care tasks, it also important to determine who has responsibility and authority to chart certain
tasks; UAPs can enter vital signs, but if they observe changes in patient status, the RN must investigate and chart
her assessment.
b. Describe the importance to the organization, you, the patient, and the delegate. Provide the delegate with an
incentive for accepting both the responsibility and the authority to do the task.
c. Clearly describe the expected outcome and the timeline for completion. Establish how closely the assignment will
be supervised. Monitoring is important because you remain accountable for the task, but controls should never
limit an individual's opportunity to grow.
d. Identify any constraints for completing the task or any conditions that could change. For example, you may ask an
assistant to feed a patient for you as long as the patient is coherent and awake, but you would feed the patient if he
were confused.
e. Validate understanding of the task and your expectations by eliciting questions and providing feedback.
4. Reach agreement. Once you have outlined your expectations, you must be sure that the delegate agrees to
accept responsibility and authority for the task. You need to be prepared to equip the delegate to complete the task
successfully. This might mean providing additional information or resources or informing others about the
arrangement as needed to empower the delegate. Before meeting with the individual, anticipate areas of
negotiation, and identify what you are prepared and able to provide.
5. Monitor performance and provide feedback. Monitoring performance provides a mechanism for feedback and
control that ensures that the delegated tasks are carried out as agreed. Give careful thought to monitoring efforts

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 when objectives are established. When defining the task and expectations clearly establish the where, and how.
Remain accessible. Support builds confidence and reassures the delegate of your interest in the delegate and
negates any concerns about dumping undesirable tasks.
Monitoring the delegate too closely, however, conveys distrust. Analyze performance with respect to the
established goal. If problem areas are identified, privately investigate and explain the problem, provide an opportunity
for feedback, and inform the individual how to correct the mistake in the future. Provide additional support as needed.
Also, be sure to give the praise and recognition due, and don't be afraid to do so publicly.

ACCEPTING DELEGATION
When you accept delegation, it is important to understand what is being asked of you. First acknowledge , the delegator's
confidence in you, but realistically examine whether you have the skills and abilities for the task and the time to do it. If you
do not have the skills, you must inform the delegator. However, it does not mean you cannot accept the responsibility. See
whether the person is willing to train or otherwise equip you to accomplish the task. If not, then you need to refuse the offer.
Accepting delegation means that you accept full responsibility for the outcome and its benefits or liabilities. Just as the
delegator has the option to delegate parts of a task, you also have the option to negotiate for those aspects of a task you feel
you can accomplish. Recognize, however, that this may be an opportunity for growth. You may decide to capitalize on it,
obtaining new skills or resources in the process.
Once you agree on the role and responsibilities you are to assume, make sure you are clear on the time frame, feedback
mechanisms, and other expectations. Don't assume anything. As a minimum, repeat to the delegator what you heard said;
better yet, outline the task in writing.
Throughout the project, keep the delegator informed. Report any concerns you have as they come up. Foremost,
complete the task as agreed. Successful completion can open more doors in the future.
If you are not qualified or do not have the time, do not be afraid to say no. Thank the delegator for the offer and clearly
explain why you must decline at this time. Express your interest in working together in the future.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. This is defined as the issuance of orders, assignments, and instructions that enable the nursing personnel to understand
what are expected of them.
a. Planning
b. Organizing
c. Directing
d. Controlling
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The two types of directing are the following, except?

a. Written
b. Verbal
c. None of the above
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. A memorandum is an example of which type of directing?

a. Written
b. Verbal
c. None of the above
d. All of the above
ANSWER: ________

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 RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. The following are the elements if directing. SATA.

a. Delegation
b. Supervision
c. Communication
d. Coordination
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. The process by which responsibility and authority for performing a task (function, activity, or decision) is transferred to
another individual.
a. Directing
b. Delegation
c. Accountability
d. Responsibility
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. With the delegated task, who is accountable?

a. Delegator
b. Delegate
c. Nurse Manager
d. None
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. This denotes an obligation to accomplish a task

a. Directing
b. Delegation
c. Accountability
d. Responsibility
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Defined as accepting ownership for the results or lack thereof

a. Directing
b. Delegation
c. Accountability
d. Responsibility
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The right to act is

a. Authority
b. Accountability
c. Directing
d. Delegation

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 ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Which of the following is the correct process of delegation?

a. Define the task -- Determine the task -- Decide on delegate -- Reach agreement -- Monitor performance and
provide feedback
b. Define the task -- Decide on delegate -- Determine the task -- Reach agreement -- Monitor performance and
provide feedback
c. Determine the task -- Decide on delegate -- Define the task -- Reach agreement -- Monitor performance and
provide feedback
d. Define the task -- Decide on delegate -- Determine the task -- Monitor performance and provide feedback --
Reach agreement
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what you learned after the discussion and the activity.

1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as you end this session?

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 Nursing Leadership and Management)
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 20

LESSON TITLE: DELEGATION Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Describe how delegation involves responsibility, Sullivan, E. J. (2009), Effective Leadership and
accountability, and authority; Management in Nursing (7th edition). Singapore:
2. Describe how to be an effective delegator; Pearson Education South Asia Pte Ltd.
3. Identify obstacles that can impede effective delegation; and,
4. Explain how liability affects delegation.

LESSON PREVIEW/REVIE
Based on the previous lesson, give the process of delegation:

MAIN LESSON

OBSTACLES TO DELEGATION
Although delegation can yield many benefits, there are potential barriers. Some barriers are environmental; others are the
result of the delegator's or delegate's beliefs or inexperience (Table below).

Potential Obstacles to Delegation

ENVIRONMENTAL DELEGATOR DELEGATE
Practice acts Lack of trust and confidence Inexperience
Standards Believe others incapable Fear of failure and reprisal
Job descriptions Believe self indispensable Lack of confidence
Policies Fear of competition Overdependence on others
Organizational structure Fear of criticism Avoidance of responsibility
Management styles Fear of liability
Norms Fear of blame for others' mistakes
Resources Fear of loss of control
Fear or overburdening
Fear of decreased job satisfaction
Insecurity
Inexperience in delegation
Inadequate organizational skills

A NONSUPPORTIVE ENVIRONMENT
Organizational Culture
The culture within the organization may restrict delegation. Hierarchies, management styles, and norms may all
preclude delegation. Rigid chains of command and autocratic leadership styles do not facilitate delegation and rarely
provide good role models. The norm is to do the work oneself because others are not capable or skilled. An atmosphere of
distrust prevails as well as a poor tolerance for mistakes. A norm of crisis management or poorly defined job descriptions or
chains of command also impede successful delegation.

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Education (Department of Nursing) 1 of 8
 Personal Qualities
Poor communication and interpersonal skills can also be a barrier to delegation. Thomas and Hume (1998) note that in
addition to good communication skills and a respecting and treating staff fairly, willingness to work with the other, to be open
to suggestions, to provide feedback and acknowledgment for work well done is essential. They also note that delegates
must be reliable and willing to follow instructions.
Resources
Another difficulty frequently encountered is a lack of resources. For example, there may be no one to whom you can
delegate. Consider the sole registered nurse in a skilled nursing facility. If practice acts define a task as one that only a
registered nurse can perform, there is no one else to whom that nurse can delegate that task.
Financial constraints also can interfere with delegation. For instance, someone from your department must attend the
annual conference in your nursing specialty area. However, the organization will only pay the manager's travel and
conference expenses, which precludes anyone else from attending.
Educational resources may be another limiting factor. Perhaps others could learn how to do a task if they could practice
with the equipment, but the equipment or a trainer is not available.
Time can also be a limiting factor. For example, it is Friday and the schedule needs to be posted Monday. No one on
your staff has experience developing schedules and you need to go out of town for a family emergency, so there is no one
else to do the schedule.

AN INSECURE DELEGATOR
The majority of the barriers to delegation arise from the delegator. Reasons people give to fail to delegate include:
"I can do it better."
"I can do it faster."
"I'd rather do it myself."
"I don't have time to delegate."
Often underlying these statements are erroneous beliefs, fears, and inexperience in delegation. Certainly, the
experienced person can do the task better and faster. Indeed, delegation takes time, but failing to delegate is a time waster.
Time invested in developing staff today is later repaid many times over. Common fears are:
• Fear of competition or criticism. What if someone else can do the job better or faster than I? Will I lose my job? Be
demoted? What will others think? Will I lose respect and control? This fear is unfounded if the delegator has selected the
right task and matched it with the right individual. In fact, the delegate's success in the task provides evidence of the
delegator's leadership and decision-making abilities.
• Fear of liability. Some individuals are not risk takers and shy away from delegation for this reason. There are risks
associated with delegation, but the delegator can minimize these risks by following the steps of delegation. A related
concern is selecting the task and delegate, then the responsibility for any mistakes made are solely those of the delegate; it
is not necessary to take on guilt for another's mistakes.
To help keep this issue in perspective, it is important to recall the benefits of delegation and balance the rewards with the
risks while making the delegation decision. Managers really need to clearly delineate what tasks can be delegated and to
whom. Additionally, RNs, LPNs and UAPs need to understand what tasks can be delegated under the state's nurse practice
act as well as abiding by organizational policies. RNs often fear blame from management if something goes wrong when a
task has been delegated to an LPN or UAP, but those fears can be relieved if state law, organizational policies, and job
descriptions are followed.
• Fear of loss of control. Will I be kept informed? Will the job be done right? How can I be sure? The more one is
insecure and' inexperienced in delegation, the more this fear is an issue. This is also a predominant concern in individuals
who tend toward autocratic styles of leadership and perfectionism. The key to retaining control is to clearly identify the task
and expectations and then to monitor progress and provide feedback.
• Fear of overburdening others. They already have so much to do; how can I suggest more? Everyone has work to do.
Such a statement belittles the decisional capabilities of others. Recall that delegation is a voluntary, contractual agreement;
acceptance of a delegated task indicates the availability and willingness of the delegate to perform the task. Often, the
delegate welcomes the diversion and stimulation, and what the delegator perceives as a burden is actually a blessing. The
onus is on the delegator to select the right person for the right reason.
• Fear of decreased personal job satisfaction. Because the type of tasks recommended to delegate are those that
are familiar and routine, the delegator's job satisfaction should actually increase with the opportunity to explore new
challenges and obtain other skills and abilities.
Additional hindrances to delegation include inadequate organizational skills, such as poor time management, and
inexperience in delegation.

AN UNWILLING DELEGATE
Inexperience and fear of failure can motivate a potential delegate to refuse to accept a delegated task. Much
reassurance and support are needed. In addition, the delegate should be equipped to handle the task. If proper selection
criteria are used and the steps of delegation followed, then the delegate should not fail. The delegator can boost the

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Education (Department of Nursing) 2 of 8
delegate's lack of confidence by building on simple tasks. The delegate needs to be reminded that everyone was
inexperienced at one time. Another common concern is how mistakes will be handled. When describing the task, the
delegator should provide clear guidelines for handling problems, guidelines that adhere to organizational policies.
Another barrier is the individual who avoids responsibility or is over dependent on others. Success breeds success;
therefore, it is important to use an enticing incentive to engage the individual in a simple task that guarantees success.

INEFFECTIVE DELEGATION
When the steps of delegation are not followed or barriers remain unresolved, delegation is often ineffective. Inefficient
delegation can result from unnecessary duplication, underdelegation, reverse delegation, and overdelegation.

UNNECESSARY DUPLICATION
If staff are duplicating the work of others, related tasks may have been given to too many people (Barter, 2002). To avoid
unnecessary duplication, try to delegate associated tasks to as few people as possible. This allows the person to complete
the assignment without spending time negotiating with others about which task should be done by which person. Also
reporting is simplified for both the delegate and the delegator.
To prevent work duplication, Barter (2002, p. 57) suggests that you ask:
• How often does staff duplicate an activity that someone else has recently performed?
• Why does this duplication occur and is it necessary?
• How could nurses delegate to prevent duplication?

UNDERDELEGATION
Underdelegation occurs when
• The delegator fails to transfer full authority to the delegate;
• The delegator takes back responsibility for aspects of the task; or
• The delegator fails to equip and direct the delegate.
As a result, the delegate is unable to complete the task, and the delegator must resume responsibility for its completion.
Sharon, RN, is a school nurse with three separate buildings under her direction. UAPs, called health clerks, operate in
the school health office when Sharon is at another building. Joye, a first year health clerk, has had minimal medication
administration instruction and experience. During the first week of school, Joye tries to "speed up" the medication
administration process and sets out all of the noon medications in individual, unlabeled cups for the students. The cups are
rearranged by students trying to find their meds and Joye cannot identify what meds belong to which students. Sharon is
called back to the school to administer the correct medications, students are late to class, and Joye is frustrated that she
couldn't handle the task.

REVERSE DELEGATION
In reverse delegation, someone with a lower rank delegates to someone with more authority.
Thomas is a nurse practitioner for the burn unit. He recently arrived on the unit to find several patients whose dressing
changes have not been completed due to a code situation earlier in the morning. Dawn, LPN asks Thomas to complete a
few dressing changes to help the staff complete dressing changes before physician rounds begin.

OVERDELEGATION
Overdelegation occurs when the delegator loses control over a situation by providing the delegate with too much
authority or too much responsibility. This places the delegator in a risky position, increasing the potential for liability.
Ellen, GPI, is in her sixth week of orientation in the trauma ICU. Her mentor, Dolores, RN, notes that Mr. Anderson is
scheduled for an MRI off the unit. Dolores delegates the task of escorting Mr. Anderson to the MRI unit. Ellen is not ACLS
certified. During the MRI, Mr. Anderson is accidentally extubated and suffers respiratory and cardiac arrest. A code is called
in the MRI suite and ER nurses must respond since an ACL.S certified nurse is not with the Patient.

LIABILITY AND DELEGATION

Fear of liability often keeps nurses from delegating. State nurse practice acts determine the legal parameters for practice,
professional associations set practice standards, and organizational policy and job descriptions define delegation
appropriate to the specific work setting,
Also several guidelines can help. The National Council of State Boards of Nursing (2007) identified the five rights of
delegation:
• Right task (task is one that can be delegated for specific patient)
• Right circumstances (setting is appropriate and resources are available)
• Right person (give the right task to the right delegate for the right patient)
• Right direction and communication (describe objectives, limits, and expectations)
• Right supervision (monitor, evaluate, give feedback, and intervene if necessary)

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Education (Department of Nursing) 3 of 8
 In addition, the American Nurses Association and the National Council of State Boards of Nursing issued a joint
statement on delegation to explain both the profession's practice guidelines and the legal requirements for delegation (ANA
& NCSBN, 2006). Figure 10-1• shows a decision tree for delegation from the joint statement.

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Education (Department of Nursing) 4 of 8
Figure 10-1 Decision tree for delegation to nursing assistive personnel. Adapted from National Council State
Boards of Nursing. (2006). Joint statement on delegation,. Retrieved December 2007 from
www.ncsbn.org/Joint_statement.pdf

One situation that may present a challenge to the manager is when the staff receives written or verbal orders from a
physician's office nurse (Austin, 2004). The same legal guidelines for the nurse giving the orders apply to the staff receiving
them. If the nurse's license allows prescribing privileges, such as a nurse practitioner, the staff can accept appropriate
orders. Otherwise, the orders must also be verified by the prescribing physician. The staff put their own licenses in jeopardy
if not.
Delegation is a skill that can be learned. Like other skills, delegating successfully requires practice. Sometimes it seems
it might be easier to do it yourself. But it is not. Once you learn how to delegate, you will extend your ability to accomplish
more by using others' help. No one in health care today can afford not to delegate.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice
1. The following are potential environmental obstacles to delegation, except.
a. Standards
b. Job descriptions
c. Insecurity
d. Norms
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is a potential obstacle on the delegator?

a. Management styles
b. Lack of trust
c. Fear of failure and reprisal
d. Fear of failure and reprisal
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. The following are the possible obstacles on the delegate. Select all that apply:
a. Inexperience
b. Fear of failure and reprisal
c. Lack of confidence
d. Overdependence on others
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Which of the following statements if made by the delegator indicates her/his fear of criticism?
a. Will the job be done right?
b. They already have so much to do; how can I suggest more?
c. Will I be kept informed?
d. What will others think?
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

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Education (Department of Nursing) 5 of 8
5. RNs often fear blame from management if something goes wrong when a task has been delegated to an LPN or UAP, to
avoid this, the following should be followed. Except.
a. State law
b. Organizational policies
c. Job descriptions
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Which of the following questions will least likely to prevent work duplication?
a. Is the delegate willing to accept the task?
b. How often does staff duplicate an activity that someone else has recently performed?
c. Why does this duplication occur and is it necessary?
d. How could nurses delegate to prevent duplication?
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The following are the reason uderdelegation occurs, except.

a. The delegator fails to transfer full authority to the delegate;
b. The delegator takes back responsibility for aspects of the task; or
c. The delegator fails to equip and direct the delegate.
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Reverse delegation means

a. Someone with a higher rank delegates to someone with lesser authority
b. Someone with a lower rank delegates to someone with more authority
c. Delegation with same ranks
d. Delegation with a different medical professional
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The following are the five rights of delegation. Select all that apply:
a. Right task
b. Right circumstances
c. Right person
d. Right direction and communication
e. Right time
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Who among the following identified the five rights of delegation?
a. American Nurses Association
b. World Health Organization
c. National Council of State Boards of Nursing
d. Association of Nursing Service Administrators of the Philippines
ANSWER: ________

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Education (Department of Nursing) 6 of 8
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 7 of 8
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 21

LESSON TITLE: SUPERVISION/NURSING CARE Materials:

ASSIGNMENT AND MOTIVATION
Book, pen and notebook, and index card/class list
LEARNING OUTCOMES:
References:
Upon completion of this lesson, the nursing student can:
Sullivan, E. J. (2009), Effective Leadership and
1. Define supervision; Management in Nursing (7th edition). Singapore:
2. Enumerate the principles and technique in supervision; Pearson Education South Asia Pte Ltd.
3. Discuss the four basic methods of nursing care assignment;
4. Describe how motivation and ability affect job performance;
5. Describe how different theories explain motivation; and,
6. Discuss how different theories explain learning;

LESSON PREVIEW/REVIEW

Based on the previous lesson, list down three potential obstacles to delegation in the environment, delegator and delegate:

1.
2.
3.

MAIN LESSON

SUPERVISION
- Providing guidelines for the accomplishment of task or activity with initial direction and periodic inspection of the actual
accomplishment of the task or activity.

PRINCIPLES OF GOOD SUPERVISION

1. Requires adequate planning & organization which facilitate cooperation, coordination & synchronization of
services.
2. Gives autonomy to workers depending on their competency, personality, & commitment.
3. Stimulates the worker’s ambition to grow into effectiveness.
4. Creates an atmosphere of credibility and trust.
5. Considers the strengths & weaknesses of employees.
6. Strives to make the unit an effective learning situation.
7. Considers equal distribution of work considering age, physical condition and competence.

TECHNIQUES IN SUPERVISION
1. Observation of the worker while making rounds.
2. Spot checking of charts through nursing audits.
3. Asking every patient about the care they receive.
4. Looking into the general condition of units.
5. Getting feedback from co-workers or other supervisors or relatives.
6. Asking questions discretely to find out the problems they encounter in the wards or drawing out suggestions from
the workers for improvement of their work or work situation.

NURSING CARE ASSIGNMENT

May be called by various terms:
ü Modalities of Nursing Care
ü Systems of Nursing Care
ü Patterns of Nursing Care

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Education (Department of Nursing) 1 of 11
ü Styles of Nursing Care
Basic methods used:
1. Functional Nursing
2. Total Patient Care / Case Method
3. Team Nursing
4. Primary Nursing

FUNCTIONAL NURSING
Functional nursing, also called task nursing, began in hospitals in the mid -1940s in response to a national nursing
shortage. The number of registered nurses (RNs) serving in the armed forces during World War II depleted the supply of
nurses at home. As a result of this loss of RNs, the composition of nursing staffs in hospitals changed. Staff that had been
composed almost entirely of RNs gave way to the widespread use of licensed practical nurses (LPNs) and unlicensed
assistive personnel (UAPs) to deliver nursing care.
In functional nursing, 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.

