STAFFING Involves deciding what type of and how many personnel are needed to provide adequate and quality

y patient or client care. Involves selection of qualified and competent personnel, a system of assignment and staffing schedules. Selection of Personnel: Recruitment o Process of enlisting personnel for employment o Methods of recruitment include: Advertising: most common method of informing the public of vacant positions (e.g. Newspaper, bulletins, etc.) Word of mouth Employee recommendation Screening Interview Orientation o Assisting and introducing the nurse to her new job o A well-designed orientation program includes: A tour of physical facilities Introduction to co-workers Description of the organizational structure Information on the philosophy, goals, policies and standards of the institution. Functions of the members of the health team Staffing Needs: Nursing Personnel AM shift - 45% PM shift - 37% N shift -18 % Scheduling Assign working days and days off to individual members of the nursing staff in order to: o Provide adequate nursing care while avoiding overstaffing o Achieve a desirable distribution of the nursing staff fairly o Let the personnel know well in advance what their schedules are Types of scheduling 1. Centralized Scheduling Based on a master staffing pattern that is carried out by one person who plans and coordinates the schedule of nurses 2. Decentralized Scheduling

 Allows the nurse manager to staff his or her own unit 3. Self-Scheduling Process by which staff nurses in a unit collectively decide and implement the monthly work schedule Patient Classification System: Means of categorizing present patients on the basis of certain care needs that can be clinically observed Can serve as a basis for planning the staffing needs of the patients Category I: Minimal Care Category II: Moderate Care Category III: Maximum Care Category IV: Intensive Care

DIRECTING Elements of directing: Motivation Communication Delegation Coordination Supervision Conflict Management Collaboration Motivation: Motivation is the force within the individual that influences or directs behavior. Because motivation comes from within the person, managers cannot directly motivate subordinates. Motivation: o Family o Money o House o Car o Food o Promotion o Caring to patient o Giving quality care o Making a difference in the lives of others As Leaders, you should apply: o Techniques o Knowledge o Skills Leader-manager must create a work environment in which both organizational and individual needs can be met. Creating a motivational climate:

o Achievement, recognition and feedback. o Interesting work o Opportunity to assume responsibility o A chance for advancement o Fairness o Good Leadership o Job Security and acceptance o Adequate monetary Positive Reinforcement: Negative Reinforcement: The following are simple approaches for an effective rewardfeedback system that uses positive reinforcement: McConnell o Positive reinforcement must be specific or relevant to a particular performance o Reinforce any improvement, not just excellence. Both large and small achievements should be recognized or rewarded in some way. Strategies to create a motivating climate: o Have clear expectations for workers and communicate these expectations effectively o Be fair and consistent when dealing with all employees o Be a firm decision maker using an appropriate decisionmaking style o Develop the concept of framework. Develop group goals and projects that will build a team spirit o Integrate the staffs needs and wants with the organizations interests and purpose o Provide experiences that challenge or stretch the employee and allow opportunities for growth Some antidotes to the burn out and negativism: Davidhizar and Hart ( 2006): o Keeping appropriate humor in the workplace o Practicing joy building o Keeping the work environment fun and comfortable. The most important strategy for avoiding burn out and maintaining a high motivation level? SELF-CARE Manager should do the following : o Seek time off on a regular basis. o Seek recreation o Form relationships outside the work setting o Have Fun. o Proper Diet and exercise are important to maintain physical health as well as emotional health.

o Separate his/her work life and personal life (there is life outside work) o Ultimately!!! Rest!!! Delegation: Delegation is getting the work done by others or as directing the performance of one or more people to accomplish organisational goals. Direct o Verbal Direction o Activity o Task Indirect o Approved list of activities or tasks Assigning specific task to subordinates w/ commensurate authority to perform the job o Principles: 1. Select the right person to whom the job is to be delegated. 2. Delegate both interesting & uninteresting task. 3. Provide subordinates w/ enough time to learn. 4. Delegate gradually 5. Delegate in advance 6. Consult before delegating 7. Avoid gaps & overlaps Guidelines in Client Care Assignment and Delegation: o Client Care Assistants Activities that have very specific guidelines o RN Uses nursing judgment NCPs, teaching plan, plans for client discharge 5 Rights of Delegation: o Right Task o Right Circumstances o Right Person o Right Direction/Communication o Right Supervision/Evaluation Delegation of authority is guided by several key principles and concepts: o Exception principle o Scalar Chain of Command o Decentralization o Parity Principle o Span of Control

