NBHS4142 Management and Medico Legal in Healthcare - Cdec2018 (Bookmark) PDF

NBHS4142
Management and
Medico Legal in Healthcare
Copyright © Open University Malaysia (OUM)

NBHS4142
MANAGEMENT AND
MEDICO LEGAL IN
HEALTHCARE
Raijah A Rahim
Dr Khatijah Lim
Assoc Prof Hjh Rohani Arshad

Project Directors: Prof Dato’ Dr Mansor Fadzil
Prof Dr Siti Aishah Hashim Ali
Open University Malaysia
Module Writers: Assoc Prof Raijah A Rahim

Dr Khatijah Lim
Assoc Prof Hjh Rohani Arshad
Universiti Malaya
Moderators: Prof Dr T K Mukherjee

Mariam Hj Mohd Nasir
Pusat Perubatan Universiti Malaya
Enhancers: Assoc Prof Raijah A Rahim

Mispan Mangon
Developed by: Centre for Instructional Design and Technology

First Edition, December 2018

Copyright © Open University Malaysia, December 2018, NBHS4142
All rights reserved. No part of this work may be reproduced in any form or by any means without
the written permission of the President, Open University Malaysia (OUM).

Table of Contents
Course Guide ix–xiv
Topic 1 Introduction to Management in Healthcare 1

1.1 Management Process 3
1.1.1 Planning 3
1.1.2 Organising 8
1.1.3 Staffing 9
1.1.4 Directing 11
1.1.5 Controlling 12
1.2 Management Theories 14
Summary 18
Key Terms 18
Self-Test 1 19
Self-Test 2 19
References 19
Topic 2 Leadership and Motivation 21

2.1 Interpretation of Leadership 22
2.1.1 Key Concepts of Leadership 25
2.1.2 Characteristics of a Leader 26
2.1.3 Transformational Leadership Competencies 26
2.1.4 Developing the Role of a Leader 29
2.1.5 Healthcare Providers as Leaders 31
2.2 Motivation 32
2.2.1 Motivational Theories 33
Summary 37
Key Terms 38
Self-Test 1 38
Self-Test 2 39
References 39
Topic 3 Managing the Emergency Department and Clinical Area 41

3.1 Effective Staffing 42
3.1.1 Determination of Staffing Needs 43
3.1.2 Patient Classification System (PCS) 45
3.2 Scheduling 48
3.3 Evaluation 50

iv  TABLE OF CONTENTS
Summary 51
Key Terms 52
Self-Test 52
References 53
Topic 4 Models of Care Delivery System 54

4.1 Overview of Population Health 55
4.1.1 Population Health Conceptual Framework 55
4.1.2 Population Health Process Model 56
4.1.3 Health Assessment Model 58
4.1.4 Patient-centred Care Model 59
4.2 Care Delivery Management Tools 61
4.2.1 Clinical Pathways 61
4.2.2 Case Management 64
Summary 65
Key Terms 66
Self-Test 66
References 66
Topic 5 Managing Care 67

5.1 Effective Team Building 68
5.1.1 Stages in the Team Process 69
5.1.2 Key Components of Effective Teams 70
5.2 Time Management 72
5.2.1 Time Management Strategies 74
5.2.2 Time Management Strategies to Enhance 76
Personal Productivity
Summary 78
Key Terms 79
Self-Test 79
References 80
Topic 6 Decision-making 82
6.1 Factors Affecting Decision-making 83
6.2 Decision-making Theories 84
6.3 Decision-making Process 85
6.4 Group Decision-making 86
6.5 Critical Thinking 87
6.5.1 Elements of Critical Thinking 89
6.5.2 Holistic Approach to Critical Thinking 90
6.6 Change and Conflict Resolution 91
6.6.1 The Change Process 93
6.6.2 Conflict 95

TABLE OF CONTENTS  v
6.7 Managing Quality 98

6.7.1 Benefits of Quality Management (QM) 101
6.7.2 Quality Improvement (QI) Process 101
Summary 103
Key Terms 104
Self-Test 1 104
Self-Test 2 105
References 105
Topic 7 Introduction to Law 107

7.1 Definition of Law 108
7.1.1 Sources of Law 108
7.1.2 Hierarchy of Malaysian Courts 110
7.1.3 Jurisdictions of the Malaysian Courts 112
7.1.4 Types of Laws 115
7.1.5 Differences between Civil Law and Criminal Law 117
7.1.6 Tort Law 118
Summary 120
Key Terms 121
Self-Test 121
References 122
Topic 8 Introduction to Ethics 123

8.1 Standardisation of Professional Conduct 124
8.1.1 Licensure 125
8.1.2 Medical Assistant Board 125
8.1.3 Contract of Employment 127
8.2 Laws that Apply to Assistant Medical Officers 128
8.2.1 Intentional and Unintentional Tort 130
8.3 Basic Ethical Concepts 132
8.3.1 Ethical Theories 133
8.3.2 Ethical Principles 133
8.4 Ethical Dilemmas 135
8.4.1 Ethical Decision-making Process 136
Summary 138
Key Terms 139
Self-Test 1 140
Self-Test 2 140
References 140

vi  TABLE OF CONTENTS

COURSE GUIDE

COURSE GUIDE  ix
COURSE GUIDE DESCRIPTION

You must read this Course Guide carefully from the beginning to the end. It tells
you briefly what the course is about and how you can work your way through the
course material. It also suggests the amount of time you are likely to spend in order
to complete the course successfully. Please keep on referring to the Course Guide
as you go through the course material as it will help you to clarify important study
components or points that you might miss or overlook.
INTRODUCTION
NBHS4142 Management and Medico Legal in Healthcare is one of the courses
offered at Open University Malaysia (OUM). This course is worth 2 credit hours
and should be covered over a period of 15 weeks.
COURSE AUDIENCE
This course is designed for students undertaking the Bachelor of Medical and
Health Sciences with Honours. This module aims to impart the essence of
management, leadership and legal issues in the context of healthcare practice.
As an open and distance learner, you should be acquainted with learning

independently and being able to optimise the learning modes and environment
available to you. Before you begin this course, please ensure you have the right
course material and understand the course requirements as well as how the course
is conducted.

x  COURSE GUIDE
STUDY SCHEDULE
It is a standard OUM practice that learners accumulate 40 study hours for every
credit hour. As such, for a two credit hour course, you are expected to spend 80
study hours. Table 1 gives an estimation of how the 80 study hours could be
accumulated.
Table 1: Estimation of Time Accumulation of Study Hours
Study
Study Activities
Hours
Briefly go through the course content and participate in initial discussion 3
Study the module 40
Attend tutorial sessions 10
Online participation 12
Revision 12
Assignment(s), Test(s) and Examination(s) 3
TOTAL STUDY HOURS ACCUMULATED 80
COURSE LEARNING OUTCOMES

By the end of this course, you should be able to:
1. Explain management and leadership in the context of healthcare practice;
2. Describe the principles and processes of management;
3. Discuss the management and motivation theories in relation to healthcare

practice;
4. Differentiate the various models of care delivery system;
5. Apply time management strategies to work and personal life; and
6. Consider the types of law and legal issues in relation to healthcare practice.