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Education (Department of Nursing) 2 of 11
 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:
• The time 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.
• 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 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. During the 1920s, total patient care was the typical
nursing care delivery system. Student nurses often staffed hospitals, whereas RNs provided total care to the patient at
home. 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.

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Education (Department of Nursing) 3 of 11
 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.
Although the concept of 24-hour accountability is rig worthwhile, it is a fallacy. When primary nursing was first
implemented, many organizations perceived that it required an all—RN staff. This practice was viewed as not only
expensive but also ineffective because many tasks could be done by less skilled persons. As a result, many hospitals
discontinued the use of primary nursing. Other hospitals successfully implemented primary nursing by identifying one nurse
who was assigned to coordinate care and with whom the family and physician could communicate, and other nurses or
unlicensed assistive personnel assisted this nurse in providing care.

EMPLOYEE MOTIVATION
Motivation describes the factors that initiate and direct behavior. Because individuals bring to the workplace different needs
and goals, the type and intensity of motivators vary among employees. Nurse managers prefer motivated employees
because they strive to find the best way to perform their jobs. Motivated employees are more likely to be productive than are
nonmotivated workers. This is one reason that motivation is an important aspect of enhancing employee performance.

MOTIVATIONAL THEORIES
Historically, motivational theories were concerned with three things:
1. What mobilizes or energizes human behavior
2. What directs behavior toward the accomplishment of some objective

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Education (Department of Nursing) 4 of 11
 3. How such behavior is sustained over time
The usefulness of motivational theories depends on their ability to explain motivation adequately, to predict with some
degree of accuracy what people will actually do, and, finally, to suggest practical ways of influencing employees to
accomplish organizational objectives. Motivational theories can be classified into at least two distinct groups: content
theories and Process theories.

Content Theories
In general, content theories emphasize individual needs or the rewards that may satisfy those needs. There are two types
of content theories: instinct and need. Instinct theorists characterized instincts as inherited or innate tendencies that
predisposed individuals to behave in certain ways. These theories were attacked for their difficulty in pinpointing the specific
motivating behaviors and the acute awareness of the variability in the strengths of instincts across individuals. In addition,
the development of need theories supported the concept that motives were learned behaviors.

Process Theories
Whereas content theories attempt to explain why a person behaves in a particular manner, process theories emphasize
how the motivation process works to direct an individual's effort into performance. These theories add another dimension to
the manager's understanding of motivation and help to predict employee behavior in certain circumstances. Examples of
process theories are reinforcement theory, expectancy theory, equity theory, and goal-setting theory.
Reinforcement theory, also known as behavior modification, views motivation as learning (Skinner, 1953). According
to this theory, behavior is learned through a process called operant conditioning, in which a behavior becomes associated
with a particular consequence. In operant conditioning, the response–consequence connection is strengthened over time
that is, it is learned. Consequences may be positive, as with praise or recognition, or negative. Positive reinforcers are used
for the express purpose of increasing a desired behavior.

Kyle, a staff nurse, offered a creative idea to redesign work flow on the unit. His manager supported the idea and helped
Kyle implement the new process. In addition, the manager praised Kyle for the extra effort and publicly recognized him for
the idea. Kyle was encouraged by the outcome and sought other solutions to work-flow problems.

Negative reinforcers are used to inhibit an undesired behavior. Punishment is a common technique.

To get Rose to chart adequately, the manager required her to come to his office daily with her patient charts until she
achieved an acceptable level of charting. Rose found the task laborious and humiliating. As a result, Rose soon was
charting appropriately.
Because punishment is negative in character, an employee may fail to improve and also may avoid the manager and the
job, as well. Research has shown that the effects of punishment are generally temporary. Undesirable behavior will be
suppressed only as long as the manager monitors the situation and the threat of punishment is present. Conversely,
research has demonstrated that positive reinforcement is the best way to change behavior.

Extinction is another technique used to eliminate negative behavior. By removing a positive reinforcer, undesired behavior
is extinguished.

Consider the case of Jasmine, a chronic complainer. To curb this behavior, her manager chose to ignore her many
complaints and not try to resolve them. Initially jasmine complained more, but eventually she realized her behavior was not
getting the desired response and stopped complaining.

A problem with operant conditioning (behavior modification) is that there is no sure way to elicit the desired behavior so
that it can be reinforced. In addition, staff and the manager may view consequences differently.

Take Thad, for example. As a new employee, Thad conscientiously completed critical paths for his assigned patients.
When the manager recognize Thad for his good work, his peers began to exclude him from the group. Although the
manager was attempting positive reinforcement, Thad quit completing critical paths because he felt the manager had
alienated him from his coworkers.

Another procedure is shaping. Shaping involves slelectively reinforcing behaviors that are successively closer
approximations to the desired behavior. Each successively closer approximation to the desired behavior is reinforced and
well established before progressive reinforcement is given to closer approximations of the desired behavior. When people
become clearly aware that desirable rewards are contingent on a specific behavior, their behavior will eventually change.
Behavior modification works quite well, provided that rewards can be found that, in fact, employees see as positive
reinforcers and provided that supervisory personnel can control such rewards or make them contingent on performance.

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Education (Department of Nursing) 5 of 11
This does not mean that all rewards work equally well or that the same rewards will continue to function effectively over a
long time. If someone is praised four or five times a day every day, the praise would soon begin to wear thin; it would cease
to be a positive reinforcer. Care must be taken not to overdo a good thing.
Figure 17-1 illustrates the use of various schedules of reinforcement. Partial schedules of reinforcement, reinforcing
behavior with every second or third occurrence, is more effective in changing behavior. This fixed-ratio schedule of
reinforcement requires very close monitoring to reinforce every nth response and is obviously not very practical. Reinforcing
on a fairly regular basis is known as a fixed-interval schedule of reinforcement; an example is the distribution of weekly or
monthly paychecks.
A continuous schedule of reinforcement is the fastest method of establishing or learning a new behavior, whereas any
kind of partial schedule of reinforcement is a much slower. On the other hand, behaviors learned under a continuous
schedule also extinguish very quickly once reinforcement stops. Behavior learned on a partial schedule continues for a
much longer time without being reinforced. In addition, continuous schedules of reinforcement are probably better when
money is used rather than other reinforcers, such as praise.
Like reinforcement theory, expectancy theory (Vroom, 1964) emphasizes the role of rewards and their relationship to
the performance of desired behaviors. Expectancy theory regards people as reacting deliberately and actively to their
environment.
Vroom asserts that individuals are motivated by their expectancies (beliefs) about future outcomes (consequences of
behavior) and by the value they place on those outcomes. Three components are important in predicting what and how
much effort a person will exert:

Interval Ratio
Fixed Interval Fixed Ratio
Reinforcer given after a Reinforcer given after a
given time given number of behavior
Weekly or monthly occurrences
Fixed paychecks Piece rate pay
Regularly scheduled exams Commissions sales people;
certain amount is given for
each dollar of sales
Variable Interval Variable Ratio
Reinforcer given at random Reinforcer given after a
times random number of behavior
Occasional praise by boss occurrences
on unscheduled visits Random quality checks with
Variable Unspecified number of pop praise for zero defects
quizzes to students Commissioned salespeople;
a varying number of calls is
required to obtain a given
sale
Time based Behavior occurrence based

Figure 17-1 Four Types of intermittent reinforcement schedules. From Organizational Behavior, 8th ed. (p. 107), by
J.R. Schemerhorn, J.G. Hunt, and R.N. Osborn, 2003, Hoboken, NJ: Wiley. Reprinted with permission.

1. Expectancy is the perceived probability that effort will result in successful performance, that is, the degree to which
people expect they "can do" something.
2. Instrumentality is the perceived probability that performance will lead to desired outcomes.
3. Valence is the perceived value (attractiveness or unattractiveness) of an outcome.

The net effect of these three components is the amount of effort an individual will exert. Thus, when any one component
is drastically reduced, so is motivation (effort). If staff members do not believe that they are capable of performing a task
(expectancy), or if they believe there is little chance of reward for their work (instrumentality), or if the value of the outcome
(valence) is low, motivation is reduced.
In an effort to improve the amount of delegation by the nurses on her unit, Andrea approached the situation from an
expectancy theory perspective. She identified that the nurses wanted to assign more duties to assistive personnel but were
reluctant because of concerns about liability. Once Andrea was able to clarify liability issues, the nurses were eager to
delegate non-professional tasks in order to be able to devote more time to their professional responsibilities.
Expectancy theory also considers multiple outcomes. Consider the possibility of a promotion to nurse manager. Even
though a staff nurse believes such a promotion is positive and is a desirable reward for competent performance in patient

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Education (Department of Nursing) 6 of 11
care, the nurse also realizes, that there are possibly some negative outcomes (e.g., working longer hours, losing the close
camaraderie enjoyed with other staff members). These multiple outcomes will influence the staff nurse's decision.
Expectancy theory is useful because of its clear managerial implications. First, managers can maximize expectancies
by assigning to employees tasks that they are capable of performing or by providing them with the necessary training. In
addition, removing obstacles (inadequate resources, lack of information. or cooperation from others) increases employees'
expectancies. Second, instrumentalities can be maximized by making certain that rewards (and punishment) are made
contingent on performance. Finally, rewards must be perceived as desirable enough to make the effort toward high
performance worthwhile. Similarly, to act as a successful deterrent to inappropriate job behavior, punishment must be
regarded as sufficiently undesirable.
Similarly, equity theory suggests that effort and job satisfaction depend on the degree of equity, or perceived fairness,
in the work situation (Adams, 1963, 1965). Equity simply means that a person perceives that one's contribution to the job is
rewarded in the same proportion that another person's contribution is rewarded. Job contributions include such things as
ability, education, experience, and effort, whereas rewards include job satisfaction, pay, prestige, and any other outcomes
an employee regards as, valuable.
Thus, equity theory is concerned with the conditions under which employees perceive their contributions to the job and
the rewards obtained as fair and equitable. Equity does not in any way imply equality; rather, it suggests that employees who
bring more to the job will receive greater rewards. Inequity occurs when an employee's effort and rewards are perceived to
be disproportional to that of another person, whether a coworker or a person doing a similar job for a different employer.
Inequity, then, motivates a change in behavior that may either increase or decrease actual effort and job performance.
However, reducing inequity may or may not change performance.
Employees can try to restore what they perceive as equity in a variety of ways. First, they can increase or decrease
effort. Nurses can attempt to increase their status by assuming more patient care assignments, spending more time on
charting, or exhibiting other behaviors reflecting additional effort. Second, they may attempt to persuade the people to whom
they are comparing themselves to increase or decrease their inputs persuading nursing assistants to work less, for instance.
Third, they may attempt to persuade the organization to change either their own rewards or those of the comparison persons
(e.g., salary changes or perquisites). Fourth, they may psychologically distort the perceived importance and value of their
own contributions and rewards ("How could they run this unit without me?"). Fifth, they may distort the perceived importance
and value of the comparison persons' contributions or rewards ("What can you expect of assistants?").
Psychologically distorting the perceptions of a comparison person's outcomes or inputs is probably the easiest way to
restore equity without actually changing one's effort. Alternatively, the staff member may select a different comparison
person, someone who is seen as more relevant for the comparison being made, such as the nurse manager. Finally, the
individual may actually leave the organization.
Perceived fairness of rewards affects the manner in which individuals view their jobs and the organization, and it can
affect the amount of effort they expend in accomplishing tasks. Moreover, evidence indicates that inequitable rewards,
especially underpayment inequity, lead to increased psychological tension, lower job satisfaction, and poor job
performance. In times of economic retrenchment, when no one in the organization receives a salary increase, employees,
for example, may perceive the situation as equitable if they believed it to be equitable prior to the retrenchment; thus, job
satisfaction may not be adversely affected. However, simply distributing rewards equitably does not necessarily improve an
otherwise poor motivational environment. In today's economic environment, with organizations being redesigned and
reengineered and positions reduced, problems with perceived equity can be anticipated.
Unlike expectancy theory and equity theory, goal-setting theory suggests that it is not the rewards or outcomes of task
performance per se that cause a person to expend effort, but rather the goal itself. There are three basic propositions in goal
setting (Locke, 1968):
1. Specific goals lead to higher performance than do such general goals as "Do your best."
2. Specific, difficult goals lead to higher performance than specific, easy goals, provided that those involved accept the
goals.
3. Incentives such as money, knowledge of results, praise and reproof, participation, competition, and time limits affect
behavior only if they cause individuals to change their goals or to accept goals that have been assigned to them.

Timothy was new to a home care hospice program. An important skill in care with the terminally ill is therapeutic
communication. Timothy and his manager recognized that he needed help to improve his skills in communicating with these
patients and their families. His manager asked him to write two goals related to communication. Timothy expressed a desire
to attend also indicated a communications workshop and also he would try at least one new communication technique each
week. Within a month, Timothy's therapeutic communication skills had already improved. As a result, Timothy was more
satisfied with his position, his patients received more compassionate care, and Timothy found his work more rewarding.

According to goal-setting theory, the function of rewards is to help ensure that the individual will accept an assigned goal
or to set a more specific, difficult personal goal. The specificity and difficulty of the goal mobilize energy and direct behavior
toward goal accomplishment. If the person sees tasks and duties as reasonable and specific, difficult goals are likely to
produce higher performance as long as such performance is rewarded and the individual is held accountable for the task.

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Education (Department of Nursing) 7 of 11
 Figure 17-2• Illustrates a simple model of how the various motivational theories are related. First, there is a task to be
accomplished. If this task is expressed in terms of a specific, difficult goal that is accepted by the staff member, a relatively
high degree of performance may realistically be expected in most situations. How does this happen? Goals, perceived
ability, and perceived situational constraints all combine to form the perceived likelihood that effort will lead to a given level
of performance or goal accomplishment. This expectancy, when combined with the belief that valued rewards will follow
from goal attainment (instrumentality), prompts the expenditure of effort (motivation). Thus, goal-setting and expectancy
theory suggest not only that staff members should know exactly what they should be doing, but also that they should
perceive rewards as contingent on performance of their assigned tasks.
Managers who are effective leaders draw from their knowledge of various motivational theories to create the
environment in which their staff derive needs satisfaction from the work itself. No motivation theory provides a complete
description of the motivational process; each theory or technique brings a different perspective and contribution to
understanding and influencing motivation. Effective staff motivation is best accomplished by judiciously combining theories
and techniques so that their effects are complementary.

EMPLOYEE ABILITY
Managers can arrange for staff to participate in development programs that upgrade the knowledge and skills of employees
as job requirements change and in special programs, such as intensive workshops and continuing education. The nurse
manager plays a crucial role in ongoing assessment and evaluation of employees, providing opportunities and
encouragement for their advancement and maintenance of abilities. In addition, the nurse manager is in the best position to
communicate the department's educational needs to the administration so that adequate resources are allocated for this
function.

Figure 17-2 Integrated model of the motivational process.

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Education (Department of Nursing) 8 of 11
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice
1. The following are the principle of good supervision. Select all that apply:
a. Requires adequate planning & organization which facilitate cooperation, coordination & synchronization of
services.
b. Gives autonomy to workers depending on their competency, personality, & commitment.
c. Stimulates the worker’s ambition to grow into effectiveness.
d. Creates an atmosphere of credibility and trust.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is not true on the techniques in supervision?

a. Observation of the worker while making rounds.
b. Spot checking of charts through nursing audits.
c. Asking one patient about the care they receive.
d. Looking into the general condition of units.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Nursing care assignment may also be called ___________.

a. Modalities of Nursing Care
b. Systems of Nursing Care
c. Patterns of Nursing Care
d. Styles of Nursing Care
e. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. What is the original model of nursing care delivery?

a. Functional nursing
b. Team nursing
c. Total patient care
d. Primary nursing
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. This nursing care assignment was designed to place the registered nurse back at the patient’s bedside.
a. Functional nursing
b. Team nursing
c. Total patient care
d. Primary nursing
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. The nursing care assignment hat began in hospitals in the mid -1940s in response to a national nursing shortage.

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Education (Department of Nursing) 9 of 11
 a. Functional nursing
b. Team nursing
c. Total patient care
d. Primary nursing
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Under this system, a team of nursing personnel provides total patient care to a group of patients.
a. Functional nursing
b. Team nursing
c. Total patient care
d. Primary nursing
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Which nursing care assignment is infrequently used in acute care facilities?

a. Functional nursing
b. Team nursing
c. Total patient care
d. Primary nursing
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. In team nursing, the following are the activities done by the team leader. Except.
a. Developing or updating nursing care plans
b. Resolving problems encountered by team members
c. Conducting nursing care conferences
d. Communicating with physicians only.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Total patient care delivery systems are typically used in which areas?
a. Critical care units
b. Post-anesthesia recovery area
c. All of the above
d. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________

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Education (Department of Nursing) 10 of 11
 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-sentence summary

This activity is to evaluate what you have learned after the discussion.
Write a one-sentence summary on why many hospitals discontinued the use of primary nursing.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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Education (Department of Nursing) 11 of 11
 Nursing Leadership and Management
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 22

LESSON TITLE: COMMUNICATION AND COORDINATION Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Identify the factors that influence communication; Sullivan, E. J. (2009), Effective Leadership and
2. Discuss how communication can be distorted and Management in Nursing (7th edition). Singapore:
misunderstood; Pearson Education South Asia Pte Ltd.
3. Choose which communication mode to use depending on
the message and the relationship;
4. Explain how communication strategies vary according to
the situation and those involved;
5. Determine how to communicate with difficult people;
6. Develop a plan to enhance your communication skills;
7. Explain why the goal of staff development should be to
transfer learning to the job;
8. Demonstrate how educational programs enhance the
organization’s effectiveness;
9. Develop a plan to improve your decision-making and
problem-solving skills;
10. Compare and contrast individual and collective
decision-making processes in various situations;
11. Identify different approaches that can be used to manage
conflict;
12. Explain how to manage conflict; and,
13. Discuss how to handle bullying.

LESSON PREVIEW/REVIEW

Give one motivational theory based on the previous lesson and briefly explain:

MAIN LESSON

COMMUNICATION
Communication is a complex, ongoing, dynamic process in which the participants simultaneously create shared meaning in
an interaction. The goal of communication is to approach, as closely as possible, a common understanding of the message
sent and the one received. At times, this can be difficult because both participants are influenced by past conditioning, the
present situation, each person's purpose in the current communication, and each person's attitudes toward self, the topic,
and each other. It is important that participants construct messages as clearly as possible, listen carefully, monitor each
other's response, and provide feedback.

PRINCIPLES OF COMMUNICATION
ü Clear lines of communication serve as the linking process by which parts of the organization are unified toward goal
achievement.
ü Simple, exact, & concise messages ensure understanding of the message to be conveyed.
ü Feedback is essential to effective communication. Mutual interaction is required.
ü Communication thrives best in a supportive environment which encourages positive values among its personnel.

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Education (Department of Nursing) 1 of 24
ü A manager’s communication skill is vital to the attainment of the goals of the organization.
ü Adequate & timely communication of work-related issues or changes that may affect jobs enhance compliance.

MODES OF COMMUNICATION
Messages may be oral (face-to-face, one-on-one, or in groups; by telephone; on voice mail) or written (hand-written or
typed) and sent by mail, e-mail, text, or fax.
The purpose of the message determines the best mode to use. In general, the more important or delicate the issue, the more
intimate the mode should be. Any difficult issue should be communicated face-to-face, such as terminating an individual’s
employment. Conflict or confrontation also is usually best handled in person so that the individual's response, especially
nonverbal signals (discussed later), can be seen and answered appropriately.
What mode to use depends on the level of intimacy required based on the person, your relationship, and the message.
The levels of intimacy, in descending order, are:
• in person
• on the telephone
• voice mail
• e-mail, instant messaging, or by texting
• memos, faxes, and written mail
Meeting someone face-to-face is the most intimate contact. The individual can see your face, your body movements,
and your words simultaneously. The telephone is slightly less intimate than in person communication. Tone of voice, for
instance, can be conveyed and may facilitate cooperation. Voice mail is the next level of communication. Voice mail is useful
to convey information that is not necessarily sensitive and may or may not require a reply. The time and place of an
upcoming meeting, for example can be communicated by, voice mail, which has the added advantage of avoiding "phone
tag." E-mail is useful for information similar to that conveyed by voice mail and, like some voice mail systems, can be
broadcast to large groups at once. The dates and times for a blood drive are a good example of a broadcast message.
Conveying complicated information that may require thought before the receiver replies is another value of using e-mail.
The level of formality of the communication also affects the mode used. Applying for a position requires a written format
even if the letter is e-mailed rather than mailed. The relationship between the sender and receiver also affects the mode. If a
staff nurse, for example, wants to nominate a coworker for an award given by the hospital board of directors, a written letter
or e-mail is required. Memos are less formal than written messages and can be e-mailed, faxed, or mailed.