o Unity of Command Principle Authority: o RIGHT to ACT or ORDER others to act based on the individuals position. o Refers to the official power Responsibility: o The OBLIGATION to ACCOUNT for ones conduct in an assigned task. o An obligation to perform certain activities & duties Common Delegating Errors: 1. Under Delegating 2. Over Delegating 3. Improper Delegating Unlicensed Assistive Personnel: o Feeding o Hygiene o Physical Care Registered Nurse o Vital Signs o Medications o Some IVs if trained o Physical Care Delegation Decision-Making Grid: o Level of Client Acuity o Level of UAPs capability o Level of Licensed Nurse Capability o Potential for Harm o Frequency of performance of skill o Level of Decision Making o Ability for Self Care Rules of Management: o Do not delegate: Assessment Evaluation Nursing Judgment Do not make decisions on nursing care based on what you may have observed others do Delegate activities for stable patients with predictable outcomes Supervision Supervise

o Means to inspect, to guide, evaluate, and improve work performance of employees through a criterion against which the quality and quantity of work production and utilization of time and resources are made. Nurse Managers o Provide guidance and direction to workers to achieve the goals and objectives of the institution, that of the nursing service, and the nursing units. Supervisory Techniques 1. Observation of the worker while making her rounds. 2. Spot checking of charts through nursing audits. 3. Asking the patients about the care they receive. Communication Communication is defined as a process by which we assign and convey meaning in an attempt to create shared understanding. Intrapersonal communication Interpersonal communication o Dyadic Communication o Group Communication o Public Communication Principles of Effective Communication: 1. Clear lines of communication serve as the linking process by which parts of the organization are unified towards goal achievement. 2. Simple, exact and concise messages ensure understanding of the message to be conveyed 3. Feedback is essential to effective communication. Mutual interaction is required. 4. Thrives best in a supportive environment which encourages positive values 5. Vital to the attainment of the goals of the organization. 6. Adequate and timely communications of work-related issues or changes that may affect jobs enhance compliance. Elements of Communication: 1. Sender - the source o Head nurse 2. Receiver - ultimate destination of the message o the staff nurse 3. Message - Subject matter of communication. o to attend a meeting (the head nurse orders the nurse to attend a meeting) 4. Channel - the means used to pass the message 5. Feedback - Receivers response or reaction or reply to the message, which is directed towards the sender.

o The staff nurse attends the meeting Two Types of Communication: o Verbal Communication Oral/Spoken o Written Non Verbal Communication Visual Communication (Looking) Verbal Communication (Sounds) Gestural Communication (Body language) Elements: Space 0-18 inches intimate 18-4 feet personal interactions 4-12 feet for social exchanges 12 feet public distance Internal and External Climate that Affects Communication: o Internal Values Feelings Temperament Stress Levels o External Weather conditions Temperature Timing Organizational climate Status Power Authority Channels of Communication: o Upward Communication o Downward communication o Horizontal Communications o Diagonal Communication o Grapevine Communication Coordination with other departments/sectors: o Medical Service o Administrative Service o Laboratory Service o Radiology Service o Pharmacy Service o Dietary Service o Medical Social Service o Medical Records Service o Community Agencies, Other Institutions and Civic Organizations

Decision Making: Decision is a course of action that is consciously chosen from available alternatives for the purpose of achieving a desired result. Decision Making - Choosing options that are directed toward the resolution of organizational problems and the achievement of organizational goals Attributes of a Decision Maker: o The freedom to make the decision in question o The capacity and ability to make a wise decision o The will, motivation and commitment to choose Decision Making Process: o Identify the problem and analyze the situation. o Explore the alternatives. o Choose the most desirable alternative. o Implement the decision. o Evaluate the results. Major Management Functions in Implementing a Decision: o Planning o Organizing o Staffing o Controlling Types of Decisions: o Considered Decisions o Operational o Swallow-hard Decisions o Ten-second Decisions Critical Thinking systematic way to form and shape ones thinking. Dispositions that Support Critical Thinking: o Open-minded o Systematic o Analytical o Inquisitive o Judicious o Truth seeking o Confident in Reasoning Decision Making Tools: o Textbooks, Libraries, and Informational Resources o Policy and Procedure Manuals o Experienced Colleagues o Listing Pros and Cons o Algorithms