COURSE GUIDE  xi
COURSE SYNOPSIS
This course is divided into eight topics. The synopsis of each topic is presented
below:
Topic 1 introduces management in healthcare. Managers tend to focus their

energies and efforts on ensuring a smooth workflow. Effective leaders view things
globally, create visions of what might be, inspire others and are able to work with
others in more connected ways. In this topic, you will explore the management
process, strategic planning, SWOT (strengths, weaknesses, opportunities and
threats) analysis and management theories.
Topic 2 describes leadership and motivation. Leadership relies more on

personality traits and people skills. All professional assistant medical officers are
leaders because they influence others. In this topic, you will learn about leadership
styles, methods of developing the role of a leader and motivational theories.
Topic 3 focuses on ward and clinical area management. A healthcare providerÊs

ability to provide safe and effective patient care is dependent on the knowledge,
level of skills or competencies, attitude and experience, severity of the patientÊs
illness, the amount of patient care time available and organisational support. This
topic will explore these factors, how they affect manpower planning and the
outcome of staffing plans.
Topic 4 introduces care delivery system models. Each healthcare delivery model
has its advantages and disadvantages, none is ideal. Some methods are conducive
to large institutions, while other systems may work best in community settings.
Managers in any organisation must examine their organisational goals, unit
objectives, staff availability and budget when selecting a care delivery model.
Topic 5 emphasises managing care. Expert healthcare providers deal with time
management issues using contingency planning. Planning includes rapidly
assessing patient needs as well as setting and shifting priorities. Expert healthcare
providers learn to anticipate and prevent periods of extreme workload within a
shift. In this module, you will be provided with the knowledge on team healthcare
process, time management for work and personal life.
Topic 6 explores decision-making. Decision-making and critical thinking are vital

skills for healthcare providers (especially healthcare managers) as they are not just
involved in managing and delivering care but are also engaged in planning for
change. In this topic, you will learn problem-solving theories, how to make good
decisions as well as the concepts of quality assurance, quality management, quality
improvement and the change process.

xii  COURSE GUIDE
Topic 7 introduces the aspect of law. The expanded role of professional healthcare
providers has brought about new concerns amongst assistant medical officers and
a heightened awareness of the interactions between legal and ethical issues. This
topic will provide you with an overview of the legal system and specific doctrines
used by the courts to define the legal boundaries for healthcare practices.
Topic 8 introduces you to ethics. Having learnt the types of law and the differences
between various types of law in the previous topic, you will now learn about the
standards of professional conduct set by the Board of Medical Assistant Malaysia.
In this topic, you will learn about the laws that apply to assistant medical officers
as well as the legal issues, professional acts and regulations, employment rules and
ethical principles related to nursing.
TEXT ARRANGEMENT GUIDE

Before you go through this module, it is important that you note the text
arrangement. Understanding the text arrangement will help you to organise your
study of this course in a more objective and effective way. Generally, the text
arrangement for each topic is as follows:
Learning Outcomes: This section refers to what you should achieve after you have
completely covered a topic. As you go through each topic, you should frequently
refer to these learning outcomes. By doing this, you can continuously gauge your
understanding of the topic.
Self-Check: This component of the module is inserted at strategic locations

throughout the module. It may be inserted after one sub-section or a few sub-
sections. It usually comes in the form of a question. When you come across this
component, try to reflect on what you have already learnt thus far. By attempting
to answer the question, you should be able to gauge how well you have
understood the sub-section(s). Most of the time, the answers to the questions can
be found directly from the module itself.
Activity: Like Self-Check, the Activity component is also placed at various

locations or junctures throughout the module. This component may require you to
solve questions, explore short case studies, or conduct an observation or research.
It may even require you to evaluate a given scenario. When you come across an
Activity, you should try to reflect on what you have gathered from the module
and apply it to real situations. You should, at the same time, engage yourself in
higher order thinking where you might be required to analyse, synthesise and
evaluate instead of only having to recall and define.

COURSE GUIDE  xiii
Summary: You will find this component at the end of each topic. This component
helps you to recap the whole topic. By going through the summary, you should be
able to gauge your knowledge retention level. Should you find points in the
summary that you do not fully understand, it would be a good idea for you to
revisit the details in the module.
Key Terms: This component can be found at the end of each topic. You should go
through this component to remind yourself of important terms or jargon used
throughout the module. Should you find terms here that you are not able to
explain, you should look for the terms in the module.
References: The References section is where a list of relevant and useful textbooks,
journals, articles, electronic contents or sources can be found. The list can appear
in a few locations such as in the Course Guide (at the References section), at the
end of every topic or at the back of the module. You are encouraged to read or
refer to the suggested sources to obtain the additional information needed and to
enhance your overall understanding of the course.
PRIOR KNOWLEDGE
There are no prerequisites for this course.
ASSESSMENT METHOD
Please refer to myINSPIRE.
REFERENCES
Atchison, T. A. (1990). Turning healthcare leadership around. San Francisco,
CA: Jossey-Bass.
Bennis, W., & Nanus, B. (1985). Leaders: The strategies for taking charge.
New York, NY: Harper & Row.
Daft, R. L., & Marcic, D. (2001). Understanding management. Fort Worth,

TX: Harcourt College Publishers.
Huber, D. (2006). Leadership and nursing care management. Philadelphia,

CA: Saunders Elsevier.

xiv  COURSE GUIDE
Kelly-Heidenthal, H. (2003). Nursing leadership and management. Florence,

KY: Thomson Delmar Learning.
Roussel, L., Swansburg, R. C., & Swansburg, R. J. (2006). Management and

leadership for nurse administrator (4th ed.). Boston, MA: Jones and Bartlett
Publishers.
Sullivan, E. J., & Decker, P. J. (2005). Effective leadership and management in

nursing. Upper Saddle River, NJ: Pearson/Prentice Hall.
Wren, D. A. (1979). The evolution of management thought (2nd ed.). New York,
NY: Wiley.
Yoder-Wise, P. (2003). Leading and managing in nursing (6th ed.). Philadelphia,

CA: Lippincott William & Wilkins.
TAN SRI DR ABDULLAH SANUSI (TSDAS)

DIGITAL LIBRARY
The TSDAS Digital Library has a wide range of print and online resources for the
use of its learners. This comprehensive digital library, which is accessible through
the OUM portal, provides access to more than 30 online databases comprising
e-journals, e-theses, e-books and more. Examples of databases available are
EBSCOhost, ProQuest, SpringerLink, Books247, InfoSci Books, Emerald
Management Plus and Ebrary Electronic Books. As an OUM learner, you are
encouraged to make full use of the resources available through this library.