DISTORTED COMMUNICATION
Oral messages are accompanied by a number of non-verbal messages known as metacommunications. These behaviors
include head or facial agreement or disagreement; eye contact; tone, volume, and inflection of the voice; gestures of the
shoulders, arms, hands, or fingers; body posture and position; dress and appearance; timing; and environment.
Nonverbal communication is more powerful than the words one speaks and can distort the meaning of the spoken
words. When a verbal message is incongruent with the nonverbal message, the recipient has difficulty interpreting the
intended meaning; this results in intrasender conflict. For example, a manager who states, "Come talk to me anytime," but
keeps on typing at the keyboard while you talk, sends a conflicting message to the staff. Intersender conflict occurs when
a person receives two conflicting messages from differing sources. For example, the risk manager may encourage a nurse
to report medication errors, but the nurse manager follows up with discipline over the error. The nurse is caught between
conflicting messages from the two.
Other common causes of distorted communication are:
• Using inadequate reasoning
• Using strong, judgmental words
• Speaking too fast or too slowly
• Using unfamiliar words
• Spending too much time on details
Distortion also occurs when the recipient is busy or distracted, bases understanding on previous unsatisfactory
experience with the sender, or has a biased perception of the meaning of the message or the messenger. Consider the
example of distortion of written communication provided in Box 9-1.
E-mail is particularly fraught with opportunities for misunderstanding. From the greeting (e.g., dear, hi, hello) to the
sign-off (e.g., warm regards, best wishes, or the curt "best"), the sender conveys more than the choice of words. A speedy
reply is expected and encourages a response, sometimes without adequate thought. Finally, the possibility of sending the
message to the wrong person, especially the dreaded "reply to all," is another chance for your message to be
misinterpreted. Texting shares many of the same dangers as e-mail and has added pressure for a faster response.

DIRECTIONS OF COMMUNICATION
Formal or informal communication may be downward, upward, lateral, or diagonal. Downward communication (manager
to staff) is often directive. The staff is told what needs to be done or given information to facilitate the job to be done. Upward
communication occurs from staff to management or from lower management to middle or upper management. Upward

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Education (Department of Nursing) 2 of 24
communication often involves reporting pertinent information to facilitate problem solving and decision making. Lateral
communication occurs between individuals or departments at the same hierarchical level (e.g., nurse managers,
department heads). Diagonal communication involves individuals or departments at different hierarchical levels (e.g., staff
nurse to chief of the medical staff). Both lateral and diagonal communication involve information sharing, discussion, and
negotiation.
An informal channel commonly seen in organizations is the grapevine (e.g., rumors and gossip). Grapevine
communication is usually rapid, haphazard, and prone to distortion. It can also be useful. Sometimes the only way you learn
about a pending change is through the grapevine. One problem with grapevine communication is that no one is accountable
for any misinformation that is relayed. Keep in mind, too, that information gathered this way is a slightly altered version of the
truth, changing as the message passes from person to person.

GENDER DIFFERENCES IN COMMUNICATION

Men and women communicate differently, according to linguist Deborah Tannen (2001). They have become socialized
through communication patterns that reflect their societal roles. Men tend to talk more, longer, and faster, whereas women
are more descriptive, attentive, and perceptive. Women tend to use tag questions (e.g., "I can take off this weekend, can't
I?") and tend to self-disclose more than men. Women tend to ask more questions and solicit more input than their male
counterparts. Men tend to be more aggressive, express their opinion, and disagree more than women managers
(Davidhizar & Cramer, 2000). In unpleasant situations, men talk more whereas women withdraw. Table 9-1 lists some of the
differences in the ways that men and women communicate.
Using gender-neutral language in communication helps bridge the gap between men's and women's ways of
communicating. Men and women can improve their ability to communicate with each other by following the
recommendations for gender-neutral communication found in Table 9-2.

BOX 9-1 Distortion in Written Communication

There is ample opportunity for distortion in the complicated process of sending, receiving, and responding to messages, as
demonstrated by the following correspondence between a plumber and an official of the National Bureau of Standards
(Donaldson & Scannell, 1979).
Bureau of Standards Mr. Tom Brown, Plumber
Washington, D.C. Yourtown, U.S.A.
Gentlemen: Dear Mr. Brown:
I have been in the plumbing business for over 11 years We wish to inform you we have your letter of last week
and have found that hydrochloric acid works real fine for and advise that we cannot assume responsibility for the
cleaning drains. Could you tell me if it’s harmless? production of toxic and noxious residues with hydrochloric
Sincerely, acid and further suggest you use an alternate procedure.
Tom Brown, Plumber Sincerely,
Bureau of Standards
Mr. Tom Brown, Plumber Bureau of Standards
Yourtown, U.S.A. Washington, D.C.
Dear Mr. Brown: Gentlemen:
The efficacy of hydrochloric acid is indisputable, but the I have your most recent letter and am happy to find you
chlorine residue is incompatible with metallic permanence! still agree with me.
Sincerely, Sincerely,
Bureau of Standards Tom Brown, Plumber
Bureau of Standards Mr. Tom Brown, Plumber
Washington, D.C. Yourtown, U.S.A.
Gentlemen: Dear Mr. Brown:
I have your letter of last week and am mightily glad you Don’t use hydrochloric acid, it eats the hell out of pipes!
agree with me on the use of hydrochloric acid. Sincerely,
Sincerely, Bureau of Standards
Tom Brown, Plumber
For communication among more than two people, the chance of distortion increases proportionally.

GENERATIONAL AND CULTURAL DIFFERENCES IN COMMUNICATION

Generational differences, discussed in Chapter 1, affect communication styles, patterns, and expectations. Traditionals tend
to be more formal, following the chain of command without question. Baby boomers question more. They enjoy the process
of group problem solving and decision making. Independent generation X are just the opposite and want decisions made
without unnecessary discussion. Collegial millenials (generation Y) expect immediate feedback to their messages. E-mail,
text, or voice mail is the best way to connect with them (Sherman, 2006). Mutual respect and understanding of the unique
differences between and among groups will help to minimize conflict and maximize satisfaction for both managers and staff
(Kupperschmidt, 2006).

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 Cultural attitudes, beliefs, and behaviors also affect communication. Such elements as body movement, gestures, tone,
and spatial orientation are culturally defined. A great deal of misunderstanding results from people's lack of understanding of
each other's cultural expectations. For example, people of Asian descent take great care in exchanges with superiors so that
there is no conflict or "loss of face" for either person.
Understanding the cultural heritage of employees and learning to interpret cultural messages is essential to
communicate effectively with staff from diverse backgrounds. Personal and professional cultural enrichment training is
recommended. This includes reading the literature and history of the culture; participating in open, honest, respectful
communication; and exploring the meaning of behavior. It is important to recognize, however, that subcultures exist within
all cultures; therefore, what applies to one individual will not be true for everyone else in that culture.

TABLE 9-1 Gender Differences in Communication

MEN TEND TO WOMEN TEND TO
Interrupt more frequently Wait to be noticed
Talk more, longer, louder, and faster Use qualifiers (prefacing and tagging)
Disagree more Use questions in place of statements
Focus on the issue more than the person Relate personal experiences
Boast about accomplishments Promote consensus
Use banter to avoid a one-down position Withdraw from conflict
From Becoming Influential: A Guide for Nurses (p. 52), by E.J. Sullivan, 2004, Upper Saddle River, NJ: Prentice Hall,
Reprinted by permission

DIFFERENCES IN ORGANIZATIONAL CULTURE

The customs, norms, and expectations within an organization are powerful forces that shape behavior. Focusing on relevant
issues regarding the organizational culture can identify failures in communication. Poor communication is a frequent source
of job dissatisfaction as well as a powerful determinant of an organization's effectiveness. Just as violation of other norms
within the organization results in repercussions, so does violation of communication rules.
To discover what rules affect communication in your organization, ask yourself:
• Who has access to what information? Is information withheld? Is it shared widely?
• What modes of communication are used for which messages? Are they used appropriately?
• How clear are the messages? Or are they often distorted?
• Does everyone receive the same information?
• Do you receive too much information? Not enough?
• How effective is the message?
TABLE 9-2 Recommendations for Gender-Neutral Communication
MEN MAY NEED TO WOMEN MAY NEED TO
Listen to objections and suggestions State your message clearly and concisely
Listen without feeling responsible Solve problems without personalizing them
Suspend judgment until information is in Say what you want without hinting
Explain your reasons Eliminate unsure words (“sort of”) and nonwords (“truly”)
Not yell Not cry
From Becoming Influential: A Guide for Nurses (p. 52), by E.J. Sullivan, 2004, Upper Saddle River, NJ: Prentice Hall,
Reprinted by permission

THE ROLE OF COMMUNICATION IN LEADERSHIP

Although communication is inherent in the manager's role, the manager's ability to communicate often determines his or her
success as a leader. Leaders who ' engage in frank, open, two-way communication and whose nonverbal communication
reinforces the verbal communication are seen as informative. Communication is enhanced when the manager listens
carefully and is sensitive to others. The major underlying factor, however, is an ongoing relationship between the manager
and employees.
Successful leaders are able to persuade others and enlist their support. The most effective means of persuasion is the
leader's personal characteristics. Competence, emotional control, assertiveness, consideration, and respect promote
trustworthiness and credibility. A participative leader is seen as a careful listener who is open, frank, trustworthy, and
informative.

COMMUNICATING WITH DIFFERENT POPULATIONS

SUBORDINATES
Depending on the organization's policies, the nurse manager's responsibilities may include selecting, inter-viewing,
evaluating, counseling, and disciplining employees; handling their complaints; and settling conflicts. The principles of

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Education (Department of Nursing) 4 of 24
effective communication are especially pertinent in these activities because good communication is the adhesive that builds
and maintains an effective work group.
Giving direction is not, in itself, communication. If the manager receives an appropriate response from the subordinate,
however, communication has occurred. To give directions and achieve the desired results, develop a message strategy.
The techniques that follow can help improve effective responses from others.
• Know the context of the instruction. Be certain you within know exactly what you want done, by whom, what time
frame, and what steps should be followed to do it. Be clear in your own mind what information a person needs to carry out
your instruction, what the outcome will be if the instruction is carried that outcome can or will be evaluated. When you have
thought through these questions, you are ready to give the proper instruction.
• Get positive attention. Avoid factors that interfere with effective listening. Informing the person that the instructions
will be given is one simple way to try to get positive attention. Highlighting the background, giving a justification, or indicating
the importance of the instructions also may be appropriate.
• Give clear, concise instructions. Use an inoffensive and nondefensive style and tone of voice. Be precise, and give
all the information receivers need to carry out your expectations. Follow a step-by-step procedure if several actions are
needed.
• Verify through feedback. Make sure the receiver has understood your specific request for action. Ask for a repeat of
the instructions.
• Provide follow-up communication. Understanding does not guarantee performance. Follow up to discover if your
instruction is clear and if the person has any questions.
The nurse manager is responsible both for the quality of the work life of individual employees and for the quality of
patient care in the entire unit. To carry out this job, acknowledge the needs of individual employees, especially if the needs
of one conflict with needs of the unit, speak directly with those involved, and state clearly and accurately the rationale for the
decisions made.

SUPERIORS
The manager's interaction with higher administration is comparable to the interaction between the manager and a
subordinate, except that the manager is now the subordinate. Higher administration is responsible for the consequences of
decisions made for a larger area, such as all of nursing service or the entire organization. The principles used in
communicating with subordinates are equally appropriate. Managers should be organized and prepared to state their needs
clearly, explain the rationale for requests, suggest benefits for the larger organization, and use appropriate channels. Listen
objectively to your supervisor's response and be willing to consider reasons for possible conflict with needs of other areas.
Working effectively with a supervisor is important because this person directly influences personal success in a career
and within the organization. Managing a supervisor, or managing upward, is a crucial skill for nurses. To manage upward,
remember that the relationship requires participation from both parties. Managing upward is successful when power and
influence move in both directions. Rules for managing your supervisor are found in Box 9-2.
One aspect of managing upward is to understand the supervisor's position from her or his frame of reference. This will
make it easier to propose solutions and ideas that the supervisor will accept. Understand that a supervisor is a person with
even more responsibility and pressure. Learn about the supervisor from a personal perspective: What pressures, both
personal and professional, does the supervisor face? How does the supervisor respond to stress? What previous
experiences are liable to affect today's issues? This assessment will allow you to identify ways to help your supervisor with
his or her job and for your supervisor to help you with yours.
BOX 9-2 Rules for Managing Your Supervisor
l Give immediate positive feedback for good things that l Be your own publicist. Don’t brag, but keep your
the supervisor does; positive feedback is a welcome supervisor informed of what you achieve.
change
l Never let your supervisor be surprised; keep her or him l Keep aware of your supervisor’s achievements
informed. and acknowledge them.
l Always tell the truth. l If your supervisor asks you to do something, do it
well and ahead of the deadline of possible. If
appropriate, add some of your own suggestions.
l Find ways to compensate for weaknesses of your l Establish a positive relationship with the
supervisor. Fill in weak area tactfully. Volunteer to do supervisor’s assistant.
something the supervisor dislikes doing.

Influencing Your Supervisor

Nurses need to approach their supervisor to exert their influence on a variety of issues and problems. Support for the
purchase of capital equipment, for changes in staffing, or for a new policy or procedure all require communicating with your
supervisor. Your rationale, choice of form or format, and possible objections all are important factors to consider as you
prepare to make such a request. Timing is critical; choose an opportunity when the supervisor has time and appears
receptive. Also, consider the impact of your ideas on other events occurring at that time.

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 Should ideas be presented in spoken or written form? Usually some combination is used. Even if you have a brief
meeting about a relatively small request, it is a good idea to follow up with an e-mail, detailing your ideas and the plans to
which you both agreed. Sometimes the procedure works in reverse. If you provide the supervisor a written proposal prior to
a meeting, both of you will be familiar with the idea at the start. In the latter case, careful preparation of the written material
is essential.
What can be done if, in spite of careful preparation, your supervisor says no? First, make sure you have understood the
objections and associated feelings. Negative inquiry (e.g., "I don't understand") is a helpful technique to use. Do not
interrupt or become defensive or distraught; remain diplomatic. Fogging, agreeing with part of what was said, or negative
assertion, accepting some blame, are two additional techniques that you can use.
The next step is confrontation. Keep your voice low and measured; use "I" language; and avoid absolutes, why
questions, put-downs, inflammatory statements, and threatening gestures. Finally, if you feel you have lost and compromise
is unlikely, table the issue by saying, "Could we continue discussing this at another time?" Then, think through your
supervisor's reasoning and evaluate it.
Afterward ask yourself: "What new information did I get from the supervisor?" What are ways I can renegotiate?" What
do I need to know or do to overcome objections?" Once you can answer these questions, approach your supervisor again
with the new information. This behavior shows that the proposal is a high priority, and the new information may cause him or
her to reevaluate.
Managers often succeed in influencing superiors through persistence and repetition, especially if supporting data and
documentation are supplied. If the issue is important enough, you may want to take it to a higher authority. If so, tell your
supervisor you would like an administrator at a higher level to hear the proposal. Keep an open mind, listen, and try to meet
objections with suggestions of how to solve problems. Be prepared to compromise, which is better than no movement at all,
or to be turned down.

Taking a Problem to Your Supervisor

No one wants to hear about a problem, and your boss is no different. Nonetheless, work involves problems, and the
manager's job is to solve them. Go to your supervisor with a goal to problem solve together. Have some ideas about solving
the problem in hand if you can but do not be so wedded to them that you are unable to listen to your supervisor's ideas. Keep
an open mind. Use the following steps to take a problem to your supervisor:
• Find an appropriate time to discuss a problem, scheduling an appointment if necessary.
• State the problem succinctly and explain why it is interfering with work.
• Listen to your supervisor's response and provide more information if needed.
• If you agree on a solution, offer to do your part to solve it. If you cannot discover an agreeable solution, schedule a
follow-up meeting or decide to gather more information.
• Schedule a follow-up appointment.
By solving the problem together and, if necessary, by taking active steps together, you and your supervisor are more
likely to accept the decision and be commit ted to it. Setting a specific follow-up date can prevent a solution from being
delayed or forgotten.

If All Else Fails .. .

Sometimes no matter what you do, working with your supervisor seems nearly impossible. Kimura (2003) calls such
supervisors "toxic." Toxic managers foster a negative work environment, and employees become dissatisfied, angry, and
depressed. High absenteeism and turnover result. As a manager you are charged with supporting your superior. If working
with that superior is too difficult for you to manage your work satisfactorily, you may have to transfer elsewhere or leave.

PEERS
Interactions with peers are inevitable. Relationships can vary from comfortable and easy to challenging and complex. Peers
often share similar concerns. Camaraderie may be present; peers can exchange ideas and address problems creatively.
Peers can provide support, and the strengths of one can be developed in the other.
Conversely, there may also be competition or differences of opinion conflicts (e.g., battles over territory, personality
clashes, differences of opinion) and affected by history, the organization's mores, or generational or cultural differences.
Even when there are conflicts, peers should interact on a professional level; tactics for communicating with difficult people
and negotiating may be helpful. Both topics are discussed later in the chapter.

MEDICAL STAFF
Communication with the medical staff may be difficult for the nurse manager because the relationship of physicians and
nurses has been that of superior and subordinate. Gender-based differences in nursing (although less so in medicine today)
may add to the difficulty. Furthermore, physician training in communication skills has largely been absent (Cegala &
Lenzmeier-Broz, 2002).
Complicating physician—nurse relationships is the employee status of the medical staff. They may not be employees of
the organization but still have considerable power because of their ability to attract patients to the organization, and, finally,

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the medical staff is in itself diverse, consisting of physicians who are organizational employees, residents, physicians in
private practice, and consulting physicians.
Nurse managers are role models and leaders for establishing Nurse-physician relationships on their units.
Nurse-physician communication has been shown to affect patient outcomes in two landmark studies. Lower-than-expected
death rates in intense care units were related to excellent coordination and communication among the nurse--physician staff
in one study (Knaus, Draper, Wagner, 8c Zimmerman, 1986), and lack of communication and cooordination among health
care providers was related to unnecessarily high-cost stays for patients in another (Gavett, Drucker, McCrum, & Dickenson,
1985). Nurse managers have important reasons, then, for setting a positive tone that fosters mutual respect among nurses
and physicians on their units.
In today's competitive health care marketplace, it also is necessary to view the physician as a nursing service customer.
Organizations are competing for patients, and physicians (as well as insurers) are sources of patients. The product of
nursing service is patient care; physicians help provide the patients.
What do physicians want? Physicians first want quality staff-nurses, health care workers, and other physicians. They
want up-to-date facilities and equipment, quality care, and adequately trained nursing personnel. Physicians also want
respect (as do nurses and others who work in health care) and regard patient care as their same Primary concern. These
are many of the goals that nurses have.
To support greater improve between nurses and physicians and to improve the product of nursing service patient care
keep these principles in mind:
•Respect physicians as persons, and expect them to respect you.
• Consider yourself and your staff equal partners with physicians in health care.
• Build your staff's clinical competence and credibility. Ensure that your staff has the clinical preparation necessary to
meet required standards of care.
• Actively listen and respond to physician complaints as customer complaints. Create a problem-solving structure. Stop
blaming physicians exclusively for communication problems.
• Use every opportunity to increase your staff's contact with physicians and to include your staff in meetings that include
physicians. Remember that limited interactions contribute to poor communication.
• Establish a collaborative practice committee on your unit whose membership is composed equally of nurses and
physicians. Identify problems, develop mutually satisfactory solutions, and learn more about each other. Emphasize
similarities and the need for quality care. Begin with those physicians who have a positive attitude toward collaboration.
• Serve as a role model to your staff in nurse–physician communication.
• Support your staff in participating in collaborative efforts by words and by your actions.
But if you are confronted with power plays or intimidation, what is the best way to respond? Intimidation results from
vulnerability and a threat to self-worth (Lindeke & Sieckert, 2005). Intimidation can be counteracted by increasing
self-confidence and personal feelings of power. Four ways that generate power are:
1. With words:
• Use the other person's name frequently.
• Use strong statements.
• Avoid discounters, such as "I'm sorry, but . . . ?"
• Avoid clichés, such as "hit the nail on the head,""goes without saying,""easier said than done."
• Avoid fillers (such as "ah,""uh," and "um").
2. Through delivery:
• Be enthusiastic.
• Speak clearly and forcefully.
• Make one point at a time.
• Do not tolerate interruptions.
3. By listening:
• For facts.
• For emotions.
• For what is not being said (e.g., body language, mixed messages, hidden messages).
4. Through body posture and body language:
• Sit next to your antagonist; turn 30 degrees toward the person when you address that person.
• Lean forward.
• Expand your personal space.
• Use gestures.
• Stand when you talk.
• Smile when you are pleased, not in order to please.
• Maintain eye contact, but do not stare.