o Clinical Pathways o Thinking Hats o Gantt Chart o PERT o Decision Trees o Fishbone Analysis Selected Decision Making Tools: o Listing Pros and Cons Advantages: Simple and direct Can be done quickly and inexpensively Disadvantages: It is difficult to know all the possible alternative strategies and their various pros and cons in a typically brief time. o Algorithms o Clinical Pathways o Thinking Hats o Gantt Chart o Decision Tree Group Decision Making: o Consensus o Majority Rule o Brainstorming o Task Force o Nominal Group Technique o The Delphi Method Frequent Errors Made in Decision Making: o No clear objective or goal for decision o Faulty data gathering o Faulty logic or crooked thinking o Limited number of alternatives o Too much time identifying the problem o Using outcome only for evaluation o Lack of self-awareness Managing Conflict: Conflict Is the consequence of real or perceived differences in mutually exclusive goals, values, ideas, attitudes, beliefs, feelings, or actions (Sullivan & Decker, 2001) Means a clash between two opposing and oftentimes hostile parties. Sources of Conflict: Competition, Domination and Provocation Types of Conflict: o Covert conflicts

o Vertical conflict o Horizontal or Line and Staff Conflict o Intrapersonal Conflict o Interpersonal Conflict o Intra-group Conflict o Inter-group Conflict Competition o Plus: The winner is clear Winners usually experience gains o Minus: Establishes the battleground for the next conflict May cause worthy competitors to withdraw or leave the organization Accommodation o Plus: Curtails conflict situation Enhances ego of the other o Minus: Sometimes establishes a precedence Does not fully engage participants Compromise o Plus: Shows good will Establishes friendship o Minus: No one gets what they want May feel like a dead end Collaboration o Plus: Everyone wins Creates good feelings o Minus: Hard to achieve since no one knows how Often confusing since players can win something they didnt know they wanted Dealing with Difficult People: o Establish clear guidelines o Do not postpone indefinitely o Create an environment that makes people comfortable to make suggestion. o Keep a two way communication. o Stress a peaceful resolution rather than confrontation.

o Emphasize shared interests. Examine all solutions a select the most acceptable to both parties. o Follow-up on the progress of the plan. o Attackers: Aggressive about stating their thoughts about all situations May complain loudly that they are being ignored or if they feel they are not getting enough time to complain o Sneaks: Use sarcasm and criticism May be dishonest; often set others up for failure o Victims or Chronic Complainers: Very negative worldview Often act defeated, hopeless, and powerless Try to get others to feel that way, as well o Negators/Nay-sayers: Convinced that their way is the only way We cant do that. It wont work Do not trust people in positions of authority o Approval Seekers: People who say yes to everything Agree to do work, then never complete it Require a great deal of recognition and support o Withdrawers: Keep to themselves and avoid participating Rarely contribute to any work May perform other tasks (doodling, checking cell phone, etc.) Rules for Effective Conflict Resolution: o Protect each partys self respect o Do not blame the problem on the participants o Allow all parties in the conflict to completely discuss their perspective on the problem o Set Ground Rules o Encourage full expression o Encourage active listening o Identify the key themes in the discussion o Encourage frequent feedback o Help participants develop alternative solutions o Follow up on actions at an agreed-upon interval and provide feedback to all participants Tips for Managing Workplace Station: o Build good relationships before conflict occurs o Do not let small problems escalate; deal with them as they arise o Respect differences

o o o o o

Listen to others perspectives on the conflict situation Acknowledge feelings before focusing on facts Focus on solving problems, not changing people If you cant resolve the problem, turn to someone who can help Remember to adapt your style to the situation and persons involved

Stress Management: Stress The bodys non specific response to any demand. Sources of Stress: o Dismissal o Retirement o Changing Jobs or responsibilities o Changes in working hours or conditions o Problems with Boss, co-employees o Outstanding Achievement o Work Overload o Time Pressures 3 Stages of Stress Response: o Alarm Reaction o Resistance Stage o Exhaustion Stress is impossible to avoid! 2 Types of Stress: o Eustress o Distress Nurse Managers can control and prevent burn out by: o Setting personal and professional goals. o Establishing priorities o Practicing good health habits Awareness of Positive and Negative feelings: o Positive Feelings: Calmness Joy Care Love Compassion Relaxation Forgiveness Satisfaction Happiness Passion Hope