Topic  Introduction to
Management in
1 Healthcare
LEARNING OUTCOMES
By the end of this topic, you should be able to:
1. Distinguish between management and leadership in healthcare
practice;
2. Identify five stages in the management process in the context of
healthcare practice; and
3. Explain the management theories in relation to healthcare practice.
 INTRODUCTION
Let us start the first topic by reflecting on the following quote by Bennis and Nanus
(1985) on managers versus leaders (see Figure 1.1):
Figure 1.1: Managers versus leaders

Source: Bennis & Nanus (1985)

2  TOPIC 1 INTRODUCTION TO MANAGEMENT IN HEALTHCARE
Which do you prefer to be – a manager or a leader? Well, generally it is difficult to

distinguish between leadership and management because the terms are
interchangeable. A leader is someone who has influence over others. Effective
leaders:
(a) View things globally;
(b) Create visions of what might be;
(c) Inspire others;
(d) Are not afraid to take risks; and
(e) Are able to work with others in more connected ways.
On the other hand, managers receive their title because of their position in the
organisation. Managers tend to focus their energy and effort on ensuring a smooth
workflow. All professional assistant medical officers are leaders because they
influence others.
Is there a difference between leadership and management? Well, the answer is yes,
there is. The term management implies supervision, control or direction of the unit
or group of employees. Managers plan, organise and coordinate, often directing
individual efforts towards the achievement of a common goal. A manager is in a
position of leadership but he or she may not have leadership qualities.
Managers may have organisational skills, whereas leaders have personality and
charisma. According to Stephen Covey (1989) in his book, The 7 Habits of Highly
Effective People:
„Management is efficiency in climbing the ladder of success; leadership

determines whether the ladder is leaning against the right wall.‰
Imagine you are in a supervisory role as a head assistant medical officers or a team
leader. A manager definitely needs well-developed management skills to run and
organise a unit or department efficiently. Therefore, leadership qualities can
enhance your ability to manage successfully.
Is it desirable to have both management and leadership skills? Well, according to

Stephen Covey, both skills are important. It demonstrates to your staff that the
ladder you have put out for them to climb will lead to success because the position
where it has been placed made sense, for example, a supportive and healthy
environment.

TOPIC 1 INTRODUCTION TO MANAGEMENT IN HEALTHCARE  3
1.1 MANAGEMENT PROCESS

Generally, there are five stages in the management process as stated in Figure 1.2.
Figure 1.2: Five stages of the management process
If you are adopting the healthcare process in your clinical practice, you will have
a clearer picture since the management process is similar to the healthcare process.
The five stages in the management process are further explained in the next few
subtopics.
1.1.1 Planning
Let us start this topic by reading a quote from Oliver Wendell Holmes Jr, an
American jurist who served as an Associate Justice of the Supreme Court of the
United States (see Figure 1.3).
Figure 1.3: Oliver Wendell Holmes JrÊs quote

Source: izquotes.com

Assistant medical officers have the opportunity to make a difference by planning

new strategies for the future and by influencing the direction of healthcare.
Planning encompasses:
(a) Forecasting;
(b) Establishing objectives;
(c) Devising strategies;
(d) Developing policies; and
(e) Setting goals.
Keep in mind that planning must involve managers and employers throughout
the organisation. The important point is that all managers do plan but they should
involve their subordinates in the planning in order to facilitate employee
understanding and commitment.
In addition, planning can have a positive impact on organisational and individual

performance. Planning allows an organisation to identify and take advantage of
external opportunities as well as minimise the impact of external threats.
Remember, planning is more than extrapolating from the past and projecting it
into the future.
As a manager in an organisation, you should be familiar with the term „strategic

planning‰. So, what is strategic planning?
Strategic planning is selecting and organising the institution in order to keep it

healthy.
An organisation can employ strategic planning to establish a long-range plan or

budget to decide on the direction that the organisation should take over the next
three, five or ten years.
One of the outcomes of long-range planning is the preparation of specific

programme budgets. Programme budgets are used primarily to evaluate new
programmes that can help the organisation attain its long-range plan. The process
involves an external assessment to examine opportunities and potential threats as
well as an internal assessment to identify its strengths and weaknesses. Figure 1.4
shows an example of strategic planning in a nursing division.

Figure 1.4: An example of strategic planning in a nursing division
The strategic management process is critical to an organisationÊs success.

Managers and their staff must not only do the things they do well but they must
also carefully decide on what must be done.
There are two major types of organisational planning:

(a) Long-range or strategic planning; and
(b) Short-range or operational planning.
Let us ponder on a planning quote by Henry David Thoreau, an American essayist,

poet, philosopher, abolitionist, naturalist, tax resister, development critic, surveyor
and historian (see Figure 1.5).
Figure 1.5: Henry David ThoreauÊs quote

Source: https://izquotes.com
This simple question should cause assistant medical managers to pause and
consider their role in the budgeting process. This is because managers are always
busy with their daily routine workload that they have little time to plan for the
future or to introduce innovations.
Assistant medical managers are more likely to be involved in operational

planning, which is done in conjunction with budgeting, usually a few months
before the new fiscal year. This planning is crucial because it develops
departmental maintenance and improvement goals for the coming year.
Let us move on to the strategic planning process. It is important that top

management is committed to strategic planning. Managers need to be taught the
importance of strategic planning and the way to do it. The process, which gives
planners a sense of direction, should involve many people. During the planning
process, a situational audit or environmental assessment should be conducted to
analyse the past, current and future forces that affect the organisation. You can use
a SWOT (strengths, weaknesses, opportunities and threats) analysis worksheet. It
is a helpful tool to conduct the analysis.
How do we conduct the SWOT analysis? Firstly, take a piece of paper. Then, label
each quadrant of the paper with the four categories mentioned. The appropriate
factors are listed in each quadrant to enable a bird's eye view of the situational
audit. Figure 1.6 shows you an example of the SWOT analysis.