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OTHER HEALTH CARE PERSONNEL
The nurse manager has the overwhelming task of coordinating the activities of a number of personnel with varied levels and
types of preparation and different kinds of tasks. The patient may receive regular care from a registered nurse, unlicensed
assistive personnel, a respiratory therapist, a physical therapist, and a dietitian, among others. The nurse manager may
supervise all of them. Regardless, the manager needs considerable skill to communicate effectively with diverse personnel,
recognize their commonalities, and deal with their differences.

PATIENTS AND FAMILIES

Nurse managers deal with many difficult issues. Patient or family complaints about the delivery of care (e.g., complaints
about a staff member, violations of policy) are one example. When dealing with patient or family complaints, keep the
following principles in mind:
• The patient (and family) are the principal customers of the organization. Treat patients and families with respect;
keep communication open and honest. Dissatisfied customers fail to continue to use a service and also inform their friends
and families about their negative experiences. Handle complaints or concerns tactfully and expeditiously. Many times
lawsuits can be avoided if the patient or family feels that someone has taken the time to listen to their complaints.
• Most individuals are unfamiliar with medical jargon. Use words that are appropriate to the recipient's level of
understanding. However, take care not to be condescending or intimidating. It is just as important to assess the person's
knowledge base and level of understanding as it is to know his or her vital signs or liver status.
• Maintain privacy and identify a neutral location for dealing with difficult interactions.
• Make special efforts to find interpreters if a patient or family does not speak English. Have readily available a
list of individuals who are able to communicate in a variety of languages. The list also should include individuals experienced
in sign language and Braille. Another resource is AT&T's language line service (1-800-752-6096), which provides
interpreters for over 140 languages 24 hours a day.
• Recognize cultural differences in communicating with patients and their families. People in some cultures do
not ask questions for fear of imposing on others. Some cultures prefer interpreters from their own culture; others do not.
Cultural education for the staff can help identify some of these differences and teach them appropriate, culturally sensitive
responses.

COMMUNICATING WITH DIFFICULT PEOPLE

Difficult personalities exist in all groups of people---subordinates, superiors, physicians, other health care team members,
patients, and family members alike. Strategies for coping with difficult people follow (Nations, 1990a, 1990b, 1990c).
1. Put physical distance between you and the difficult person. A common method to achieve physical distance is
to limit the time you spend with the individual. Match the person's energy level in speed, pitch, and volume; this conveys
awareness and empathy. This technique is particularly effective with hostile, aggressive individuals. However, negative
behavior, such as yelling and tantrums, should not be mirrored; instead, remain calm but assertive.
2. Psychologically distance yourself from the individual. View the person from a different perspective; try "putting
on his shoes." Also "lose the shoulds" (for example, "Who does he think he is? He shouldn't be allowed to talk to us like
that.") Ask: What does this person's behavior accomplish? What type of personality trait is being exhibited?
3. Identify the individual's feelings and information level. Then validate those feelings and information as well as
your relationship, but don't patronize. This technique is particularly successful with a "know-it-all" who may be under the
illusion that only he or she is right.
4. Ask extensional questions. Questions that begin with "how" or "what" often help the person to focus on his or her
concerns and rethink what has just been said. Focusing on holes in the individual's argument provides an opportunity
for a graceful retreat.
5. Use physical movement. Lead an upset individual to your office or another neutral location, or suggest that the two
of you go for a cup of coffee. Physical activity often diminishes stress and hostility.
6. Try humor. If the situation is not too serious, humor is an excellent method to defuse anger and frustration; however,
be careful to avoid sarcasm or put downs.
(Difficult people include those who bully.)

ENHANCING YOUR COMMUNICATION SKILLS

Communication skills can be learned. At one program offered at Memorial Sloan Kettering Hospital, oncology nurses
improved their abilities to communicate in an assertive manner, manage conflict, motivate others, and delegate
appropriately after training (Walczak & Absolon, 2001.) Suggestions to improve your communication skills are shown in
Table 9-3.
To communicate effectively, first consider your relationship to the receiver (e.g., boss or patient). Then craft your
message. Be clear about your goal in your mind so that you can communicate it appropriately. Then think about what the
other person is liable to say and consider how you might respond.
Next decide on the medium. Is this message best conveyed in person, by phone, or e-mail? Should you leave a
message if the person isn't available? Note the personal intimacy content earlier in the chapter for guidance.

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 Timing plays a critical role in successful communication. Catch your boss in the midst of planning for a budget shortfall
and you are less apt to get a receptive hearing.
Be prepared when you deliver your message. The best-crafted message, delivered by the appropriate medium can
misfire by a sender who fails to listen carefully, avoids responding out of fear of consequences, or undermines the message
with qualifiers, such as "I don't know if you're interested."
The effort to develop excellent communication skills is well worth the effort. As Porter-O'Grady (2003) reminded us,
today's relationship-oriented environments require superb interpersonal skills. A facilitative leadership style encourages
others, empowers them to do their best work, and supports them when problems and conflict inevitably emerge.

TABLE 9-3 Improving Communication

1. Consider your relationship to the receiver.
2. Craft your message, including your goal and how to answer responses.
3. Decide on the medium based on your relationship, the content, and the setting.
4. Check your timing.
5. Deliver your message.
6. Attend to verbal or written responses.
7. Reply appropriately.
8. Conclude when both parties' messages have been understood.
9. Evaluate communication process.

COORDINATION
- The process of working or acting together harmoniously.
- Unites personnel and services towards a common objective.
- Prevents overlapping of functions, promotes good working relationships and work schedules are accomplished as targeted

Coordinate with:
ü Medical Service
ü Administrative Service
ü Laboratory Service
ü Radiology Service
ü Pharmacy Service
ü Dietary Service
ü Medical Social Service
ü Medical Records Service
ü Community Agencies, other Institutions & Civic Organization

STAFF DEVELOPMENT
Every individual is unique and, therefore, will vary in education, skills, and ability. There are a few common denominators; for
example, all new staff nurses will have passed state board examinations. Yet educational preparation will vary, and some
people will not have developed all of the skills and knowledge necessary to perform at the expected level. Furthermore, new
nursing practice and technology call for ongoing staff education. One of the nurse manager's major responsibilities is to
enhance staff performance, an activity usually referred to as staff development.

Major task: To provide structure and assistance for employees to learn in greater depth and to translate the KSA and
principles learned into nursing practice within their institution of employment.

Functions:
ü Maintain staff efficiency and effectiveness
ü Create quality employees
ü Meet the staff needs & address their problems
ü Motivate them & improve self-confidence
ü Help prepare them for greater responsibility

ORIENTATION
Getting an employee started in the right way is very important. Among other things, a well-planned orientation reduces the
anxiety that new employees feel when beginning the job. In addition, socializing the employee into the workplace contributes
to unit effectiveness by reducing dissatisfaction, absenteeism, and turnover.
Orientation is a joint responsibility of both the organization's staff development personnel and the nursing manager. In
most organizations, the new staff nurse completes the orientation program, whereupon the nurse manager (or someone
appointed to do this) provides an on-site orientation. Staff development personnel and unit staff should have a clear

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understanding of their respective, specific responsibilities so that nothing is left to chance. The development staff should
provide information involving matters that are organization-wide in nature and relevant to all new employees, such as
benefits, mission, governance, general policies and procedures, safety, quality improvement, infection control, and common
equipment. The nurse manager should concentrate on those items unique to the employee's specific job.
New employees often have unrealistically high expectations about the amount of challenge and responsibility they will
find in their first job. If they are assigned fairly undemanding, entry-level tasks, they feel discouraged and disillusioned. The
result is job dissatisfaction, turnover, and low productivity.
So one function of orientation is to correct any unrealistic expectations. The nurse manager needs to outline very
specifically what is expected of new employees. Such realistic job previews help prevent early departures from the
organization and, possibly, the nursing profession.
Socializing new employees can sometimes be difficult because of the anxiety people feel when they first come on the
job. They simply do not hear all of the information they are given. They spend a lot of energy attempting to integrate and
interpret the information presented, and consequently they miss some of it. So repetition may be necessary the first few
days or weeks on the job.
Because nurse managers are an extremely important part of the socialization process, they should discuss everything
that they expect of the new employee openly and specifically. The new employee adapts more rapidly if this is done. The
manager should address everything from standards of performance, attendance, and treatment of patients to the feedback
the employee should expect in performance appraisals.
One method of orientation is the preceptor model, which can be used to assist new employees and to reward
experienced staff nurses. The preceptor model provides a means for orienting and socializing the new nurse as well as
providing a mechanism to recognize exceptionally competent staff nurses. Staff nurses who serve as preceptors are
selected based on their clinical competence, organizational skills, ability to guide and direct others, and concern for the
effective orientation of new nurses. The primary goal is for preceptors to assist new nurses to acquire the necessary
knowledge and skills so that they can function effectively on the job.
Preceptorships offer new nurses the advantage of an on-the-job instruction program tailored specifically to their needs.
Staff nurses (preceptors) benefit by having an opportunity to sharpen their clinical skills and increasing their personal and
professional satisfaction. The new nurse works closely with the preceptor for approximately 3 weeks, although the duration
of the preceptorship may vary according to the nurse's individual learning needs or the organization's policies.
The primary function of the preceptor is to orient the new nurse to the unit. This includes proper socialization of the new
nurse within the group as well as familiarizing her or him with unit functions. The preceptor teaches any unfamiliar
procedures and helps the new nurse develop any necessary skills. The preceptor acts as a resource person on matters of
unit functions as well as policies and procedures.
New nurses may need to use their preceptors as counselors as they make their transition to the unit. If new nurses
experience discrepancy between their educational preparation or their expectations and the realities of working in the unit,
the preceptor's role as counselor can prove invaluable in helping them cope with "reality shock."
The preceptor also serves as a staff nurse role model demonstrating work-related tasks, how to set priorities, solve
problems and make decisions, manage time, delegate tasks, and interact with others. In addition, the preceptor evaluates
the new nurse's performance and provides both verbal and written feedback to encourage development. The staff
development department plays an integral role in the preceptor arrangement by providing the initial orientation, familiarizing
the new employee with the organization and general policies and procedures before he or she begins work with the
preceptor. The staff development department's function is to teach the experienced nurse the role of a preceptor, principles
of adult education applicable to learning needs, how to teach necessary skills, how to plan teaching, how to evaluate
teaching and learning objectives, and how to provide both formal and informal feedback.
Residency programs, 12 or 18 months in length, are designed to acclimate new graduates to the work environment and
have been shown to be effective in reducing turnover (McPeck, 2006; Williams et al., 2007).

STAFF DEVELOPMENT PROCESS

Needs Assessment The first step in staff development is a needs assessment for an educational program. Too often, staff
development programs are initiated simply because they have been advertised and marketed, because they have been
done in the past, or because other organizations have offered them. Because only educational institutions can legitimately
view education as an end in itself, health care organizations must justify how an educational activity can achieve an
organizational goal, such as better patient care, reduced operating costs, or more efficient or satisfied personnel.
Systematic determination of educational needs based on organizational goals can be used as a basis for developing
specific content. In this way, staff development programs are used tent in the most cost-effective and efficient manner.
The decision to offer educational programs should be based on teaching behaviors that:
1. Can be made more effective and efficient by educational efforts (e.g., a streamlined dressing technique)
2. Need maintenance (e.g., cardiopulmonary resuscitation, infection control)
3. New employees need to learn (e.g., required documentation)
4. Employees who are transferred or promoted need to learn (e.g., a nurse who transfers to intensive care and needs
education about thermodilution catheters)

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 5. Are needed as a result of new evidence for practice or new technology (e.g., a new chemotherapeutic agent)
Staff development specialists and managers can identify learning needs through a variety of strategies. checklists,
advisory groups, quality improvement data, professional standards, and group brainstorming.
Some educational programs are dictated by federal state, or local regulations. Among these mandatory classes are the
following:
• Infection control
• Employee fire and patient safety
• Quality assurance/quality improvement (QA/QI)
• Cardiopulmonary resuscitation (CPR)
• Handling of hazardous materials
Additional requirements may be established through professional organization standards. Joint Commission (2002)
requires organizations to provide education and training necessary to maintain a knowledgeable and skilled staff.

Planning
After needs have been determined, the next step is to plan staff development programs. Planning is a four-stage process
that includes establishing objectives, evaluating the present situation and predicting future trends and events, formulating a
planning statement (means), and converting the plan into an action statement. It en-tails identifying learner objectives and
matching them with educational methods. Learner objectives, like client outcomes, should be specific, measurable
statements about desired behaviors, skills, or knowledge be acquired within a specific time frame. The strategy used to
affect the desired outcome should be based on learning needs, the employee, and available resources. Box 17-1 illustrates
learning objectives for an infection control unit on hand washing.
Nurse managers have a variety of resources at their disposal. The staff development or education department may use
a variety of media, such as closed-circuit television, online Web-based instruction, satellite programs, competency-based
programs, self-study, and traditional didactic programs. Other alternatives are using experienced staff members as
teachers, preceptors, or mentors; unit-based educators; or off-site continuing education programs.
Three main questions should be considered in assessment and planning:
• Can the learner do what is required?
• How should the staff development program be arranged to facilitate learning?
• What can be done to ensure that what is learned will be transferred to the job?
BOX 17-1 Staff Development Learning Objectives
Infection Control — Hand Washing Unit
Following completion of the hand washing unit, the employee will be able to:
1. Understand and explain to the instructor why correct hand washing is important.
2. Correctly identify situations when the employee should wash hands.
3. Identify hand washing and hand sanitizing products used in the facility.
4. Demonstrate correct hand-washing technique.

Implementation
Implementation involves bringing together educators, learners, and the materials and methods needed for education.
Although most staff development is carried out by the staff development or education department, staff development is also
a unit responsibility.

STAFF DEVELOPMENT METHODS

Staff development can be divided into internal (on the unit) and external (off the unit) sources. Internal sources include
on-the-job instruction, workshops for staff, and in-service programs. External sources are formal workshops presented by
an education department within the hospital and educational activities outside the hospital, including college courses,
conferences, Web-based learning, and continuing education workshops.
For effective adult education, the student needs, at a minimum:
1. Material to be presented
2. Practice using the new knowledge and/or skill
3. Feedback about performance
There must be opportunity for practice of the desired behaviors and feedback about it. For instance, if an individual is
shown how to perform CPR, practices it, and is given feedback on his or her success, the person could be expected to be
able to perform CPR. Reading about or listening to a lecture about how to do cardiopulmonary resuscitation provides no
assurance that the recipient actually could resuscitate an individual in an emergency.
The most widely used educational method is on-the-job instruction. This often involves assigning new employees to
experienced nurse peers, preceptors, or the nurse manager. The learner is expected to learn the job by observing the
experienced employee and by performing the actual tasks under supervision.
On-the-job instruction has several positive features, one of which is its cost-effectiveness. Learners learn effectively at
the same time they are providing necessary nursing services. Moreover, this method reduces the need for outside

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instructional facilities and reliance on professional educators. Transfer of learning is not an issue because the learning
occurs on the actual job. However, on-the-job instruction often fails because there is no assurance that accurate and
complete information is presented, and the on-the-job instructor may not know learning principles. As a result, presentation,
practice, or feedback may be inadequate or omitted.
On-the-job instruction fulfills an important function; however, staff members involved may not view it as having equal
value to more standardized and formal classroom instruction.
To implement effective on-the-job instruction, the following are suggested:

1. Employees who function as educators must be convinced that educating new employees in no way jeopardizes their
own job security, pay level, seniority, or status.
2. Individuals serving as educators should realize that this added responsibility will be instrumental in attaining other
rewards for them.
3. Pair teachers and learners to minimize any differences in background, language, personality, attitudes, or age that
may inhibit communication and understanding.
4. Select teachers on the basis of their ability to teach and their desire to take on this added responsibility.
5. Staff nurses chosen as teachers should be carefully educated in the proper methods of instruction.
6. Formalize assignments so that nurses do not view on-the-job instruction as happenstance or second-class
instruction.
7. Rotate learners to expose each learner to the specific know-how of various staff nurses or education department
teachers.
8. Employees serving as teachers should understand that their new assignment is by no means a chance to get away
from their own jobs but that they must build instructional time into their workload.
9. The efficiency of the unit may be reduced when on-the-job instruction occurs.
10. The learner must be closely supervised to prevent him or her from making any major mistakes and carrying out
procedures incorrectly.

Other Educational Techniques

As technology continues to advance rapidly and the number of people requiring instruction increases, teaching is becoming
more efficient and the learning process accelerating. Many organizations are using self-learning modules, such as online
classes, closed-circuit television, computerized clinical simulations, interactive video instruction, satellite broadcasts (some
of which are interactive), CDs, DVDs, and long-distance learning via cable television. These methods allow an instructor to
convey information in a uniform manner on several occasions or at several locations at one time; many lessons can be
repeated. These methods can enhance the instructor's presentation as well as reduce the need for an instructor to present
every detail in person.

Evaluation
Few issues in education create as much controversy or discussion as evaluation. Evaluation is an investigative process to
determine whether the education was cost-effective, the objective was achieved, and learning was applied to the job.
Educators usually agree on the need for sound appraisal of educational programs, but they seldom agree on the best
method to do evaluation and rarely do empirical evaluation. Typically, a program is initially reviewed at the corporate level
before its implementation. The same program is used over and over until someone in authority decides the program is no
longer useful or no longer effective, or, more commonly, until attendance decreases.
The purpose of evaluation is to determine whether the educational program has a positive effect on day-to-day
operating problems and to identify elements of the program that need improvement. Designing sound evaluation tools is
difficult and costly, though necessary.
Four evaluation criteria should be used:
1. Learner reaction
2. Learning acquired
3. Behavior change
4. Organizational impact
Learner reaction is usually ascertained through a questionnaire completed at the end of a program. The questionnaire
may ask about the program's content, the educator, the educator's objectives, the methods used, physical facilities, and
meals. Only required questions should be asked; irrelevant data should not be gathered.
Learner reactions are important because:
1. Positive reactions ensure organizational support for a program
2. Reactions can be used to assess the program
3. Reactions indicate whether the learners liked the program
Learning criteria assess the knowledge—the facts and figures—learned in the educational program. Knowledge is
typically measured by paper-and-pencil tests that can include true–false, multiple-choice, fill-in-the-blank, matching, and
essay questions.