 Excitement o Negative Feelings: Anger Fear Confusion Frustration Depression Relaxation Techniques: o Abdominal breathing o Massage o Meditation o Music o Baths o Visualization and mental imagery CONTROLLING Control in management means setting standards, measuring actual performance and taking corrective action. According to Harold Koontz, Controlling is the measurement and correction of performance in order to make sure that enterprise objectives and the plans devised to attain them are accomplished. Quality Control: Process: o The criterion or standard is determined o Information is collected to determine if the standard has been met o Educational or corrective action is taken if the criterion has not been met. - Standards o Characteristics: Predetermined Established by an Authority Communicated and accepted by the people o Nursing Standards PNA & ANSAP Professionally desirable norms against a performance can be measured. o Nursing Service Policies Are broad guidelines Govern the action of workers and supervisors Should be written and understandable and known by those who will be affected by them Comprehensive, stable, flexible

 Consistent to prevent uncertainty Realistic and prescribe limits o Nursing Procedures Specific directions for implementing written policies. Quality Control Tool: o Audit is a systematic and official examination of a record, process, structure, environment, or account to evaluate performance. Nursing Audit method of assuring documentation of the quality of nursing care in keeping with the standards of organization, the nursing department, the professional, & the accrediting group o Collecting Data for Evaluation: Outcome Audit Process Audit Structure Audit Key indicator specific data that will provide information about the whole situation. Quality Assurance (QA) Reports provide a way to track the occurrence of untoward incidents. Direct Observation and Interview sometimes used to gather information related to standards. Concurrent audits (or real-time audits) involve examining records of clients who are still receiving care. Retrospective audits involve examining records after clients are discharged.

Hospitalists and Quality Improvement o Complex process problems need multidisciplinary solutions o We are at the frontlines seeing system failures, process errors, and performance gaps with our own eyes -- which is our competitive advantage o Improved quality delivers: better patient care at lower costs with potentially higher reimbursements (pay-for-performance) Quality Meeting the needs and exceeding the expectations of those we serve Improvement:

 It is NOT: o yelling at people to work harder, faster, or safer o creating order sets or protocols and then failing to monitor their use or effect o traditional Quality Assurance o research (but they can co-exist nicely) Principle #1: Improvement Requires Change Principle #2: Less is More Quality Assurance: doing it right Determine whether performance meets standards QA models target currently existing quality Strategies for QI: o Plan-Do-Check-Act (PDCA) develop a change aimed for improvement(Plan) carrying out the test (Do) Study the results to evaluate(Check/Study) Adopt the change and determine what modifications should be made to the test (Act) o FOCUS Methodology Focus on an improvement idea Organize a team that knows the process Clarify what is happening in the current process Understand the degree of change needed Solve the problem Change: Understanding Change in The Hospital Atmosphere: o Change engineered to drive improvement depends on Workplace Culture Awareness Evidence Experience Processes all those affecting relevant aspects of patient care Personnel anybody who touches the patient or a relevant process in the system Tools for Engineering Change: o Cause and Effect Diagram sometimes also called a fishbone or Ishikawa diagram graphically displays list of possible factors, focused on one topic or objective Fishbone Analysis:

 A cause & effect diagram is used to identify the root cause of a problem or outcome Head: effect, opportunity, or desired outcome Major spines: 4 categories of causes Man all persons involved in the process Method process w/c include system, procedures, policies, standards Material supplies, forms, manuals Machine equipments o Pareto Chart graphical display of the relative weights or frequencies of competing events, choices, or options a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class o Sketching Processes or Flows Macro Process Maps Decision Flow Diagrams o Run Charts Our brains understand graphics better than tables Tabular information doesnt convey trends over time very well Keep it simple The Engineering Change o The PDSA Cycle (The benefits of repeated cycles) Sources of Standards of Care: Nurse Practice Act identifies legal standards for the practice of nursing in each state Standards of Clinical Nursing Practice o outlines standards for client care based on a nursing process approach o outlines standards for professional performance focusing on the nurses responsibilities as a member of the discipline of nursing Regulatory agencies o set standards for health care institutions o state health departments o government working through Medicare and Medicaid Accrediting groups o Have standards for all aspects of institutional care, structure, process, and outcomes. o JCAHO (Joint Commission on Accreditation of Health Care Organization)