Figure 1.6: An example of SWOT analysis
After the situational audit is completed, the management team will proceed to do
the following (Huber, 2006; Roussel, Swansburg & Swansburg, 2006; Sullivan &
Decker, 2005; Yoder-Wise, 2007):
(a) Review the philosophy;
(b) Identify the vision and values;
(c) Write a purpose or mission statement;
(d) Identify organisational goals and objectives;
(e) Plan strategies to accomplish the objectives;
(f) Identify the required resources; and
(g) Determine priorities and accountability while setting the time frame.
You can visit https://goo.gl/EmBjxc to know more about the benefits, pitfalls and
the stages in strategic planning.

ACTIVITY 1.1
Suppose you are the manager of a unit and intend to change the patient
care management system from task-oriented to patient-centred care. How
will you plan this? Discuss your answer in the myINSPIRE online forum.
1.1.2 Organising
What does organising in the healthcare setting mean?
Organising is defined as establishing the structure to carry out plans,

determining the most appropriate type of patient care delivery and grouping
the activities to meet the unitÊs goals.
Other functions involve working within the structure of the organisation and
understanding how to use power and authority appropriately.
In addition, organising also involves determining who does what and who reports
to whom. The organising function of management can be viewed as consisting of
three sequential activities:
(a) Breaking tasks into jobs (work specialisation);
(b) Combining jobs to form departments (departmentalisation); and
(c) Delegating authority.
In The Wealth of Nations (published in 1776), Adam Smith cited the advantages
of work specialisation in the manufacture of pins:
„One man draws the wire, another straightens it, a third cuts it, a fourth points
it, a fifth grinds it at the top for receiving the head. Ten men working in this
manner can produce 48,000 pins in a single day but if they had all wrought
separately and independently, each might at best produce 20 pins in a day.‰
Departmentalisation results from the limitations of an effective span of

management, division of work and the need for cooperation. Its primary purpose
is to subdivide the organisational structure so that managers can specialise within
the limited range of activities.

Delegating authority is an important activity as evidenced in the old saying, „You

can tell how good a manager is by observing how his department functions when
he isnÊt there.‰
1.1.3 Staffing
The profession of an assistant medical officer has existed for more than 230 years
in Malaysia and has undergone many changes and transformations in delivering
services to the public in an effective and efficient manner (DG of Health, 2018).
Various issues and challenges have surfaced but this profession remains as one of
the most important front-line professions in Malaysia. Assistant medical officers
have been involved in delivering prehospital care services and ambulance services
when providing essential medical services.
There are many activities involved in recruiting assistant medical officers. The
management function of staffing (also referred to as human resource management
activities) is shown in Figure 1.7.
Figure 1.7: Human resource management activities for recruiting

assistant medical officers

How does turnover relate to staffing? Before we answer that, let us first find out
what turnover means.
Turnover is the rate at which employees leave their jobs for reasons other than
death or retirement.
The increase of assistant medical officers is not in line with the increase of the
population in the country. The professionÊs ratio to the population in 2017 was
1: 2,029 (DG of Health, 2018). This has led to the shortage of assistant medical
officers in various fields and programmes under medical or health activities.
Existing staff are also burdened with having to perform additional tasks such as
double-time shifts. This condition affects the quality of the services delivered. As
such, the job description needs to be clear and meets the role in order to recruit
and maintain the right person for the right job. In fact, the shortage of assistant
medical officers is not only an issue in Malaysia but also worldwide.
How does one plan for staffing in response to such manpower shortage? To
answer this question, let us look at Table 1.1 which explains the leadership roles
and management functions associated with preliminary staffing functions.
Table 1.1: Leadership Roles and Management Functions
Leadership Role Management Function

• Plans for present and future staffing • Ensures that there is adequate skilled
needs by adopting a proactive workforce to meet the goals of the
approach based on the knowledge of organisation.
current and past staffing events. • Shares responsibility for the
• Identifies and recruits talented people recruitment of staff with organisation
to the organisation based on their recruiters.
performance and competency levels. • Plans and structures appropriate
• Seeks diversity in staffing from interview activities.
different backgrounds, work • Uses techniques that increase the
experiences and knowledge, which validity and reliability of the interview
reflect the diversity of the population process.
being served.
• Applies knowledge of the legal
• Is aware of personal biasness during requirements of interviewing and
the pre-employment process. selection to ensure that the
• Seeks to find the best possible fit organisation does not discriminate in
between employeesÊ unique talents its hiring practices.
and organisational staffing needs. • Develops established criteria for
selection.

• Periodically reviews the induction and • Uses knowledge of organisational

orientation programmes to ascertain needs and employee strengths to make
that they meet the unitÊs needs. placement decisions.
• Ensures that each new employee • Interprets information in the employee
understands the organisational handbook and provides input for
policies. handbook revisions.
• Continually aspires to create a work • Participates actively in employee
environment that promotes retention orientation, continuous nursing
and worker satisfaction. education and research activities.
ACTIVITY 1.2
1. What do you think about the professional development of assistant
medical officers in Malaysia?
2. Have you decided on your career pathway after you have

completed this programme?
Share your thoughts with your course mates in myINSPIRE.
1.1.4 Directing
Directing includes several staffing functions. Directing entails human resource
management responsibilities such as:
(a) Motivating;
(b) Managing conflict;
(c) Counselling;
(d) Delegating;
(e) Communicating; and
(f) Facilitating collaboration.
Assistant medical officers should be equipped with communication skills in order

to provide correct information on what the patient needs to know so that the
patient can make informed decisions, reduce patientÊs anxiety and help him or her
to feel safe and secure. Therefore, counselling is important in helping patients
share their problems with assistant medical officers.