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 But the acquisition of knowledge is not enough. Was that knowledge converted into behavioral change? One of the
biggest problems in education is that instruction does not necessarily transfer from the classroom to the job—often because
learners are taught the theory and the technique but never learn how to translate these into behavior on the job. There is a
big difference between learning and doing; if behavior is not measured after the program (or on the job), it cannot be
determined whether the instructional program has affected behavior or helped the employee transfer the new behavior to
the job.
One technique to ensure transfer of learning to clinical practice is peer coaching (Waddell & Dunn, 2005). Peer
coaching uses partners who have both participated in the educational program, observe each other practicing the skill, ask
appropriate questions during the demonstration, and offer feedback about the performance.
The objective of many staff development programs can be expressed in terms of organizational impact, such as reduced
turnover, fewer grievances, reduced absenteeism, improved quality of care, and fewer accidents. These are usually
expressed in quantified data and can be easily tied to dollars.
It is often difficult to determine whether changes in such areas can be unequivocally attributed to the staff development
program or to other variables in the organization, such as changes in management, increased pay, new equipment, better
selection, or changes of some other kind. To rule out the effect of these variables, those who establish the program must
take particular care in deciding the length of time for data collection, the unit of analysis, randomization, and other
experimental design issues. The most important criteria for measuring results are those that are closely related to the key
training behaviors. Despite all of the difficulties in collecting and analyzing such data, cost-related data should be collected
because they can provide evidence to higher administration that educational efforts do affect organizational effectiveness.

DECISION MAKING
Considering all the practice individuals get in making decisions, it would seem they might become very good at it. However,
the number of decisions a person makes does not correspond to the person's skill at making them. The assumption is that
decision making comes naturally, like breathing. It does not.
The decision-making process described in this chapter provides nurses with a system for making decisions that is
applicable to any decision. It is a useful procedure for making practical choices. A decision not to solve a problem is also a
decision.
The label decision making is used inconsistently and often interchangeably with problem solving.. Although the two
processes appear similar and may in some instances depend on one another, they are not synonymous. The main
distinctions between the two are that decision making may or may not involve a problem, but it always involves selecting
one of several alternatives, each of which may be appropriate under certain circumstances, whereas problem solving
involves diagnosing a problem and solving it, which may or may not entail deciding on one correct solution.
Most of the time, decision making is a subset of problem solving. However, some decisions are not of a problem-solving
nature, such as decisions about scheduling, equipment, in-services, or other matters that do not involve problem solving as
a deliberate process.
Also habit and tradition may be modes of decision making, such as holding onto the wall when walking down a wet
hospital corridor or scheduling patient care activities in traditional ways (e.g., giving every patient a bath every morning).
Research has discredited the early belief that decisions are choices people make after extensive evaluation of all
options in order to find an optimal solution. Simon (1955) and others recognized that evaluation is seldom extensive and
virtually never exhaustive. In the 1970s it was recognized that decision makers have a variety of strategies for making
choices and a variety of aims in addition to utility. Most often, past experiences provide ways of dealing with problems.
Making a deliberate choice is relatively rare and usually is done by screening out the unacceptable options and choosing the
best option from the remainders.

TYPES OF DECISIONS
The types of problems nurses and nurse managers encounter and decisions they must make vary widely and determine the
problem-solving or decision-making methods they should use. Relatively well defined, common problems can usually be
solved with routine decisions, often using established rules, policies, and procedures. For instance, when a nurse makes a
medication error, the manager's actions are guided by policy and the report form. Routine decisions are more often made
by first-level managers than by top administrators.
Adaptive decisions are necessary when both problems and alternative solutions are somewhat unusual and only
partially understood. Often they are modifications of other well known problems and solutions. Managers must make
innovative decisions when problems are unusual and unclear and when creative, novel solutions are necessary.

DECISION-MAKING CONDITIONS

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The conditions surrounding decision making can vary and change dramatically. Consider the total system. Whatever
solutions are created will succeed only if they are compatible with other parts of the system. Decisions are made under
conditions of certainty, risk, or uncertainty.

Decision Making under Certainty

When you know the alternatives and the conditions surrounding each alternative, a state of certainty is said to exist.
Suppose a nurse manager on a unit with acutely ill patients wants to decrease the number of venipunctures a patient
experiences when an IV is started, as well as reduce costs resulting from failed venipunctures. Three alternatives exist:
• Establish an IV team on all shifts to minimize IV attempts and reduce costs
• Establish a reciprocal relationship with the anesthesia department to start IVs when nurses experience difficulty
• Set a standard of two insertion attempts per nurse per patient although this does not substantially lower equipment
costs
The manager knows the alternatives (IV team, anesthesia department, standards) and the conditions associated with
each option (reduced costs, assistance with starting IVs, minimum attempts and some cost reduction). A condition of strong
certainty is said to exist and the decision can be made with full knowledge of what the payoff probably will be.

Decision Making under Uncertainty and Risk

Seldom do decision makers know everything there is to know about a subject or situation. If everything was known, the
decision would be obvious for all to realize.
Most critical decision making in organizations is done under conditions of uncertainty and risk. The individual or group
making the decision does not know all the alternatives, attendant risks, or possible consequences of each option.
Uncertainty and risk are inevitable because of the complex and dynamic nature of health care organizations. Successful
decisions, McConnell (2000) asserts, are dependent on human knowledge, experience, and judgment.
Here is an example: If the weather forecaster predicts a 40 percent chance of snow, the nurse manager is operating in
a situation of risk when trying to decide how to staff the unit for the next 24 hours.
In a risk situation, availability of each alternative, potential successes, and costs are all associated with probability
estimates. Probability is the likelihood, expressed as a percentage, that an event will or will not occur. If something is
certain to happen, its probability is 100 percent. If it is certain not to happen, its probability is 0 percent. If there is a 50-50
chance, its probability is 50 percent.
Suppose a nurse manager decides to use agency nurses to staff a unit during heavy vacation periods. Two agencies
look attractive, and the manager must decide between them. Agency A has had modest growth over the past 10 years and
offers the manager a 3-month contract, freezing wages during that time. In addition, the unit will have first choice of available
nurses. Agency B is much more dynamic and charges more but explains that the reason they have had a high rate of growth
is that their nurses are the best and the highest paid in the area. The nurse manager can choose Agency A, which will
provide a safe, constant supply of nursing personnel, or B, which promises better care but at a higher cost.
The key element in decision making under conditions of risk is to determine the probabilities of each alternative as
accurately as possible. The nurse manager can use a probability analysis, whereby expected risk is calculated or estimated.
Using the probability analysis shown in Table 8-2, it appears as though Agency A offers the best outcome. However, if the
second agency had a 90 percent chance of filling shifts and a 50 percent chance of fixing costs, a completely different
situation would exist.
TABLE 8-2 Probability Analysis
PROBABILITY ANALYSIS
Agency A 60% Filling shifts
100% Fixed wages
Agency B 50% Filling shifts
70% Fixed wage

The nurse manager might decide that the potential for increased costs was a small tradeoff for having more highly
qualified nurses and the best probability of having the unit fully staffed during vacation periods. Objective probability is the
likelihood that an event will or will not occur based on facts and reliable information. Subjective probability is the likelihood
that an event will or will not occur based on a manager's personal judgment and beliefs.

Janeen, a nurse manager of a specialized cardiac intensive care unit, faces the task of recruiting scarce and highly
skilled nurses to care for coronary bypass patients. The obvious alternative is to offer a salary and benefit package that rivals
that of all other institutions in the area. However, this means Janeen will have costly specialized nursing personnel in her
budget who are not easily absorbed by other units in the organization. The probability that coronary bypass procedures will
become obsolete in the future is unknown. In addition, other factors (e.g., increased competition, government regulations
regarding reimbursement) may contribute to conditions of uncertainty.

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THE DECISION-MAKING PROCESS
The rational decision-making model is a series of steps that managers take in an effort to make logical, well-grounded
rational choices that maximize the achievement of objectives. First identify all possible outcomes, examine the probability of
each alternative, and then take the action that yields the highest probability of achieving the most desirable outcome. Not all
steps are used in every decision nor are they always used in the same order. The rational decision-making model is thought
of as the ideal but often cannot be fully used.
Individuals seldom make major decisions at a single point in time and often are unable to recall when a decision was
finally reached. Some major decisions are the result of many small actions or incremental choices the person makes without
regarding larger issues. In addition, decision processes are likely to be characterized more by confusion, disorder, and
emotionality than by rationality. For these reasons, it is best to develop appropriate technical skills and the capacity to find a
good balance between lengthy processes and quick, decisive action.
The descriptive rationality model, developed by Simon in 1955 and supported by research in the 1990s (Simon,
1993), emphasizes the limitations of the rationality of the decision maker and the situation. It recognizes three ways in which
decision makers depart from the rational decision-making model:
• The decision maker's search for possible objectives or alternative solutions is limited because of time, energy, and
money
• People frequently lack adequate information about problems and cannot control the conditions under which they
operate
• Individuals often use a satisficing strategy.
Satisficing is not a misspelled word; it is a decision-making strategy whereby the individual chooses an alternative that
is not ideal but either is good enough (suffices) under existing circumstances to meet minimum standards of acceptance or
is the first acceptable alternative.
Many problems in nursing are ineffectively solved with satisficing strategies.

Elena, a nurse manager in charge of a busy neurosurgical floor with high turnover rates and high patient acuity levels,
uses a satisficing alternative when hiring replacement staff. She hires all nurse applicants in order of application until no
positions are open. A better approach would be for Elena to replace staff only with nurse applicants who possess the skills
and experiences required to care for neurosurgical patients, regardless of the number of applicants or desire for immediate
action. Elena also should develop a plan to Promote job satisfaction, the lack of which is the real reason for the vacancies.
Individuals who solve problems using satisficing may lack specific training in problem solving and decision making. They
may view their units or areas of responsibility as drastically simplified models of the real world and be content with this
simplification because it allows them to make decisions with relatively simple rules of thumb or from force of habit.
The political decision-making model describes the process in terms of the particular interests and objectives of
powerful stakeholders, such as hospital boards, medical staffs, corporate officers, and regulatory bodies. Power is the ability
to influence or control how problems and objectives are defined, what alternative solutions are considered and selected,
what information flows, and, ultimately, what decisions are made.
The decision-making process begins when a gap exists between what is actually happening and what should be
happening, and it ends with action that will narrow or close this gap. The simplest way to learn decision-making skills is to
integrate a model into one's thinking by breaking the components down into individual steps. The seven steps of the
decision-making process (Box 8-2) are as applicable to personal problems as they are to nursing management problems.
Each step is elaborated by pertinent questions clarifying the statements, and they should be followed in the order in which
they are presented.
BOX 8-2 Steps in Decision Making
1. Identify the purpose: Why is a decision necessary? What needs to be
determined? State the issue in the broadest possible terms.
2. Set the criteria: What needs to be achieved, preserved, and avoided by
whatever decision is made? The answers to these questions
are the standards by which solutions will be evaluated.
3. Weight the criteria: Rank each criterion on a scale of values from 1 (totally
unimportant) to 10 (extremely important).
4. Seek alternatives: List all possible courses of action. Is one alternative more
significant than another? Does one alternative have
weaknesses in some areas? Can these be overcome? Can
two alternatives or features of many alternatives be
combined?
5. Test alternatives: First, using the same methodology as in step 3, rank each
alternative on a scale of 1 to 10. Second, multiply the weight
of each criterion by the rating of each alternative. Third, add
the scores and compare the results.
6. Troubleshoot: What could go wrong? How can you plan? Can the choice be

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 improved?
7. Evaluate the action: Is the solution being implemented? Is it effective? Is it
costly?
DECISION-MAKING TECHNIQUES
Decision-making techniques vary according to the nature of the problem or topic, the decision maker, the context or
situation, and the decision-making method or process. For routine decisions, choices that are tried and true can be made for
well-defined, known situations or problems. Well-designed policies, rules, and standard operating procedures can produce
satisfactory results with a minimum of time. Artificial intelligence, including programmed computer systems such as
expert systems that can store, retrieve, and manipulate data, can diagnose problems and make limited decisions.
For adaptive decisions involving moderately ambiguous problems and modification of known and well-defined
alternative solutions, there are a variety of techniques. Many types of decision grids or tables can be used to compare
outcomes of alternative solutions. Decisions about units or services can be facilitated, with analyses comparing output,
revenue, and costs over time or under different conditions. Analyzing the costs and revenues of a proposed new service is
an example.
Regardless of the decision-making model or strategy chosen, data collection and analysis are essential. In many health
care organizations, quality teams are using a variety of tools to gather, organize, and analyze data about their work such as
cause-and-effect diagrams, flow charts, Pareto charts, run charts, histograms, control charts, and scatter diagrams. These
tools help nurses understand facts and relationships in processes they are examining. Figure 8-3 illustrates a
cause-and-effect diagram that a team of nurses created to help them improve the documentation process for their
ambulatory oncology unit.

GROUP DECISION MAKING

The widespread use of participative management, quality improvement teams, and shared governance in health care
organizations requires every nurse manager to determine when group, rather than individual, decisions are desirable and
how to use groups effectively. A number of studies have shown that professional people do not function well in a
micromanaged environment. As an alternative, group problem solving of substantial issues casts the manager in the role of
facilitator and consultant. Compared to individual decision making, groups can provide more input, often produce better
decisions, and generate more commitment. Several group decision-making techniques can be used.

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Figure 8-3 Brainstorming session of a nursing quality focus team.

Nominal Group Technique

The nominal group technique (NGT), developed by Delbecq, VandeVen, and Gustafson (1975), is a structured and
precise method of eliciting written questions, ideas, and reactions from group members. NGT is a group process in name
only because no direct exchange occurs among members. NGT consists of:
• Silently generating ideas in writing
• Round-robin presentation by group members of their individual ideas in a terse phrase on a flip chart
• Discussion of each recorded idea for clarification and evaluation
• Voting individually on priority ideas, with the group solution being derived mathematically through rank ordering or
rating using the group's decision rule

Delphi Technique
In the Delphi technique, judgments on a particular topic are systematically gathered from participants who do not meet face
to face. Ideas are collected through a carefully designed sequence of questionnaires interspersed with summaries of
information and opinions derived from previous questionnaires. The process may involve many iterations but normally does
not exceed three. This technique can rely on the input of experts widely dispersed geographically. It can be used to evaluate
the quality of research proposals or to make predictions about the future scientific knowledge. This technique is useful when
expert opinions are needed and expense would prohibit bringing them together.
For fact-finding problems with no known solution, the NGT and the Delphi technique are superior to other group
techniques. Both NGT and the Delphi technique minimize the chances of vocal members dominating discussion and allow
independent consideration of ideas.

Statistical Aggregation
Like the Delphi technique, statistical aggregation does not require a group meeting. Individuals are polled regarding a
specific problem, and their responses are tallied. It is a very efficient technique, but it is limited to problems for which a
quantifiable answer can be obtained. One disadvantage of both statistical aggregation and the Delphi technique is that no
opportunity exists for group members to strengthen their interpersonal ties or for the generative effect of group interaction.

Brainstorming
In brainstorming, group members meet together and generate many diverse ideas about the nature, cause, definition, or
solution to a problem without consideration of their relative value. A premium is placed on generating lots of ideas as quickly
as possible and on coming up with unusual ideas. Most importantly, members do not critique ideas as they are proposed.
Evaluation takes place after all the ideas have been generated. Members are encouraged to improve on each other's ideas.
These sessions are very enjoyable but are often unsuccessful because members inevitably begin to critique ideas, and as a
result, meetings shift to the ordinary interacting group format. Criticisms of this approach are the high cost factor, the time
consumed, and the superficiality of many solutions.

STUMBLING BLOCKS
The leader's personality traits, inexperience, lack of adaptability, and preconceived ideas may be obstacles to problem
solving and decision making.

Personality
The leader's personality can and often does affect how and why certain decisions are made. Many nurse managers are
selected because of their expert clinical, not management skills. Inexperienced in management, they may resort to various
unproductive activities. On the one hand, a nurse manager who is insecure may base decisions primarily on approval
seeking. When a truly difficult situation arises, the manager, rather than face rejection from the staff, makes a decision that
will placate people rather than one that will achieve the larger goals of the unit and organization.
On the other hand, a nurse manager who demonstrates an authoritative type of personality might make unreasonable
demands on the staff, fail to reward staff for long hours because he or she has a "workaholic" attitude, or give the staff no
control over patient care activities. Similarly, an inexperienced manager may cause a unit to flounder because the manager
is not inclined to act on new ideas or solutions to problems. Optimism, humor, and a positive approach are crucial to
energizing staff and promoting creativity.

Rigidity
Rigidity, an inflexible management style, is another obstacle to problem solving. It may result from ineffective trial-and-error
solutions, fear of risk taking, or inherent personality traits. You can avoid ineffective trial-and-error problem solving by
gathering sufficient information and determining a means for early correction of wrong or inadequate decisions. Also, to
minimize risk in problem solving, understand alternative risks and expectations.

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 The person who uses a rigid style in problem solving easily develops tunnel vision—the tendency to look at new things
in old ways and from established frames of reference. It then becomes very difficult to see things from another perspective,
and problem solving becomes a process whereby one person makes all of the decisions with little information or data from
other sources. In the current changing health care setting, rigidity can be a barrier to effective problem solving.

Preconceived Ideas
Effective leaders do not start out with the preconceived idea that one proposed course of action is right and all others wrong.
Nor do they assume that only one opinion can be voiced and others will be silent. They start out with a commitment to find
out why others disagree. If the staff, other professionals, or patients see a different reality or even a different problem,
leaders need to integrate this information into developing additional problem-solving alternatives.

MANAGING CONFLICT
Managing conflict is an important part of the nurse manager's job. They often are involved in conflict management on
several different levels. They may be participants in the conflict as individuals, supervisors, or representatives of a unit. In
fact, they must often initiate conflict by confronting staff, individually or collectively, when. a problem develops. They also
may serve as mediators or judges to conflicting parties. There could be a conflict within the unit, between parties from
different units, or between internal and external parties (for example, a nursing instructor from the university may have a
conflict with staff on a particular unit).
Everyone must be realistic regarding the outcome. Often those inexperienced in conflict negotiation expect unrealistic
outcomes. When two or more parties hold mutually exclusive ideas, attitudes, feelings, or goals, it is extremely difficult,
without the commitment and willingness of all concerned, to arrive at an agreeable solution that meets the needs of both.
Conflict management begins with a decision regarding if and when to intervene. Failure to intervene can allow the
conflict to get out of hand, whereas early intervention may be detrimental to those involved, causing them to lose confidence
in themselves and reduce risk-taking behavior in the future. Some conflicts are so minor, particularly if they are between only
two people, that they do not require intervention and would be better handled by the two people involved. Allowing them to
resolve their conflict might provide a developmental experience and improve their abilities to resolve conflict in the future.
When the conflict might result in considerable harm, however, the nurse manager must intervene.
Sometimes it is best to postpone intervention purposely to allow the conflict to escalate, because increased intensity can
motivate participants to seek resolution. You could escalate the conflict even further by exposing participants to each other
more frequently without the presence of others and without an easy means of escape. Participants are then forced to face
the conflict between them. Giving participants a shared task or shared goals not directly related to the conflict may help them
understand each other better and increase their chances to resolve their conflicts by themselves. Using such a method is
useful only if the conflict is not of high intensity, if the participants are not highly anxious about it, and if the manager believes
that the conflict will not decrease the efficiency of the department in the meantime.
If you decide to intervene in a conflict between two or more parties, you can apply mediation techniques, deciding when,
where, and how the intervention should take place. Routine problems can be handled in either the superior's or
subordinate's office, but serious confrontations should take place in a neutral location unless the parties involved are of
unequal power. In this case, the setting should favor the disadvantaged participant, thereby equalizing their power.
The place should be one where distractions will not interfere and adequate time is available. Because conflict
management takes time the manager must be prepared to allow sufficient time for all parties to explain their points of view
and arrive at a mutually agreeable solution. A quick solution that inexperienced managers often resort to is to impose
positional power, making a premature decision. This results in a win-lose outcome, which leads to feelings of elation and
eventual complacency for the winners and loss of morale for the losers.
The following are basic rules on how to mediate a conflict between two or more parties:
1. Protect each party's self-respect. Deal with a conflict of issues, not personalities.
2. Do not put blame or responsibility for the problem on the participants. The participants are responsible for developing
a solution to the problem.
3. Allow open and complete discussion of the problem from each participant.
4. Maintain equity in the frequency and duration of each party's presentation. A person of higher status tends to speak
more frequently and longer than a person of lower status. If this occurs, the mediator should intervene and ask the
person of lower status for response and opinion.
5. Encourage full expression of positive and negative feelings in an accepting atmosphere. The novice mediator tends
to discourage expressions of disagreement.
6. Make sure both parties listen actively to each other's words. One way to do this is to ask one person to summarize
the comments of the other prior to stating her or his own.
7. Identify key themes in the discussion, and restate these at frequent intervals.
8. Encourage the parties to provide frequent feedback to each other's comments; each must truly understand the
other's position.
9. Help the participants develop alternative solutions, select a mutually agreeable one, and develop a plan to carry it
out. All parties must agree to the solution for successful resolution to occur.