Regulatory Requirements: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Agency for Healthcare Research and Quality (AHRQ) Total Quality Management: Continuous quality improvement (CQI) CQI is an analytical decision making tool which allows you to see when a process is working predictably and when it is not. process in which ongoing analysis and improvement lay the foundation for change Steps in the CQI Process: o Carry out planned data collection. o Identify an area to improve. o Form a task force of stakeholders. o Plan a change in systems or processes. o Implement the change. o Collect data again to evaluate the change. TQM o A philosophy that involves everyone in an organization in a continual effort to improve quality and achieve customer satisfaction. o Overall management program to implement CQI. o TQM Model (Greens, 1992): The 3 Domains for each standard The patient or clinical domain The staff or professional domain The administrative or system domain o TQM Approach: Find out what the customer wants Design a product or service that meets or exceeds customer wants Design processes that facilitates doing the job right the first time Keep track of results Extend these concepts to suppliers o Elements of TQM: Continual improvement Competitive benchmarking Employee empowerment Team approach Decisions based on facts Knowledge of tools Champion Employee Supplier quality

 Quality of the source o TQM Methods: Six Sigma (DMAIC) used for projects aimed at improving an existing business process. PDSA Cycle Process Improvement Cycle Continuous Improvement: o Philosophy that seeks to make never-ending improvements to the process of converting inputs into outputs. o Kaizen: Japanese word for continuous improvement Quality at the Source: The philosophy of making each worker responsible for the quality of his/her work Monitoring and Evaluating the Quality of Care: Clinical Practice Guidelines: o Parameters o Protocols o Algorithms o Critical Pathway Performance Appraisal individual performance, personal traits o Self appraisal o Job Dimension Scales o Behaviourally Anchored Rating Scales (BARS) o Trait Rating Scale o Checklist o Essay o Management by Objectives o Peer Review Problematic Responses to Evaluation: o Crying in Response to Evaluation o Anger and Hostility o Providing Excuses in Response to Evaluation Accreditation o Evaluation of the quality of nursing education provided Quality Improvement o CQI o TQM o Risk Management

Problem Solving: Effective supervision aids supervisors in analyzing the work problems of their subordinates. Management as problem solving: o Define the Problem o Define Objective(s) o Generate Alternatives o Develop Action Plan o Troubleshoot (anticipate potential problems) o Communicate o Implement o Evaluate if objective achieved Health Care Process: o Assess the patients needs o Diagnose the problems o Determine altrn. Treatment plans. o Select the best treatment altrn. o Implement the plan (treat the patient) o Evaluate impact of treatment plan (outcome studies) Disciplinary Action: o Any employee charged for breach of the rules and regulations, policies, norms of conduct shall be given due process. The employee charged must be notified in writing about the violation and given the right to counsel. o Disciplinary action should be progressive in nature such as: Counselling and Oral Warning Written Warning Suspension Dismissal Risk Management: Involves in the development and implementation of strategies to prevent patient injury, minimize financial loss and preserve agency assets. Goals for Risk Management: o To provide patient, staff, and visitor safety and to prevent injury or harm to all concerned. o To avoid liability exposure by evaluating new and existing services, practices and procedures. Steps in Risk Management: o Identify potential or actual risks for accidents, injury and financial loss. Risk Indicators:

 Patient Falls Medication Errors Infections Operative & post op complications Wrong site surgery Patient Suicide Equipment Failures Improper maintenance of utilities Patient Protective systems Patient grievances Non-compliance with regulations/laws Preventive Activities: Providing safe physical environment Fostering customer satisfaction Providing high quality service Review of monitoring system o Analyze to determine the frequency and severity of problems in general categories. (consequence) o A plan to reduce the risks should be developed and implemented o Results of the risk management programs should be reported to appropriate groups. Methods for Generating Ideas: o Brainstorming is a group creativity technique designed to generate a large number of ideas for the solution of a problem. 4 Basic Rules in Brainstorming: Focus on quantity Withhold criticism Welcome unusual ideas Combine and improve ideas Quality circles Team Approach: List reduction Eliminate other causes, find exact cause Balance sheet / Causes = Effects Each cause has an effect, and an effect has a cause o Interviewing Benchmarking Process: Identify a critical process that needs improving Identify an organization that excels in this process Contact that organization Analyze the data Improve the critical process