Now, let us focus on delegation. What does it mean?
Delegation is defined as transferring authority to a competent individual to

perform a selected healthcare task in selected situations.
The effective assistant medical manager should be able to empower his

subordinate to perform the tasks as well as to monitor the process and outcomes.
However, some common errors in delegation might happen such as:

(a) Failure to delegate;
(b) Failure to release control;
(c) Inadequate or unclear direction or miscommunication;
(d) Lack of follow-up or supervision;
(e) Incompetent personnel; or
(f) Inadequate authority (empowerment).
There are many things that can interfere with our ability to delegate. One may be
our need for control. In addition, inability to delegate may be a result of, „If I want
it done correctly, IÊd better do it myself.‰
1.1.5 Controlling
What does control mean in the context of healthcare practice?
Control is defined as an attempt to ensure that actual results come as closely to

plan results as possible.
All managers in organisations have controlling responsibilities. Examples include

conducting performance evaluations and taking necessary actions to minimise
inefficiencies. Controlling consists of four basic steps (see Figure 1.8).

Figure 1.8: Four steps in controlling
For example, at the end of the year, your manager will evaluate you based on your
job performance. He will highlight your achievements while giving guidance to
your career development.
ACTIVITY 1.3
1. You have a staff shortage problem in your ward. As an assistant
medical manager, how would you apply the concept of the
management process to solve the problem?
2. An adverse effect is one of the risk management components which

is important in healthcare. In a group of three, find out more
information on the adverse effects. Post your answer in the online
forum.
SELF-CHECK 1.1
Describe the five stages in the management process.

1.2 MANAGEMENT THEORIES

Did you know that the current theories of management practice have evolved from
earlier theories? Most of the current understanding of management is based on the
classical perspective of management that were introduced in the 1800s during the
industrial age as factories developed.
The classical perspective include three subfields of management, namely scientific

management, bureaucratic theory and administrative principles (Wren, 1979; Daft
& Marcic, 2001).
(a) Scientific Management

There are three main contributors to scientific management theories
(see Figure 1.9).
Figure 1.9: Main contributors of scientific management

Source: https://en.wikipedia.org/wiki/Scientific_management
There are six key aspects in scientific management. They are as follows:
(i) Machine-like elements of an operation;
(ii) Training of the worker;
(iii) Use of proper tools and equipment;
(iv) Use of incentives; and
(v) Use of time and motion studies to make the work easier.

(b) Bureaucratic Theory

The main contributor of this theory is Max Weber (1864-1920), a German
sociologist (see Figure 1.10).
Figure 1.10: Max Weber (1864-1920)

Source: https://en.wikipedia.org/wiki/Max_Weber
There are six key aspects to this theory, namely:

(i) Division of labour and hierarchy of authority;
(ii) Chain of command;
(iii) Rationality and impersonal management;
(iv) Use of merit and skills as basis for promotion or reward;
(v) Use of rules and regulations  focus on exacting work processes; and
(vi) Career service  salaried.

(c) Administrative Principles

A summary of administrative principles is shown in Table 1.2.
Table 1.2: Administrative Principles
Main Contributor Key Aspect

Mary Parker Follett (1868–1933)  Scientific management.
 Trained in  Principle of organisation, which is
philosophy/political applicable in any setting.
science at Radcliff
Henri Fayol (1841–1925)  Unity of command.
 French mining engineer  Division of work.
 Head of major mining  Unity of direction.
company  Scalar chain and management functions 
planning, organising, coordinating and
controlling.
Chester Barnard (1886–1961)  Concerned with the optimal approach for
 Management theorist administrators to achieve economic
efficiency.
 President of New Jersey Bell
Telephone
Luther Gulick and Lyndal  Planning, organising, supervising,
Urwick (1937) directing, controlling, organising,
 Papers on the science reviewing and budgeting (POSDCORB).
administration
James Mooney (1939)  Coordination.
 Principles of organisation  Hierarchical structure (scalar).
 Functional (division of labour).
 Staff/line principle.
Besides these three subfields of management as described in Table 1.2, there is

another theory, namely organisational behaviour (which is summarised in
Table 1.3 alongside the three main subfields of management).

Table 1.3: Management Theories
Management Theory Descriptions

Scientific management Productivity is the main focus in this theory. Productivity can
be achieved by equipping staff with the adequate skills and
knowledge as well as using advanced equipment to increase
efficiency.
For example, in the Intensive Care Unit (ICU), all nurses should
be well trained while cutting edge equipment should be used to
provide maximum care for patients.
Bureaucratic theory In this theory, Weber believed efficiency is achieved through
impersonal relations within a formal structure, for example,
from matron to sister to staff nurse.
Competence is the basis for hiring and promoting an employee.
Decisions are made in an orderly and rational way based on
rules and regulations.
The bureaucratic organisation is a hierarchy with clear
superior-subordinate communication and relations. It is based
on positional authority whereby an order coming from
someone at the top such as the matron, is transmitted through
the organisation via a clear chain of command.
Administrative This theory focuses on general principles of management, for
principles example, the management process of planning, organising,
directing, coordinating and controlling.
Another aspect of this theory, which is attributed by Barnard, is
the emphasis on the concept of the informal organisation.
Barnard believed that the informal organisation, which consists
of naturally forming social groups, can become strong and
powerful contributors to an organisation.
This theory also identifies people as having the free will in
choosing to comply with orders directed at them.
Organisational This theory focuses on the effect individuals have on the success
behaviour or failure of an organisation. The main concerns of the human
relations movement are individuals, group process,
interpersonal relations, leadership and communication.
Instead of concentrating on the organisationÊs structure,
assistant medical managers encourage staff to develop their
potential and help them to meet their needs for recognition,
accomplishment and a sense of belonging.

SELF-CHECK 1.2
1. List the main contributors of scientific management,
bureaucratic theory and administrative principles.
2. What are the key aspects of these theories mentioned in Q1

above?
 The management process is similar to the healthcare process. Both processes

may occur simultaneously.
 The stages in the management process are planning, organising, staffing,

directing and controlling.
 Not only would the assistant medical manager be performing all the stages of
the management process but also each function has its own planning,
implementing and control phases.
 The current understanding of management is based on the classical

perspective of management that was introduced in the 1800s during the
industrial age as factories developed.
 The classical perspective include three subfields of management, which are

scientific management, bureaucratic theory and administrative principles. In
addition to these theories is organisational behaviour.
Administrative principles Organisational behaviour

Autocratic leadership Organising
Bureaucratic theory Planning
Controlling Scientific management
Directing Staffing
Nursing

Which of the following statement is true regarding the bureaucratic theory?