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 10. At an agreed-upon interval, follow up on the progress of the plan.
11. Give positive feedback to participants regarding their cooperation in solving the conflict.
Conflict management is a difficult process, consuming both time and energy. Management and staff must be concerned
and committed to resolving conflict by being willing to listen to others' positions and to find agreeable solutions.

FILLEY'S STRATEGIES
Filley (1975) identified three basic strategies for dealing with conflict according to the outcome: win-lose, lose-lose, and
win-win. In the win-lose strategy, one party exerts dominance, usually by power of authority, and the other party submits
and loses. Forcing, competing, and negotiation are techniques likely to lead to win-lose competition. Majority rule is another
example of the win-lose outcome, especially within groups. It may be a satisfactory method of resolving conflict, however, if
various factions vote differently on different issues and the group functions over time so that members win some and lose
some. Win-lose outcomes often occur between groups. Frequent losing, however, can lead to the loss of cohesiveness
within groups and diminish the authority of the group leader.
In the lose-lose strategy, neither side wins. The settlement reached is unsatisfactory to both sides. Avoiding,
withdrawing, smoothing, and compromising may lead to lose-lose outcomes. One compromising strategy is to use a bribe to
influence another's cooperation in doing something he or she dislikes. For example, the nurse manager may promise a
future raise in an attempt to coerce a staff member to work an extra weekend. Using a third party as arbitrator can lead to a
lose-lose outcome. Because an outsider may want to give something to each side, neither gets exactly what he or she
desires, resulting in a lose-lose outcome. This is a common strategy in arbitration of labor management disputes. Another
strategy that may result in a lose-lose or win-lose outcome is resorting to rules. The outcome is determined by whatever the
rules say, and confrontation is avoided.
The win-lose and lose-lose methods share some common characteristics:
1. The conflict is person-centered (we—they) rather than problem-centered. This is likely to occur when two cohesive
groups that do not share common values or goals are in conflict.
2. Parties direct their energy toward total victory for themselves and total defeat for the other. This can cause long-term
problems for the organization.
3. Each sees the issue from her or his own point of view rather than as a problem in need of a solution.
4. The emphasis is on outcomes rather than definition of goals, values, or objectives.
5. Conflicts are personalized.
6. Conflict-resolving activities are not differentiated from other group processes.
7. There is a short-run view of the conflict; the goal is to settle the immediate problem rather than resolve differences.
Win-win strategies focus on goals and attempt to meet the needs of both parties. Two specific win-win strategies are
consensus and integrative decision making. Consensus involves attention to the facts and to the position of the other
parties and avoidance of trading, voting, or averaging, where everyone loses something. The consensus decision is often
superior to even the best individual one. This technique is most useful in a group setting because it is sensitive to the
negative characteristics of win-lose and lose-lose outcomes. True consensus occurs when the problem is fully explored, the
needs and goals of the involved parties are understood, and a solution that meets these needs is agreed upon. Integrative
decision making focuses on the means of solving a problem rather than the ends. They are most useful when the needs of
the parties are polarized.
Integrative decision making is a constructive process in which the parties jointly identify the problem and their needs.
They explore a number of alternative solutions and come to consensus on a solution. The focus of this group activity is to
solve the problem, not to force, dominate, suppress, or compromise. The group works toward a common goal in an
atmosphere that encourages the free exchange of ideas and feelings. Using integrative decision-making methods, the
parties jointly identify the value needs of each, conduct an exhaustive search for alternatives that could meet the needs of
each, and then select the best alternative. Like the consensus methods, integrative decision making focuses on defeating
the problem, not each other.

OTHER STRATEGIES
Several other strategies can be used to manage conflict. Some tend to be more successful than others depending on the
situation, those involved, and the organization.
Confrontation is considered the most effective means for resolving conflicts. This is a problem-oriented technique in
which the conflict is brought out into the open and attempts are made to resolve it through knowledge and reason. The goal
of this technique is to achieve win-win solutions. Facts should be used to identify the problem. The desired outcome should
be explicit. "This is the third time this week that you have not been here for report. According to hospital policy, you are
expected to be changed, scrubbed, and ready for report in the lounge at 7:00 A.M. " is an example.
Confrontation is most effective when delivered in private as soon as possible after the incident occurs. Employee
respect and manager credibility are two important considerations when a situation warrants confrontation. A more
immediate confrontation also helps both the employee and manager sort out pertinent facts. In an emotionally charged
situation, however, it may be best for the parties to wait. Regardless of timing, the message is usually more effective if the
manager listens and is empathetic.

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 Many other techniques besides intervention can be used to resolve conflict and are consistent with the problem-solving
approach. Some of these include changing or clarifying goals, making appeals to the hierarchy, providing cooling-off
periods, using intermediaries, and dividing the resources so each party can partially achieve its goals.
Negotiation involves give-and-take on various issues among the parties. Its purpose is to achieve agreement even
though consensus will never be reached. Therefore, the best solution is not often achieved. Negotiation often becomes a
structured, formal procedure, as in collective bargaining. However, negotiation skills are important in arriving at an
agreeable solution between any two parties. Staff learn to negotiate schedules, advanced practice nurses negotiate with
third-party payers for reimbursement, insurance companies negotiate with vendors and hospitals for discounts, and clinic
managers negotiate employment contracts with physicians. Although negotiation involves adept communication skills, its
usefulness revolves around issues of conflict. Without differences in opinion, there would be no need for negotiation.
Levenstein (1984) lists ten commandments for negotiators:
1. Clarify the common purpose.
2. Keep the discussion relevant.
3. Get agreement on terminology.
4. Avoid abstract principles; concentrate on the facts.
5. Look for potential tradeoffs.
6. Listen.
7. Avoid debating tactics; use persuasive tactics.
8. Keep in mind the personal element.
9. Use logic logically.
10. Look for solutions that satisfy the other person's real interests.
Collaboration implies mutual attention to the problem, in which the talents of all parties are used. In collaboration, the
focus is on solving the problem, defeating the opponent. The goal is not to satisfy both parties' concerns. Collaboration is
useful in situations in which the goals of both parties are too important to be compromised.
Compromise is used to divide the rewards between both parties. Neither gets what she or he wants. Compromise can
serve as a backup to resolve conflict when collaboration is ineffective. It is sometimes the only choice when opponents of
equal power are in conflict over two or more mutually exclusive goals. Compromising also is. expedient when a solution is
needed rapidly.
Competing is an all-out effort to win, regardless of the cost. Competing may be needed in situations involving unpopular
or critical decisions. Competing also is used in situations in which time does not allow for more cooperative techniques.
Accommodating is an unassertive, cooperative tactic used when individuals neglect their own concerns in favor of
others' concerns. Accommodating frequently is used to preserve harmony when one person has a vested interest in an
issue that is unimportant to the other party.
In situations where conflict is discouraged, suppression is often used. Suppression could even include the elimination of
one of the conflicting parties through transfer or termination. Other, less effective techniques for managing conflict include
withdrawing, smoothing, and forcing, although each mode of response is useful in given situations.
In avoiding, the participants never acknowledge that a conflict exists. Avoidance is the conflict resolution technique
often used in highly cohesive groups. The group avoids disagreement because they do not want to do anything that may
interfere with the good feelings they have for each other.
Withdrawal from the conflict. simply removes at least one party, thereby making it impossible to resolve the situation.
The issue remains unresolved, and feelings about the issue may resurface inappropriately. If the conflict escalates into a
dangerous situation, avoiding and withdrawing are appropriate strategies.
Smoothing is accomplished by complimenting one's opponent, downplaying differences, and focusing on minor areas
of agreement, as though little disagreement existed. Smoothing may be appropriate in dealing with minor problems, but in
response to major problems, it produces the same results as withdrawing.
Forcing is a method that yields an immediate end to the conflict but leaves the cause of the conflict unresolved. A
superior can resort to issuing orders, but the subordinate will lack commitment to the demanded action. Forcing may be
appropriate in-life-or-death situations but is otherwise inappropriate. Negotiation and confrontation are generally more
effective modes of responding to conflict (Hader, 2007).
Resistance can be positive or negative. It may mean a resistance to change or disobedience, or it may be an effective
approach to handling power differences, especially verbal abuse (Caron, 2006).

BULLYING: A UNIQUE CASE OF CONFLICT

Bullying in the workplace increases staff dissatisfaction, turnover, and litigation, and damages the organization's reputation
and 70 percent leave the workplace (Dempster, 2006). Both students and practicing nurses report cases of workplace
bullying (Stevenson, Randle, & Grayling, 2006). Such workplace aggression is similar to domestic violence in that it involves
abuse of power (DelBel, 2003). Verbal abuse, such as publicly chastising or shaming, physical threats, intimidation, or
sexual advances are just a few ways that bullies attempt to coerce their victims. To confront bullies, several strategies are
suggested (Mladineo, 2006).

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Education (Department of Nursing) 20 of 24
 1. Don't blame yourself. Bullies tend to target those they feel threaten them or their status, and they use their superior
position to try to make their victims blame themselves.
2. Learn how to bully-proof yourself. Know Put rights and prepare answers in advance.
3. Confront the bully. Sometimes simply telling the bully that you find the behavior offensive and unacceptable will stop
the behavior, especially if others you know are allies are present.
4. Avoid the bully if possible.
5. Keep a record. Detail each event with date, time, location, any others present, and what happened. This is invaluable
should the situation escalate.
The manager has a special duty to protect staff from bullying by others, to each other, or to students. Take every report
of verbal aggression seriously and use the appropriate conflict strategy to resolve it. Left on its own, bullying is likely to
continue and escalate.
Managing conflict is an essential skill for the manager and, indeed, all nurses. Avoiding conflict or allowing it to fester
and remain unresolved undermines the manager's effectiveness and can result in dissatisfied staff and nursing shortages.
Resolving conflict, on the other hand, can lead to better outcomes both with the immediate situation and encourage the
manager to resolve conflict in the future.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Which of the following is the correct definition of communication?

a. Simple, ongoing, dynamic process in which the participants simultaneously create shared meaning in an
interaction.
b. Complex, ending, dynamic process in which the participants simultaneously create shared meaning in an
interaction.
c. Complex, ongoing, dull process in which the participants simultaneously create shared meaning in an
interaction.
d. Complex, ongoing, dynamic process in which the participants simultaneously create shared meaning in an
interaction.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. The goal of communication is to:

a. Approach, as closely as possible, a common understanding of the message sent and the one received.
b. Recede, as closely as possible, a common understanding of the message sent and the one received.
c. Approach, as open as possible, a common understanding of the message sent and the one received.
d. Approach, as closely as possible, a unique understanding of the message sent and the one received.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Behaviors such as head or facial agreement or disagreement accompanies oral messages called:
a. Miscommunication
b. Misinterpretation
c. Metacommunication
d. Metainterpretation
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 21 of 24
4. A manager states, “Come talk to me anytime”, but keeps on typing at the keyboard while you talk. This can lead to:
a. Intrasender Conflict
b. Intersender Conflict
c. Intrareceptor Conflict
d. Interreceptor Conflict
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. The risk manager may encourage a nurse to report medication errors, but the nurse manager follows up with discipline
over the error. This is an example of:
a. Intrasender Conflict
b. Intersender Conflict
c. Intrareceptor Conflict
d. Interreceptor Conflict
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. The nurse managers of the operating room and delivery room held a meeting regarding a CS client. This is an example of
what type of communication?
a. Downward communication
b. Upward communication
c. Lateral communication
d. Diagonal communication
e. Grapevine
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The staff nurse is to report the daily activities to the nurse supervisor this is a/an:
a. Downward communication
b. Upward communication
c. Lateral communication
d. Diagonal communication
e. Grapevine
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The staff nurse of the oncological unit coordinated with the ER nurse supervisor. This is a/an:
a. Downward communication
b. Upward communication
c. Lateral communication
d. Diagonal communication
e. Grapevine
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. The nurse manager assigned the staff nurse to be the medication nurse of the day. This is a/an:
a. Downward communication
b. Upward communication
c. Lateral communication
d. Diagonal communication

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Education (Department of Nursing) 22 of 24
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. A rumor started in the unit about a staff nurse dating his/her patient. This came from what type of communication?
a. Downward communication
b. Upward communication
c. Lateral communication
d. Diagonal communication
e. Grapevine
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 23 of 24
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This activity is to evaluate what you have learned after the discussion.

Three things you learned:

1) _______________________________________________________________________________________________
2) _______________________________________________________________________________________________
3) _______________________________________________________________________________________________

Two things that you’d like to learn more about:

1) _______________________________________________________________________________________________
2) _______________________________________________________________________________________________

One question you still have:

1) _______________________________________________________________________________________________

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Education (Department of Nursing) 24 of 24
 Nursing Leadership and Management)
BS NURSING / FOURTH YEAR
STUDENT ACTIVITY SHEET
Session # 23

LESSON TITLE: CONTROLLING/EVALUATION Materials:

LEARNING OUTCOMES: Book, pen and notebook, and index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Describe criteria that can be used to evaluate staff Sullivan, E. J. (2009), Effective Leadership and
performance; Management in Nursing (7th edition). Singapore:
2. Discuss different methods used to evaluate performance; Pearson Education South Asia Pte Ltd.
3. Describe problems to expect when evaluating performance;
4. Explain how to use critical incidents to improve annual
evaluations;
5. Explain how to conduct a performance evaluation; and,
6. Describe how to evaluate skill competency.

LESSON PREVIEW/REVIEW
Based on the previous lesson, list down the strategies for conflict management and briefly explain each:

MAIN LESSON

CONTROLLING
- Involves comparing actual results with projected results
- Includes assessing and regulating performance in accordance with the plans that have been adopted, the instructions
issued, and the principle established
- This process opens opportunities for improvement and comparing performance against set standards.

STANDARD
- A pre-determined level of excellence that serves as a guide to nursing practice
- Desirable set of conditions and performance necessary to ensure the quality of nursing service
- This includes:
ü Predetermined
ü Established by an authority
ü Communicated to and accepted by the people affected by them

COMPONENTS OF CONTROL PROCESS

ü Establish the Standards of Performance
ü Determining the Means or Methods to be Used in Measuring Performance
ü Evaluating Performance
ü Providing Feedback

Establish the Standards of Performance

- Relate to 3 major dimensions of quality care:
1. STRUCTURE – relate to the physical environment, organization, & management of an organization

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Education (Department of Nursing) 1 of 17
 2. PROCESS – are those connected with the actual level of care
3. OUTCOME – involves the end results of care that has been given

Evaluating Performance
- Measuring the actual performance.
- Comparing results of performance with the standards.

Providing Feedback
- Reinforcing strengths of success and taking corrective action as necessary

PRINCIPLES OF EVALUATION
1. The evaluation must be based on the behavioral standards of performance which the position requires.
2. In evaluating performance, there should be enough time to observe employee’s behavior.
3. The employee should be given a copy of the job description, performance standards, and evaluation form before
the scheduled evaluation conference.
4. The employee’s performance appraisal should include both satisfactory and unsatisfactory results with specific
behavioral instances to exemplify these evaluative comments.
5. Areas needing improvement must be prioritized to help the worker upgrade his/her performance.
6. The evaluation conference should be scheduled and conducted at a convenient time for the rater and the
employee under evaluation, in a pleasant surrounding and with ample time for discussion.
7. The evaluation report and conference should be structured in such a way that it is perceived and accepted
positively as a means of improving job performance.

THE PERFORMANCE APPRAISAL

- Periodic formal evaluation of how well personnel have performed their duties during specified period.
- Most valuable tool in controlling human resources and productivity.
The performance appraisal process includes:
• Day-to-day manager—employee interactions
• Making notes about an employee's behavior
• Completing the performance appraisal form
• The formal appraisal interview
• Follow-up sessions that may involve coaching and/or discipline when needed
Performance appraisals are conducted for a number of reasons. The primary reason is to give constructive feedback. A
good appraisal system ensures that staff know what they are to do and how well they are doing it.
Performance appraisals often serve as the basis on which administrative decisions, such as the size of a salary increase
or who gets promoted, are made. Ideally, accurate appraisal information allows the organization to tie rewards to
performance. However, accuracy is a skill developed only with experience.
A final reason for doing performance reviews concerns fair employment practice law. Performance appraisals and the
decisions based on those appraisals, such as layoffs, are covered by several federal and state laws. In the past two
decades, many employees have successfully sued their organizations over employment decisions that were based on
questionable performance appraisal results.
There are several steps to help ensure that an appraisal system is nondiscriminatory.
1. The appraisal should be in writing and carried out at least once a year.
2. The performance appraisal information should be shared with the employee.
3. The employee should have the opportunity to respond in writing to the appraisal.
4. Employees should have a mechanism to appeal the results of the performance appraisal.
5. The manager should have adequate opportunity to observe the employee's job performance during the course of the
evaluation period. If adequate contact is lacking (e.g. the appraiser and the appraisee work different shifts), then
appraisal information should be gathered from other sources.
6. Anecdotal notes on the employee's performance should be kept during the entire evaluation period (e.g., 3 months, 1
year). These notes, called critical incidents and discussed later, should be shared with the employee during the course
of the evaluation period.
7. Evaluators should be trained to carry out the performance appraisal process, including
a. What is reasonable job performance,
b. How to complete the form, and
c. How to carry out the feedback interview.
8. As far as possible, the performance appraisal should focus on employee behavior and results rather than on personal
traits or characteristics, such as
a. Initiative
b. Attitude

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Education (Department of Nursing) 2 of 17
 c. Personality
Regardless of how an organization uses performance appraisals, they must accurately reflect the employee's actual job
performance. If performance ratings are inaccurate, an inferior employee may be promoted, another employee may not
receive needed training, or there may not be a tie between performance and rewards (thus lessening employee motivation).
For appraisals to be successful, the needs of the staff and requirements of the organization must be bridged.

COMPONENTS TO BE EVALUATED
Nurses engage in a variety of job-related activities. To reflect the multidimensional nature of the job, the performance
appraisal form usually requires a nurse manager to rate several different performance dimensions, such as use of the
nursing process, professionalism, safety, continuing education, and initiative. In developing an appraisal device, an
organization can focus on employee traits, results, behaviors, and/or some combination thereof. The specific focus of the
form affects the whole appraisal process.

Traits and Personal Characteristics

Some appraisal systems focus on personal traits and characteristics, such as stability or ability to handle stress, because
trait-oriented instruments are inexpensive to develop and can be used for a wide variety of positions. Today, however,
employers seldom use trait-oriented systems, primarily because of charges that they discriminate against some groups. To
satisfy legal requirements, the organization should be able to demonstrate the validity (job-relatedness) of the appraisal
ratings.
Also trait ratings are not useful in helping to develop employees. In most health care organizations, a major reason for
doing performance appraisals is to help employees improve. However, because most trait-rating dimensions are somewhat
ambiguous (for example, what precisely is meant by "initiative"?), trait-oriented systems do not tell a staff nurse what to do
differently in the future.

Results-Oriented System
All organizations need to be concerned with the bottom line. If a hospital has a 35 percent occupancy rate or a 20 percent
employee absenteeism rate, its future is in jeopardy. In recent years, therefore, top management has turned to appraising
some employees at least partly on results. With a results-oriented appraisal system, employees know in advance what is
expected. Objectives are quantifiable, objective, and easily measured.

Sylvia is an experienced critical care nurse. Her goals for the year include:
• Complete advanced cardiac life support (ACTS) recertification.
• Obtain CCRN credentialing.
• Preceptor one new graduate nurse.
• Serve on hospital shared governance committee.

At Sylvia's annual performance review, her manager noted that she had:
• Become ACLS recertified.
• Obtained CCRN credentialing.
• Preceptored a new graduate nurse who was functioning above expectations.
• Chaired subcommittee of hospital shared governance committee.

Behavioral Criteria
In recent years, many health care organizations have adopted behavior-oriented performance appraisal systems rather than
focusing on difficult-to-measure results or on vague traits that may cause legal problems. Behavior-oriented systems focus
on what the employee actually does, as exemplified in Figure 18-1.
Such a system gives new employees specific information on how they are expected to behave and is less likely to lead
to legal problems. The behavioral focus facilitates employee development. The major draw-backs of a behavior-oriented
appraisal system are that it is relatively time consuming to develop and is tied to only one job or a narrow range of jobs. For
example, the behavioral items presented in Figure 18-1 would be applicable only to staff nurses.

Combining Different Types of Criteria

As health care organizations have become more concerned with employee productivity in the last few years, some have
developed appraisal systems that combine various types of criteria. In such a system, each employee may have a few major
objectives he or she is expected to accomplish. In addition to being evaluated on whether these results were attained,
individuals are also evaluated in terms of both general personal characteristics and behaviorally specific criteria.

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Education (Department of Nursing) 3 of 17
SPECIFIC EVALUATION METHODS
Traditional Rating Scales
Many organizations use a traditional rating scale for all employees in a class (e.g., staff nurse, clinical nurse specialist),
regardless of their specific job setting (e.g., outpatient surgery, ambulatory clinic).
A traditional rating scale includes:
• General performance dimensions not necessarily based on a job description
• Equally weighted dimensions
• Absolute judgment standards
• Judgments based on the supervisor's idea of satisfactory performance

Figure 18-1 Behavior-oriented performance appraisal items for the job of staff nurse.

In filling out a traditional rating scale, the appraiser is required to reflect on the appraisee's performance over the entire
evaluation period (usually 12 months) and rate the individual against the rater's internal standard of performance. Individuals
using trait-rating scales commonly complain either that the performance dimension (e.g., leadership) is irrelevant to the job
in question or that they do not know exactly what is meant by the dimension. Such complaints arise because one appraisal
form is being used across a variety of jobs and because the performance dimensions are not tied to concrete behaviors.

Essay Evaluation
With the essay evaluation technique, the nurse manager is required to describe the employee's performance over the
entire evaluation period by writing a narrative detailing the strengths and weaknesses of the appraisee. If done correctly, this
approach can provide a good deal of valuable data for discussion in the appraisal interview. If used alone, however, an
essay evaluation is subject to a number of constraints that can limit its effectiveness. For example, essay evaluations can be
time consuming to write, they depend on appraisers' abilities to express themselves in prose, and they can be difficult to
defend in court because comments made by the manager may not be closely tied to actual job performance. Most
organizations have found that essay evaluations are more useful when they are used in combination with other evaluation
formats and when they are based on notes taken by the manager during the course of the evaluation period.

Forced Distribution Evaluation

The forced distribution evaluation is similar to grading on a curve. If the rating scale has five categories, the manager may
be required to spread employees' ratings equally over the five categories.
Because this technique is constraining, most evaluators do not like it. One hears such complaints as:
"I have two exceptional employees, but this system only allows me to put one of them in the highest category."
"I don't have an employee who deserves to be rated in the lowest category."
Because of the general dislike of forced distribution systems, they are not commonly used. In those instances where
they are used, forced distribution systems were generally implemented because managers were giving all of their
employees high ratings.

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Education (Department of Nursing) 4 of 17
Behavior-Oriented Rating Scales
As noted earlier, focusing on specific behaviors in appraising performance has tremendous advantages. For example, new
employees have specific information on how they should behave. Although there are several varieties of behavior-oriented
rating scales, they all share a number of things in common:
1. Groups of workers who are very familiar with the target job (generally, individuals doing the job and their immediate
supervisors) provide written examples (critical incidents) of superior and inferior job behaviors.
2. These critical incidents are stated as measurable/quantifiable behaviors. (Examples are given in Figure 18-1.)
3. Critical incidents that are similar in theme are grouped together. These behavioral groupings (performance
dimensions) are labeled, for example, nursing process or communication.
4. Statistical procedures are used to arrive at a subset of the original pool of critical incidents. These procedures
eliminate items that do not clearly reflect the performance dimension into which they were grouped, overlap other critical
incidents, or are poorly worded.
In view of the way that behavior-oriented rating scales are developed, it is apparent that such behavior-oriented
appraisal measures can be used only for one job or a cluster of very similar jobs and that these scales are time consuming
and therefore expensive to develop. For these reasons, behavior-oriented systems are generally developed when a large
number of individuals are doing the same job, such as staff nurses. Because employees and their managers actually
develop the appraisal instrument, they have faith in the system and are motivated to use it.

Results-Oriented Evaluations
Whereas the other approaches to performance evaluation focus on an employee's personal characteristics (traits) or
behavior, a focus on results requires setting objectives for what the employee is to accomplish. Although this technique has
many variations, basically it involves two steps.
First, a set of work objectives is established at the start of the evaluation period for the employee to accomplish during
some future time frame. These objectives can be developed by the employee's supervisor and given to the employee;
however, it is better if the manager and employee work together to develop a set of objectives for the employee.
Each performance objective should be defined in concrete, quantifiable terms and have a specific time frame. For
example, one objective may need to be accomplished in 1 month (e.g., "Revise the unit orientation manual to reflect the new
Joint Commission standards"); another objective may not have to be met for 12 months (e.g., "Take and pass the CCRN
examination within the next year"). In setting objectives, it is important that the employee perceive them as challenging yet
attainable.
The second step involves the actual evaluation of the employee's performance. At this time, the supervisor and
employee meet and focus on how well the employee has accomplished his or her objectives.
With increasing emphasis on outcomes, results-oriented assessments are becoming more commonly used in health
care settings.

POTENTIAL APPRAISAL PROBLEMS

No matter what type of appraisal device is used, problems that lessen the accuracy of the performance rating can arise,
such as leniency, recency, and halo errors; ambiguous evaluation standards; and written comments problems. These, in
turn, limit the usefulness of the performance review. For example, if a performance rating can be shown to be inaccurate, it
will be difficult to defend in court.

Leniency Error
Many nurse managers tend to overrate their staff's performance. This is called leniency error. For example, a manager
may rate everyone on her or his staff as "above average." Although numerous reasons are given for inflated ratings (e.g., "I
want my nurses to like me," "It's difficult to justify giving someone a low rating"), these reasons do not lessen the problems
that leniency error can create for both the manager and the organization. For example, if you give a mediocre nurse lenient
ratings, it is difficult to turn around and take some corrective action, such as discipline.
Leniency error can also be demoralizing to the best staff nurses, because they would have received high ratings without
leniency. However, with leniency error, these outstanding nurses look less superior compared to their coworkers. Thus,
leniency error tends to be welcomed by poorer performers and disliked by better ones.

Recency Error
Another difficulty with frost appraisal systems is the length of time over which behavior is evaluated. In most organizations,
employees are formally evaluated every 12 months. Evaluating employee performance over such an extended period of
time, particularly if one supervises more than two or three individuals, is a difficult task. Typically, the evaluator recalls recent
performance and tends to forget more distant events. Thus, the performance rating reflects what the employee has
contributed lately rather than over the entire evaluation period. This tendency is called recency error; it too can create both
legal and motivational problems.

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Education (Department of Nursing) 5 of 17
 Shelby Miller, RN, transferred from a medical unit to the telemetry unit 9 months ago. Overall, her performance has been
good and she is an excellent team member. On two occasions, other nursing staff told the nurse manager, Lucinda Amos,
about Shelby's quick and accurate assessment of critical changes in patient status. Last week, Shelby misread a physician's
order and didn't administer preprocedure medications as directed. The procedure had to be rescheduled, resulting in
surgical delays as well. The physician was angry and complained to both Lucinda and the cardiology nursing director. On
her annual performance appraisal, Lucinda rated Shelby "below average" on Patient care delivery.

Legally, if a disgruntled employee can demonstrate that an evaluation that supposedly reflects 12 months actually
reflects performance over the last 2 or 3 months, an organization will have difficulty defending the validity of its appraisal
system. In terms of motivation, recency error demonstrates to all employees that they only need to perform at a high level
near the time of their performance review. In such situations, an employee is highly motivated (e.g., asking the supervisor for
more work) just prior to appraisal but considerably less motivated as soon as it is completed.
As with leniency error, recency error benefits the poorly performing individual. Nurses who perform well year round may
receive ratings similar to those mediocre nurses who spurt as their evaluation time approaches. Fortunately, a simple
procedure (recording critical incidents, discussed later in the chapter) greatly lessens the impact of recency error.

Halo Error
Sometimes an appraiser fails to differentiate among the various performance dimensions (e.g., nursing process,
communication skills) when evaluating an employee and assigns ratings on the basis of an overall impression, positive or
negative, of the employee (Goffin, 2001). Thus, some employees are rated above average across dimensions, others are
rated average, and a few are rated below average on all dimensions. This is referred to as halo error.
If a nurse is excellent, average, or poor on all performance dimensions, she or he deserves to be rated accordingly, but
in most instances, employees have uneven strengths and weaknesses. Thus, it should' be relatively uncommon for an
employee to receive the same rating on all performance dimensions. Although halo error is less common and troublesome
than leniency and recency error, it still is not an accurate assessment of performance.

Ambiguous Evaluation Standards

Most appraisal forms use rating scales that include words such as "outstanding," "above average," "satisfactory," or "needs
improvement"; but different managers attach different meanings to these words, giving rise to what has been labeled the
ambiguous evaluation standards problem. Organizations have attempted to address this problem in two ways. One
approach is to have a group of nurse managers meet and discuss what each of them sees as outstanding performance,
above-average performance, and poor performance on each dimension. The goal is to arrive at a consensus on what level
of performance is expected on each dimension. Thus, the group of nurse managers may decide that to be rated excellent on
the dimension of self-development, a nurse must attend at least 10 in-service meetings in a year. When agreement is
reached on the behavior that reflects each level of a dimension, this information should be communicated to those being
evaluated.
A more formal approach to dealing with the ambiguous evaluation standards problem is to develop rating forms that
have each gradation along the performance continuum (e.g., excellent, satisfactory) anchored by examples of behavior that
is representative of that level of performance. Although a detailed discussion of the process an organization would use for
developing such performance standards is too complex to go into here (usually, a consulting firm works with the
organization), it involves groups of knowledgeable employees (e.g., job incumbents and their managers) meeting to discuss
the important performance dimensions (e.g., nursing process) of a job. Then examples of different levels of performance are
developed for each performance standard. For example, a rating of excellent on the performance standard of nursing
process/assessment might be anchored by "assessment documented on 95 percent of charts reviewed," whereas a rating
of poor on the same standard might be anchored by "assessment completed on 75 percent of charts reviewed."

Written Comments Problem

Almost all performance appraisal forms provide space for written comments by the appraiser. The wise manager uses this
space to justify in detail the basis for the ratings, to discuss developmental activities for the employee in the coming year, to
put the ratings in context (e.g., although the evaluation period is 12 months, the appraiser notes on the form that he or she
has only been the nurse's manager for the past 3 months), or to discuss the employee's promotion potential. Unfortunately,
few nurse managers use this valuable space appropriately; in fact, the spaces for written comments are often left blank.
When there are comments, they tend to be few and general (e.g., "Joan is conscientious"), focus totally on what the
individual did wrong, or reflect only recent performance.

Dawn Stanley, RN, is director of nursing for an assisted living center. Two certified nurse aides transferred to her center
from other facilities in the health care system. Both CNAs have struggled to meet performance expectations in the first 94
days of their new positions. In preparing performance appraisals for both employees, Dawn reviewed previous appraisals to
see if other managers had indicated areas for improvement or performance trends. Both employees were rated as "marginal
performers" but no written comments were provided, making the appraisal process more difficult for Dawn.

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Education (Department of Nursing) 6 of 17
 The existence of the written comments problem should not be surprising. Most nurse managers wait until the end of
the evaluation period to with written comments; thus, the manager is faced with a difficult, time-consuming task. Small
wonder, then, that the few comments tend to be vague, negative in tone, and reflect recent events. Fortunately, regular note
taking can lessen the problems associated with written comments.

THE APPRAISER
In most organizations, an employee's immediate manager is in charge of evaluating her or his performance. In many
situations, this makes sense. The manager is familiar with the employee's work and thus is best able to evaluate it. If the
immediate supervisor does not have enough information to evaluate an employee's performance accurately, alternatives
are necessary. The manager can informally seek out performance-related information from other sources, such as the
employee's co-workers, patients, or other managers who are familiar with the person being evaluated. The manager weighs
this additional information, integrates it with his or her own judgment, and completes the evaluation.
Another alternative involves a formal use of other sources. Peer review, self-assessments, and group evaluations are
growing in use and are appropriate for professionals. Peer review is a process by which registered nurses assess and judge
the performance of professional peers against predetermined standards. Peer review is designed to make performance
appraisal more objective because multiple ratings give a more objective appraisal. It is used frequently in clinical ladder
pro-grams, self-governance models, and evaluation of advanced practice nurses.
The steps for peer review are as follows:
1. The employee selects peers to conduct the evaluation. Usually, two to four peers are identified through a
predetermined process.
2. The employee submits a self-evaluation portfolio. The portfolio might describe how he or she met objectives and/or
predetermined standards during the past evaluation cycle. Supporting materials are included.
3. The peers evaluate the employee. This may be done individually or in a group. The individuals or group then submit a
written evaluation to the manager.
4. The manager and employee meet to discuss the evaluation. The manager's evaluation is included, and objectives for
the coming evaluation cycle are finalized.
Implementing a peer review involves several considerations. First, it is best to avoid selecting personal best friends for
the review. Friends can provide poor ratings as well as inflated ratings, resulting in a negative experience. Second, consider
how often to evaluate expert e practitioners; for example, those nurses who have reached the top of a clinical ladder. The
usual annual evaluations may not be necessary. Third, monitor the time needed for portfolio preparation. The object is to
improve professionalism and quality of patient care, not to create more paperwork.
Self-assessments help the employee examine performance over the year and consider improvements to be made. It is
difficult for anyone to accurately rate one's own performance so self-assessments tend to be overly positive or, in some
cases, excessively negative. Nonetheless, it is a valuable exercise to require employees to focus attention on how well they
have met the requirements of the job regardless of whether the appraisal is behavioral-oriented ("Completes patient care
plan within 24 hours of admission") or results-oriented ("Presented one in-service on the unit").
Another technique is group evaluation. In group evaluation, several managers are asked to rank employee
performance based on job descriptions and performance standards. Usually, one manager facilitates the process. In
addition to evaluating individual performance, performance of groups of nurses can also be evaluated in this way and group
variances can be benchmarked and evaluated. Using group evaluation reduces personal bias, is timely, and can be
effective.

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 Figure 18-2 Example of a critical incident.

DOCUMENTING PERFORMANCE
Appraising an employee's performance can be a difficult job. A nurse manager is required to reflect on a staff member's
performance over an extended period of time (usually 12 months) and then accurately evaluate it. Given that many nurse
managers have several employees to evaluate, it is not surprising that they frequently forget what an individual did several
months ago or that they may actually confuse what one employee did with what another worker did.
A useful mechanism for fighting such memory problems is the use of critical incidents, which are reports of employee
behaviors that are out of the ordinary, in either a positive or a negative direction. Critical incidents include four items: name
of employee, date and time of incident, a brief description of what occurred, and the nurse manager's comments on what
transpired (Figure 18-2.). Index cards or a PDA are best to use so that notes can be taken immediately without waiting until
time is available to note information on a 1 computer or paper file. Also this lag time increases the likelihood of errors and the
possibility that the manager will neglect to share the incident with the employee.
Recording critical incidents as they occur is bound to increase the accuracy of the year-end performance appraisal
ratings. Although this type of note taking may sound simple and straightforward, a manager can still run into problems; for
instance, some managers feel sheepish about this kind of record keeping. Many managers are uncomfortable about
recording behaviors; they see themselves as spies lurking around the work area attempting to catch someone. What they
need to remember is that this note taking will enable them to evaluate the employee more accurately and makes recency
error much less likely.
The best time to write critical incidents is just after the behavior occurred. The note should focus specifically on what
took place, not on an interpretation of what happened. For example, instead of writing, "Ms. Hudson was rude," write, "Ms.
Hudson referred to the patient as a slob." The nurse manager is responsible for deciding what are critical incidents. In some
departments, coming to work on time may be noteworthy; in other departments coming to work late is. Once a critical
incident has been recorded, the manager should share it with the employee in private. If the behavior is positive, this
provides a good opportunity for the nurse manager to praise the employee; if the behavior is considered in some way
undesirable, the manager may need to coach the employee.
Because most nurse managers are extremely busy, they sometimes question whether note taking is a good use of their
time. In fact, keeping notes is not a time-consuming process. The average note takes less than 2 minutes to write. If one
writes notes during the gaps in the day (e.g., while waiting for a meeting to start), little, if any, productive time is used. In the
long run, such note taking saves time. For example, keeping and sharing notes forces a manager to deal with problems

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when they are small and thus are more quickly addressed. In addition, completing the appraisal form at the end of the
evaluation period takes less time when one has notes for reference.
A key factor in effectively using this note-taking approach is how nurse managers introduce the technique to their staff.
To get maximum value out of note taking, nurse managers need to keep in mind two important facts:
1. The primary reason for taking notes is to improve the accuracy of the performance review.
2. When something new is introduced, people tend to react negatively to it.
Managers should be open and candid about the first fact, admitting that they cannot remember every event associated
with every employee and telling employees that these notes will make more accurate evaluations possible. Even then,
employees will still be suspicious about this new procedure. One way to get this note-taking procedure off to a good start is
for managers to make the first note they record on an employee a positive one, even if they have to stretch a bit to find one.
By doing this, each employee's first contact with critical incidents is positive.
Three types of mistakes common with using notes are:
1. Some managers fail to make them specific and behavior oriented; rather, they record that a nurse was "careless" or
"difficult to supervise."
2. Some managers record only undesirable behavior.
3. Some managers fail to give performance feedback to the employee at the time that a note was written.
Each of these errors can undermine the effectiveness of the note-taking process. If the notes are vague, the employee
may not know specifically what was done wrong and therefore does not know how to improve. If only poor performance is
documented, employees will resent the system and the nurse manager. If the nurse manager does not share notes as they
are written, the employee will often react defensively when confronted with them at the end of the evaluation period. In sum,
any nurse manager who is considering using this powerful note-taking procedure needs to take the process seriously and to
use it as it is designed.
By increasing the accuracy of the performance re-view, written notes also diminish the legal liability of lawsuits. If a
lawsuit is brought, written notes are very persuasive evidence in court. Sharing the notes with employees throughout the
evaluation period also improves the communication flow between the manager and the employee. Having written notes also
gives the manager considerable confidence when it comes time to complete the evaluation form and to carry out the
appraisal interview.
The nurse manager will be less prone to leniency and recency error and will feel confident that the appraisal ratings are
accurate. Not only does the nurse manager feel professional, but also the staff nurse shares that perception. In fact, it is
typically found that with the use of notes, the performance appraisal interview focuses mainly on how the employee can
improve next year rather than on how he or she was rated last year. Thus, the tone of the interview is constructive rather
than argumentative.
One final issue needs to be addressed. Different employees react differently to the use of notes. Good employees react
positively. Although the nurse manager records both what is done well and what is done poorly, good employees will have
many more positive than negative notes and therefore will benefit from notes being taken. In contrast, poorer employees do
not react well to notes being taken.
Whereas once they could rely on the poor memory of the nurse manager as well as on a leniency tendency to produce
inflated ratings, note taking is likely to result in more accurate (i.e., lower) ratings for poor employees. The negative reaction
of poor employees, however, tends not to be a lasting one. Generally, the poor performers either leave the organization, or
when they discover that they no longer can get away with mediocre performance, their performance actually improves.