A. Efficiency is achieved through impersonal relations within a formal
structure.
B. Efficiency is achieved through equipping staff with adequate skills and
knowledge as well as using advanced equipment to improve efficiency.
C. The theory focuses on the effects that individuals have on the success or
failure of an organisation.
D. Informal organisations consist of naturally forming social groups that can
become strong and powerful contributors to an organisation.
Bureaucratic theory is one of the management theories. Discuss the advantages

and disadvantages of this theory in relation to healthcare practice.
Bennis, W., & Nanus, B. (1985). Leaders: The strategies for taking charge. New
York, NY: Harper & Row.
Covey, S. (1989). The 7 habits of highly effective people. New York, NY: Free Press.
Daft, R. L., & Marcic, D. (2001). Understanding management. Fort Worth, TX:
Harcourt College Publishers.
DG of Health. (2018). Kenyataan akhbar KPK 10 Mac 2018  Sambutan Hari

Pembantu Perubatan Peringkat Kebangsaan tahun 2018. Retrieved from
https://kpkesihatan.com/2018/03/10/kenyataan-akhbar-kpk-10-mac-2018
-sambutan-hari-pembantu-perubatan-peringkat-kebangsaan-tahun-2018/
Huber, D. (2006). Leadership and nursing care management. Philadelphia,

CA: Saunders Elsevier.
Ong, T. H., & Chua, S. C. (2010). Energy efficiency and carbon trading potential in
Malaysia. Renewable & Sustainable Energy Reviews, 14(7), 2095–103.

Roussel, L., Swansburg, R. C., & Swansburg, R. J. (2006). Management and

leadership for nurse administrator (4th ed.). Boston, MA: Jones and Bartlett
Publishers.
Smith, A. (1776). The wealth of nations. London, England: W. Strahan; T. Cadell.

nursing. Upper Saddle River, NJ: Pearson/Prentice Hall.
US Department of Energy (USDOE). (2011). Building energy data book 2010.

Washington, D.C.
Wren, D. A. (1979). The evolution of management thought (2nd ed.). New York,
NY: Wiley.
Yoder-Wise, P. (2003). Leading and managing in nursing (6th ed.). Philadelphia,

CA: Lippincott William & Wilkins.

Topic  Leadership and
Motivation
2
LEARNING OUTCOMES
1. Identify different types of leadership styles;
2. Describe the characteristics, qualities, roles and responsibilities of a
team leader in healthcare; and
3. Discuss motivation theories.
 INTRODUCTION
Were you aware that leadership comes from the motivation for desired responses
and getting work done through others? Leaders focus on the purpose and doing
the right thing. They are future-oriented, challenged by change, able to plan
strategies and facilitate human potential as well as use their knowledge with
regard to power and politics to motivate people to act and to manage conflict.
In addition, knowledge of leadership theories help leaders adjust their leadership

styles to fit different situations (Tomey, 2009).
Leadership is often thought of as more inspirational or guidance-oriented as well

as informal. Leaders have followers and supporters and can influence others
through a formal structure or an informal relationship.
However, a leader does not necessarily have to be a manager. This is because

leadership relies more on personality traits and people skills. These skills
definitely can be developed by gaining experience, having a mentor or attending
courses.

22  TOPIC 2 LEADERSHIP AND MOTIVATION
The job of a healthcare leader whether in service or in education is to get things

done through his or her employees or staff. In other words, the leader should be
able to motivate them to do their jobs well. Why do we need to motivate the
employees? The answer is survival. Motivated employees are more productive
and more creative. To be effective, leaders need to understand what motivates
employees within the context of the roles they perform.
However, motivating employees is easier said than done! Despite the abundance
of research and theories on motivation, the subject of motivation is not clearly
understood and in many instances, poorly practised. It has been suggested that in
order to understand motivation, you need to understand the whole of human
nature. Obviously, this would be problematic as human nature or human
behaviour can be very simple and yet, at the same time, be very complex too.
I am sure you know the old saying, „You can take a horse to water but you cannot
force it to drink‰, unless, of course, it is thirsty. Similarly with people, they will
behave in a certain manner if they are motivated to do so. In this topic, you will
explore leadership styles and motivation theories and relate them to your
experiences.
So are you ready to start the journey? Let us continue with the lesson.
2.1 INTERPRETATION OF LEADERSHIP

How do you define a leader? Here is one definition that describes a leader.
A leader is a one who leads a group of people to achieve certain objectives that
might have been agreed by the followers but set by the leader or as in a
democratic organisation, the objectives have been derived through discussions
and deliberations by all members of the group including the leader.
A leader plays a major role in ensuring that group objectives are realised. In every
group (even though no leader has been appointed), a leader would naturally
surface amongst the group members.
In a battle, if the leader is killed, the second in command will automatically take
over the leadership. But in situations where all the leaders of the platoon have
died, the person who provides ideas and suggestions for their survival and
well-being is usually accepted by the platoon to be their natural leader. This person

TOPIC 2 LEADERSHIP AND MOTIVATION  23
assumes leadership indirectly, not by choice but more so for the sake of his and his
friendsÊ well-being and their survival.
Leadership studies from the 1930s by Kurt Lewin and his colleagues at the Iowa
State University conveyed information about three leadership styles that are still
widely recognised today. The three leadership styles are autocratic, democratic
and laissez-faire leadership (see Table 2.1).
Table 2.1: Leadership Styles
Leadership
Description
Style
Autocratic This style involves centralised decision-making, with the leader
making the decisions and using power to command and control
others. The autocratic style is used by the leader in the following
situations:
(a) The task outcome is relatively simple (such as telling the nursing
student to take the patientÊs temperature);
(b) Most team members would agree with the decision and provide
consensus; and
(c) A decision has to be made promptly.
Democratic It is participatory, with authority often delegated to others. To be
influential, the democratic leader uses expert power and the power
base which is afforded by having close, personal relationships.
In the democratic style, the leader will ask the opinions of the entire
team, but the final decision usually lies with the leader. Alternatively,
there may be mutual decision-making by both team members and the
leader, with everyone having an equal vote. This process encourages
everyone to fully accept the teamÊs decision. This mutual style may
be the most creative because everyone has the opportunity to provide
input and different perspectives into the decision.
Laissez-faire This type of leadership is passive and permissive. Group members
are allowed to make decisions. However, the leader often defers
decision-making. As a result, confusion can arise over the roles of
members in the group.
Source: Lewin & Lippitt (1938)
Lewin and Lippitt (1938) also concluded that autocratic leaders are associated with
high-performing groups, close supervision is necessary and feelings of hostility
are often present. Low productivity and feelings of frustration are associated with
laissez-faire leaders. Therefore, leaders must be carefully selected, as mentioned
by the ex-President of the National Union of Journalists, Norila Mohd Daud (2006):