DIAGNOSING PERFORMANCE PROBLEMS

If the manager notes poor or inconsistent performance during the appraisal process, the manager must investigate and
remedy the situation. Certain questions should be asked:
"Is the performance deficiency a problem?"
"Will it go away if ignored?"
"Is the deficiency due to a lack of skill or motivation? How do I know?"
The first step is to begin with accepted standards of performance and an accurate assessment of the current
performance of the staff member. This means job descriptions must be current and performance appraisal tools must be
written in behavioral terms. It also implies that employee evaluations are regularly carried out and implemented according to
recognized guidelines. Also, the employee must know what behavior is expected.
Next decide whether the problem demands immediate attention and whether it is a skill-related or motivation-related
problem. Skill-related problems can be solved through informal training, such as demonstration and coaching, whereas
complex skills require formal training (e.g., in-service sessions or workshops). If there is a limit to the time an employee has
to reach the desired level of skill, the manager must determine whether the job could be simplified or whether the better
decision would be to terminate or transfer the employee. If the performance problem is due to motivation rather than ability,
the manager must address a different set of questions. Specifically, the manager must determine whether the employee
believes that there are obstacles to the expected behavior or that the behavior leads to punishment, reward, or inaction. For
example, if the reward for conscientiously coming to work on holidays (rather than calling in sick) leads to always being
scheduled for holiday work, then good performance is associated with punishment.

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 Only when the employee sees a strong link between valued outcomes and meeting performance expectations will
motivation strategies succeed. The manager plays a role in tailoring motivational efforts to meet the individual needs of the
employee. Unfortunately, creating a performance—reward climate does not eliminate all problem behaviors. When the use
of rewards proves ineffective, other strategies, such as coaching and discipline, are warranted.
To differentiate between lack of ability and lack of motivation, the manager can analyze past performance. If past
performance has been acceptable and little change in standards of performance has taken place, then the problem results
from a lack of motivation. In contrast, if the nurse has never performed at an acceptable level, then the problem may be
primarily skill related. Different intervention strategies should be used, depending on the source of the problem. The
objective should be to enhance performance rather than to punish the employee. Figure 18-30 summarizes the steps to
take.

THE PERFORMANCE APPRAISAL INTERVIEW

Once the manager completes an accurate evaluation of performance, he or she should arrange an appraisal interview. The
appraisal interview is the first step in employee development.

Preparing for the Interview

Keep in mind what needs to be accomplished during the interview. If the appraisal ratings are accurate, they are more likely
to be perceived as such by the employee. This perception should, in turn, make the employee more likely to accept them as
a basis for both rewards as well as developmental activities. More specifically, to motivate employees, rewards need to be
seen as linked to performance.
The performance appraisal interview is the key to this linkage. In the interview, establish that performance has been
carefully assessed and that, when merited, rewards will be forthcoming. Developmental activities also need to be derived
from an accurate evaluation. If an employee is rated as "needs immediate improvement" on

Figure 18-3 Decision tree for evaluating performance.

delegation skills, for example, any effort to remedy this deficiency must stem from the employee's acceptance of the need
for improvement in delegation.
Even though nurse managers try to fill out the appraisal form accurately, they should still anticipate disagreement with
their ratings. Most employees tend to see themselves as above-average performers. This tendency to exaggerate our own
performance results from the fact that we tend to forget our mistakes and recall our accomplishments; we often rationalize
away those instances where our performance was substandard (e.g., "I forgot, but with this heavy workload, what do you
expect?"). Given this tendency to over evaluate one's own performance and the fact that most staff previously have had poor
experiences with the evaluation process, expect that staff will lack confidence in the whole appraisal process.
A key step for making the appraisal interview go well is proper planning (Smith, 2003). Set up the performance appraisal
interview in advance, preferably giving at least 2 days' notice. Schedule enough time: Most interviews last 20 to 30 minutes,

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although the time needed will vary considerably depending on the degree to which the nurse manager and the staff nurse
have talked regularly during the year.
In preparing for the appraisal interview have specific examples of behavior to support the ratings. Such documentation is
particularly important for performance areas in which an employee receives low ratings. In addition, try to anticipate how the
staff member will react to the appraisal. For example, will the individual, challenge the manager's ratings as being too low?
Anticipating such a reaction, one can respond by saying, "Before I made my ratings, I talked with two other unit managers to
make sure my standards were reasonable."
The setting also should be considered in planning the meeting. It is critical that the interview take place in a setting that
is private and relatively free from interruptions. This allows a frank, in-depth conversation with the employee. Although it is
difficult to limit interruptions in a health care setting, choosing the meeting time carefully will help. You may be able to
schedule the meeting when another manager can cover, or at a time when interruptions are least likely to occur. The most
important point to remember is that a poor setting limits the usefulness of the interview. No one wants weaknesses
discussed in public. Similarly, interruptions destroy the flow of the feedback session.

The Interview
The appraisal interview is most likely too well if the nurse manager has written and shared critical incidents throughout the
evaluation period. If such feed-back has occurred, staff members go into the interview with a good idea of how they are likely
to be rated, as well as what behaviors led to the rating. If the nurse manager has not kept notes throughout the year, it is very
important to recall numerous, specific examples very of behavior, both positive and negative, to support the ratings given.
The major focus of the feedback interview should be on how the nurse manager and the staff member can work together
to improve performance in the coming year. However, establishing such an improvement-oriented climate is easier said
than done. In giving feed-back, be aware that every employee has a tolerance level for criticism beyond which
defensiveness sets in. Thus, in reviewing an employee's performance, emphasize only a few areas—preferably, no more
than two—that need immediate improvement.
Unfortunately, evaluators often exceed an employee's tolerance level, particularly if performance has been mediocre.
Typically, the manager will come up with an extensive list of areas needing improvement. Confronted with such a list, the
staff member gradually moves from a constructive frame of mind ("I need to work on that") after one or two criticisms are
raised to a destructive perspective ("She doesn't like me," "He's nitpicking," "How can I get even?") as the list of criticisms
continues.
Following are recommendations for conducting an appraisal interview:
1. Put the employee at ease. Many subordinates are nervous at the start of the appraisal interview, especially new
employees who are facing their first evaluation or those who have not received frequent performance feedback from
their manager over the course of the evaluation period. To facilitate two-way communication during the interview, some
managers rely on small talk; others begin the interview by giving an overview of the type of information that was used in
making the performance ratings, such as, "In preparing for this review, I relied heavily on the notes I have taken and
shared with you throughout the year." Rather than trying to reduce the tension an employee may have at the start of the
interview, it is better to ignore it. In many cases, if the manager has given the employee feedback throughout the
evaluation period, the employee will not be unduly nervous at the start of the session.
2. Clearly state the purpose of the appraisal interview. This improvement-oriented theme should be conveyed at the
beginning of the interview and will help the employee do the best possible job in the coming year.
3. Go through the ratings one by one with the employee. Provide a number of specific examples of behavior that led
to each rating. Some nurse managers use only negative examples to support ratings, and this can cause problems.
Employees are more likely to become defensive because the entire focus is on problem areas. If the manager pays no
attention to good performance in certain areas, the employee will pay less attention to these behaviors in the future.
In reviewing the ratings, be careful not to rush. By systematically going through the ratings and providing
behavioral examples, the nurse manager projects an image of being prepared and of being a professional. This is
important for getting the staff nurse to accept the ratings and act on them.
4. Draw out the employee's reactions to the ratings. More specifically, ask for the employee's reaction to the ratings
and then listen, accept, and respond to them. Of the seven key behaviors for doing performance reviews, nurse
managers have the most difficulty with this one. To carry out this phase of the interview effectively, you must have
confidence in the accuracy of the ratings.
When asked to express their reactions, individuals who have received low ratings will frequently question the
rater's judgment ("Don't you think your standards are a little high?"). Not surprisingly, the manager whose judgment has
been questioned then tends to get defensive, cutting off the employee's remarks and arguing for the rating in question.
Being cut off sends a contradictory message to the employee. The individual was asked for reactions, but when given,
the supervisor did not want to hear them. You should anticipate that the ratings will be challenged and must truly want to
hear the staff nurse's reaction to them.
After having listened to the employee's reactions, accept and respond to them in a manner that conveys the
manager has heard what the employee said (e.g., paraphrase some of the comments) and accepts the individual's
opinion ("I understand your view"). In addition, you may want to clarify what has been said ("I do not understand why you

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 feel your initiative rating is too low. Could you cite specific behavior to justify a higher rating?"). Strive for a candid,
two-way conversation to know exactly how the employee feels.
5. Decide on specific ways in which performance areas can be strengthened. The focus of the interview should
now shift to the future. If a thorough review of an employee's performance reveals deficiencies, the manager and
employee may jointly develop action plans to help the individual improve. An action plan describes mutually agreed-on
activities for improving performance. Such developmental activities may include formal training, academic course work,
or on-the-job coaching. Together, the nurse manager and the staff nurse should write down the resulting plans.
Because of the possibility of defensiveness, only one or two performance areas needing improvement should be
addressed. Choose only the areas that are most troublesome and focus attention on these. In arriving at plans for
improving performance, begin by asking the staff member for ideas on how to enhance personal performance. After the
individual has offered suggestions, you can offer additional suggestions. It is critical that such performance plans refer to
specific behavior. In some cases, not only will the staff member be expected to do things in a different manner ("I will
refer to a patient as Mr., Mrs., or Ms. unless specifically told otherwise"), but the manager may also be expected to
change behavior ("I will post changes in hospital policy before enforcing them").
6. Set a follow-up date. After having agreed on specific ways to strengthen performance in problem areas, schedule a
subsequent meeting, usually 4 to 6 weeks after the appraisal interview. At this later meeting, provide specific feedback
on the nurse's recent performance. This meeting also gives the manager and the nurse an opportunity to discuss any
problems they have encountered in attempting to carry out their agreed-on performance improvement plans. In most
cases, this follow-up session is quite positive. With only one or two areas to work on and a specific date on which
feedback will be given, the nurse's performance usually improves dramatically. Thus, the follow-up meeting is one in
which the nurse manager has the opportunity to praise the employee.
7. Express confidence in the employee. The final key behavior is simple but often overlooked. It is nevertheless
important that the manager indicate confidence that improvement will be forthcoming.
Since no more than two problem areas should be addressed in the appraisal interview, other problem areas may be
considered later in the year. If the targeted performance areas continue to improve significantly, then 1 or 2 weeks after this
follow-up session, meet again with the staff member, this time raising an additional area that needs attention. As before,
specific ways to improve the performance deficiency are developed and written down, and another follow-up meeting is
scheduled. In short, performance deficiencies are not ignored, they are merely temporarily overlooked.

IMPROVING APPRAISAL ACCURACY

For the manager and employee to get maximum benefit from an appraisal, it needs to encompass all facets of job
performance and be free from rater error. Al-though attempting to get totally accurate evaluations is much like the search for
the Holy Grail, there are ways to greatly improve the accuracy of appraisals.

APPRAISER ABILITY
Accurately evaluating an employee's performance involves using the job description to identify behaviors required,
observing the worker's performance over the course of the evaluation period and recalling it, and knowing how to use the
appraisal form accurately (e.g., understanding what is meant by performance dimensions such as "initiative"). To the extent
that any of these things are lacking, a manager's ability to rate accurately is limited.
Fortunately, a manager's ability to rate employees can be improved. An organization can develop detailed job
descriptions and share them with the rater. Steps can be taken to give the rater greater opportunity to directly or indirectly
observe an employee's behavior. For example, other supervisors can provide information on an employee's performance
when the immediate supervisor is not present. Managers can be taught to take notes on an employee's behavior to facilitate
recall. Also, managers can learn to use the appraisal form better through formal training.
Formal training programs help to increase appraiser ability by making raters aware of the various types of rating errors
(the assumption being that awareness may reduce the error tendency), by improving raters' observational skills, and by
improving raters' skill in carrying out the performance appraisal interview.

Simone Hurtado is team manager for the pediatric home services team. In previous years, Simone has struggled to
adequately evaluate her employees. Since all of the patient care is delivered in client's homes, Simone relied on sporadic
client feedback and review of patient care documentation to complete employee appraisals. Recently Simone attended an
appraisal workshop. Using some of the suggested strategies, Simone and the other team managers have set up an
observation schedule for their employees. Each employee will be randomly observed by a team manager in a client's home
every 6 to 8 weeks. Additionally, employees will be asked to complete self-evaluations as well as evaluations of other team
members they work with on a regular basis. Simone has also established a system for compiling ongoing employee
performance documentation.

APPRAISER MOTIVATION
Although it is often assumed that managers are motivated to accurately appraise their employees, such an assumption is
often fallacious. Nurse managers have a multitude of tasks to perform, often immediately. Not surprisingly, then, they often

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view performance appraisals as something that can be done later. Furthermore, many managers do not see doing
appraisals as a particularly important task, and some question the need for doing them at all. This is especially true if all
employees receive the same percentage salary increase. Thus, if nurse managers are to be motivated to do appraisals well,
they need to be rewarded for their efforts.
A nurse manager may spend little time on appraisals for several reasons:
• The organization does not reward the person for doing a good job.
• The manager's superior spends little time on the nurse manager's on appraisal (thus sending the message that doing
appraisals is not important).
• If a nurse manager gives low ratings to a poor employee, a superior may overrule and raise the ratings.
In short, in many health care organizations, the environment may actually dampen appraiser motivation rather than
stimulate it. Given these reasons for not spending time on appraisals, it is fairly obvious how an organization can enhance
appraiser motivation:
• The nurse manager needs to be rewarded for conscientiously doing performance reviews.
• The nurse manager's superior needs to present a good model of how an appraisal should be carried out.
• As far as possible, the nurse manager should be able to reward the highly rated staff.
This becomes more likely as outcomes are used as the basis for reimbursement to the organization and, subsequently,
the organization bases rewards on productivity. For the organization and its employees to benefit from the performance
appraisal system, pay increases should not be across the board, layoffs should not be based on seniority, and promotions
should be tied to superior performance.

EVALUATING SKILL COMPETENCY

Health care organizations are required to assess their employees' abilities to perform the skills and tasks required for their
positions (Joint Commission, 2005). Validation of competency is an ongoing process, initiated in orientation, followed up by
development, and assessed on an annual basis and, possibly, remediation. Skill evaluation most commonly takes place in a
skills lab, with simulation models, or by direct observation at the point of care (Ringerman, Flint, & Hughes, 2006; Whelan,
2006). The manager plays a key role in determining the competences required on the job, especially for unit or
department-specific competencies.
Several programs are available for skills assessment. One system commonly used is the Performance-Based
Development System (PBDS) created by Dorothy del Bueno (1979). PBDS is used to assess and validate skills for
beginning nurses at orientation and skills required for nurses at advanced levels (Whelan, 2006). Skills days are another
method to validate skills. A variety of stations can be set up and nurses can move from one to the other for assessment of
that specific skill. Another option is peer evaluation at the bedside or point of care (Ringerman, Flint, & Hughes, 2006).
Specially selected staff complete a competency validator training program who observe, but do not coach, staff in
clinical situations. For those staff unable to satisfactorily perform the skills required, the manager then follows up to ensure
that the staff member receives the necessary remediation. Regardless of the system used, skills must be evaluated and
updated regularly to reflect changes in evidence-based practice.

RULES OF THUMB
For approximately 5 percent of employees, the prescriptions given in this chapter will not work, for reasons yet unknown.
Additional suggestions or "rules of thumb" derived from practical experience include the following:
• Go beyond the form. Too often, people doing evaluations cite an inadequate form as an excuse for doing a poor job
of evaluating their employees. No matter how inadequate an appraisal form is, managers can go beyond it. They can focus
on behavior even if the form does not require it. They can set goals even if other supervisors do not. They can use critical
incidents. In short, nurse managers should do the best job of managing they can and not let the form handicap them.
• Postpone the appraisal interview if necessary. Once the appraisal interview begins, there appears to be some
natural law of management that the session must be completed in the time allotted, whether the session is going well or has
degenerated into name calling. Managers forget the goal of the appraisal interview is not merely to get an employee's
signature on the form but also to get the employee to improve performance in the coming year. Therefore, if the interview is
not going well, a manager should discontinue it until a later time. Such a postponement allows both the manager and the
employee some time to reflect on what has transpired as well as some time to calm down.
In postponing the meeting, the manager should not assign blame ("If you're going to act like a child, let's postpone the
meeting"), but should adopt a more positive approach ("This meeting isn't going as I hoped it would; I'd like to postpone it to
give us some time to collect our thoughts"). Most managers who have used this technique find that the second session,
which generally takes place 1 to 2 days later, goes much better.
• Don't be afraid to change an inaccurate rating. New managers often ask whether they should change a rating if an
employee challenges it. They fear that by changing a rating, they will be admitting an error. They also fear that changing a
rating will lead to other ratings being challenged. A practical rule of thumb for this situation is if the rating is inaccurate,
change it, but never change it during the appraisal interview. Rather, if an employee challenges a rating and the manager
believes the employee has a case, the manager should tell the person that some time is needed to think about the rating
before getting back to the employee.

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 The logic behind this rule of thumb is as follows: If a manager does a careful job of evaluating performance, few
inaccurate ratings will be made. But no one is perfect, and on occasion, managers will err. When such an error occurs, the
manager should correct it. Most employees respect a manager who admits a mistake and corrects it. By allowing for time to
reflect on the ratings, a manager eliminates the pressure to make a snap judgment.

Karlene Kerfoot (2000) states that "Performance management systems are a way to hold a mirror up to employees and
let them see their performance through the eyes of others". An effective performance evaluation contributes to the
employee's development, improves job satisfaction, and enhances employee’s morale. Learning how to evaluate
employees is one of the nurse manager's useful activities.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Which of the following is not true about controlling?

a. A pre-determined level of excellence that serves as a guide to nursing practice
b. Involves comparing actual results with projected results
c. Includes assessing and regulating performance in accordance with the plans that have been adopted, the
instructions issued, and the principle established
d. This process opens opportunities for improvement and comparing performance against set standards.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following is true about standard?

a. A pre-determined level of excellence that serves as a guide to nursing practice
b. Desirable set of conditions and performance necessary to ensure the quality of nursing service
c. Established by an authority
d. All of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Components of control process includes the following, except?

a. Establish the Standards of Performance
b. Determining the Means or Methods to be Used in Measuring Performance
c. Established by an authority
d. Evaluating Performance
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. A major dimension of quality care which refers to those connected with the actual level of care:
a. Structure
b. Process
c. Outcome
d. Standard
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 14 of 17
5. This dimension of quality care relate to the physical environment, organization, & management of an organization.
a. Structure
b. Process
c. Outcome
d. Standard
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Which dimension of quality care involves the end results of care that has been given?
a. Structure
b. Process
c. Outcome
d. Standard
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Which of the following is not included in the principles of evaluation?

a. The evaluation must be based on the behavioral standards of performance which the position requires.
b. In evaluating performance, there should be enough time to observe employee’s behavior.
c. The employee should be given a copy of the job description, performance standards, and evaluation form
before the scheduled evaluation conference.
d. The employee’s performance appraisal should include only satisfactory results with specific behavioral
instances to exemplify these evaluative comments.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. The performance appraisal process includes

a. Day-to-day manager—employee interactions
b. Making notes about an employee's behavior
c. Completing the performance appraisal form
d. All of the above
e. None of the above
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. What is the primary reason performance appraisal is done?

a. Ensure the employee is doing her/his job.
b. Basis for salary changes
c. To give constructive feedback
d. To show authority
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. When a nurse manager overrates her/his staff’s performance, this is called?
a. Leniency error
b. Recency error
c. Halo error
d. Appraisal error
ANSWER: ________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 15 of 17
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 16 of 17
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: One-Minute Paper

This activity is to evaluate what you learned after the discussion and the activity.
1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 17 of 17