„⁄..the public had the right to know the progress of any government
programmes since the leaders were elected through the democratic process to
govern the country on behalf of the people.‰
Now, let us discuss leadership in relation to healthcare practice. Throughout your

experience in the healthcare profession, can you identify someone with the
characteristics of a good leader? The assistant medical officerÊs leadership is vital.
This is because assistant medical officers depend on their leaders to set goals as
well as the pace for achieving them. The leader, not the manager, inspires others
to work at their highest level. The presence of strong leadership sets the tone for
achievements in the work environment.
According to Yukl (1998), leadership is a process of influence in which the leader

influences others to achieve the goal. Influence is an instrumental part of
leadership  inspiring and engaging others to participate.
In addition, the assistant medical officerÊs satisfaction within the workplace is an

important construct in healthcare practice and administration. For example,
Figure 2.1 shows how a nurse feels when she is being recognised for her excellent
service by her organisation.
Figure 2.1: Recognition by the organisation motivates staff

What happens if nurses are not satisfied with the work environment? If nurses are
not satisfied with the work environment, they are less likely to work at the highest
level, more likely to leave the organisation and go elsewhere (Stamps, 1997).
Therefore, in an attempt to be effective leaders, perhaps we should spend a minute

to reflect on this statement:
„When we look through the lens towards othersÊ weaknesses, we make othersÊ
strengths irrelevant and their weaknesses more evident.‰
ACTIVITY 2.1
1. In your opinion, who has the characteristics of an effective leader in
our country or in your organisation? Identify what makes that
person an effective leader.
2. In groups of two, discuss how a leader should help others grow as

professional healthcare providers. Post your answer in myINSPIRE
online forum.
SELF-CHECK 2.1
Develop a comparison table that compares between autocratic,
democratic and laissez-faire leadership styles.
2.1.1 Key Concepts of Leadership

Healthcare providers are leaders who make a difference in healthcare
organisations through their contributions of expert knowledge and leadership.
Leadership development is therefore a necessary component for an assistant
medical officer in preparation to be healthcare providers.
As stated earlier, leadership is a process of influence that involves the leader and
the followers, and their interactions. Followers can be individuals, groups of
people, communities and members of the society in general.
Leadership can be formal and informal, occurring by virtue of being in a position

of authority in an organisation (for example, a manager) or outside the scope of a
formal role (for example, member of a group).

Take note that leadership and management are two different things. Management
is viewed as actions employed to cope with changes while leadership is the effort
to envision and inspire change.
Table 2.2 gives a description of the different perspectives of a leader and how a
leader can influence or modify the behaviour of his or her subordinates.
Table 2.2: Leader through Different Perspectives
Perspective Description
Traditional view A leader is one who is in the position of authority, exerting
command and control, using power over subordinates.
As professionals, assistant medical officers function as leaders
when they influence others towards goal achievement.
Formal leadership A person is in the position of authority or in an assigned role
within an organisation that connotes influence, for example, the
head of medical assistant officers.
Informal A person is considered to have emerged as a leader when he or
leadership she is accepted by others and is perceived to have influence.
2.1.2 Characteristics of a Leader

There are three characteristics of a leader as explained in Table 2.3.
Table 2.3: Characteristics of a Leader
Characteristic Description
Guiding vision Focuses on a professional and purposeful vision that provides
direction towards the preferred future.
Passion Ability to aspire and align people towards life goals.
Integrity Self-honesty and maturity. These will develop through experience
and growth.
2.1.3 Transformational Leadership Competencies

Effective leadership requires the leader to display confidence and competence in
working with and through other persons. Some people may appear to be natural
born leaders, whereas others have to learn to develop leadership qualities and
skills.

Gurka (1995) has identified three qualities of a transformational leader as

explained in Table 2.4.
Table 2.4: Three Qualities of a Transformational Leader
Quality Description
Individual It is exhibited by promoting the growth of others, recognising and
consideration supporting othersÊ needs and feelings as well as giving positive
feedback and recognition.
Charisma It is exhibited by inspiring and motivating others, demonstrating
enthusiasm and communicating in a positive manner.
Intellectual This can be exhibited by creating a questioning environment, acting as
stimulation a mentor and challenging others to grow and learn.
Source: Gurka (1995)
Let us consider the following descriptions of effective leaders by Covey (2004)

which can be adapted for assistant medical officers (see Table 2.5).
Table 2.5: CoveyÊs Eight Habits of an Effective Leader (Adapted for Assistant Medical Officers)
Habit Description
1. Be proactive Healthcare providers need to set goals and work to achieve them.
They accept their own ability to be „response-able‰ in dealing with
clientsÊ whole human responses with regard to their health
concerns. They believe that, „It is not what happens to us but our
response to what happens to us that hurts us.‰
2. Begin with The assistant medical officer should identify what is really
the end in important and try to do what really matters the most every day.
mind „Management is efficiency in climbing the ladder of success;
leadership determines whether the ladder is leaning against the
right wall.‰
3. Put first The formula for the assistant medical officer who wants to stay
things first focused on the important business of healthcare practice and gives
less energy to the unimportant is to set priorities, organise and
finally perform. The challenge for the assistant medical officer is to
manage time in such a way that most of it is used for urgent
important projects such as health promotion or illness prevention.
4. Think Interdependence is the most mature goal for any relationship. For
win-win or example, a client benefits from being empowered by a professional
no deal nurse who provides informational support. On the other hand, the
nurse benefits by having the interventions validated as well as the
valued sense of presence with the client.

5. Seek first to Empathy is the habit that is reflected in this principle. The ability
understand, to focus on the clientÊs reality to experiences is vital in positive
then to be communication.
understood
6. Value Respect is the characteristic that enables an assistant medical
differences officer to develop this habit. When the assistant medical officer
and bring all respects his clientÊs perspective, the client is likely to feel freer to
perspectives seek possible alternatives.
together
7. Have a This involves consistency in having a regularly planned and
balanced, balanced programme for renewal to prevent weakening of the
systematic body, mechanisation of the mind, exposure of raw emotions and
programme desensitisation of the spirit. Healthcare leadership ability is
for self- enhanced if healthcare providers consistently participate in
renewal activities that renew the four aspects of the self, which are physical,
mental, emotional-social and moral being.
8. Find your Being truly authentic towards oneÊs personal life mission and
own voice helping others find themselves, foster the development of new
and inspire leaders and promote deep satisfaction with life and work.
others to find
theirs
Source: Covey (2004)
ACTIVITY 2.2
In groups of three, discuss the following questions and post your answers
in the myINSPIRE online forum:
(a) Based on your understanding thus far, what is the difference between
leadership and management? How do you distinguish between the two?
(b) Identify one leadership characteristic which is suitable in your
healthcare practice. Elaborate on your answer.
(c) Can the eight habits of an effective leader by Covey be implemented
in your healthcare practice? Elaborate on your answer.
SELF-CHECK 2.2
1. Describe three leadership styles.
2. Explain three characteristics of an effective leader and three

qualities of a transformational leader.

2.1.4 Developing the Role of a Leader

In order to develop the role of a leader, we need to perform certain tasks listed in
Figure 2.2.
Figure 2.2: Leadership development tasks
The tasks in Figure 2.2 are further explained in Table 2.6.
Table 2.6: Six Tasks in Leadership Development
Task Description
Select a mentor A mentor is someone who models behaviour, offers advice and
criticism as well as coaches the novice to develop a personal
leadership style. If you want to be a mentor, you should have the
qualities of a teacher, resourceful person, stimulator and provider of
experience in a day-to-day (healthcare) practice (Earnshaw, 1995).
Where can you find a mentor? Usually, a mentor is someone who is
experienced and has some success in the leadership realm of interest
such as in a clinical setting or in an organisation. The mentor must
agree to work with the novice leader and must have some interest in
the noviceÊs future development.

Lead by An effective leader knows that the most effective and visible way to
example influence people is to lead by example. Desired behaviour can be
modelled. If the goal is to have improved relationships amongst the
followers, the leader must exhibit respect for and patience with his
or her followers. This is because great leaders create civilised work
environments (Kerfoot, 1999). In addition, an effective leader does
not send members to do a job but rather leads them towards a
mutual team goal.
Accept A leader sometimes reacts in strange ways when negative outcomes
responsibility/ occur. Sometimes, the leader seeks to blame others or makes excuses
empowerment for undesirable or unintended outcomes. In accepting responsibility,
the leader needs to know that there is reward in victory and growth
in failure. Remember, no one plans to fail but an effective leader sees
failure as an opportunity to learn and grow so that past failures are
never repeated.
People who cannot accept any personal responsibility and become

demoralised by their perfectionist attitude towards life when failure
occurs will not progress as leaders (Kerfoot, 1998).
Have a clear Leaders see beyond where they are and where they are going. Strong
vision leaders are proactive and futuristic. The effective leader knows why
the journey is necessary and takes the time and energy to inspire
others to go along.
Effective leaders share their vision and empower followers to come

along to achieve it. They also share their leadership skills and
successes towards the achievement of a goal.
Share the An effective leader is as eager to share the glory as he or she is to
rewards receive it. The more respect and trust he or she shares with others,
the more they are returned to the leader.
Followers who think that the leader is working to make them look
good will follow eagerly. Followers form a network and a support
base for the leader.
Be willing to Complacency leads to stagnation. Leaders must continually read
grow about new ideas and approaches, experiment with new concepts
and capitalise on a changing world. Continued education
contributes to self-confidence by contributing to skills and
knowledge needed for success (Allen, 1998).
Setting goals that complement the vision will help the aspiring
leader know where to invest time and energy needed to grow into
the desired role.

SELF-CHECK 2.3
Describe the six tasks in leadership development.
2.1.5 Healthcare Providers as Leaders

How do healthcare providers become a leader? In this discussion, there are two
positions involved  assistant medical officer as leader and assistant medical
officer as manager (see Table 2.7).
Table 2.7: Assistant Medical Officer as Leader and Manager
Assistant Medical Officer as Leader Assistant Medical Officers as Manager

Healthcare providers who believe that Management and leadership can be a
they have good ideas for future strong combination for success. The
improvements should volunteer for assistant medical manager ensures that the
opportunities to lead. day-to-day elements of the workplace are
done correctly.
Developing leadership skills for assistant
medical officer can happen in several As a leader, the manager raises the level of
ways. Besides volunteering for expectations and helps employees reach
leadership roles within the workplace, their highest level of potential excellence.
professional involvement with The primary role of the leader is to inspire
organisations outside of the workplace (Atchison, 1990).
can also help in the development of
leadership skills (Kerfoot, 1999). An essential element of success for the
healthcare manager as a leader is the
Remember, leadership can be developed inclusion of assistant medical officers in
and that assistant medical officer leaders decision-making.
can help establish workplaces that are
satisfying and rewarding. The healthcare manager inspires his or her
staff by involving them in making the
workplace more satisfying. In doing so, the
healthcare manager also develops
personal leadership skills.

Last but not least, here are some tips to become a leader:
(a) Take advantage of leadership opportunities to practice your leadership skills;
(b) Every leader makes mistakes and has made mistakes. Truly inspired leaders
learn from their mistakes and moved forward; and
(c) Get some help. A caring mentor is the best way to develop leadership ability.
The mentor can give you the benefit of experience and will serve as a
resource to give you feedback on actions as well as suggestions for exploring
options.
ACTIVITY 2.3
Answer the following questions and share your thoughts in the
myINSPIRE online forum:
(a) Are people born to be leaders or can leadership be taught and
learned?
(b) How can leaders keep themselves from experiencing burnout?
(c) Is there one best way to lead?
2.2 MOTIVATION
Motivation can be defined as „the act or process of motivating‰ or „the condition
of being motivated‰ (Merriam-Webster, 2018). According to Lussier (1999),
motivation is a process that occurs internally to influence and direct our behaviour
in order to satisfy needs. As for Hughes, Ginnett and Curphy (1999), they see
motivation as being able to influence our choices, direction, intensity and
persistence in our behaviour.
Do you know that motivation is not explicitly demonstrated by people but rather
interpreted from their behaviour? Motivation is a difficult concept to analyse
because many different factors influence that which triggers your behaviour and
more importantly, keeps it going.

Motivation is important because it affects you in the following ways:

(a) Arousal level (the intensity or enthusiasm with which you will pursue
something);
(b) Choice (in which you will make into your work);
(c) Performance level (the amount of effort you will put into your work); and
(d) Persistence (whether you will continue working despite resistance or just
give up).
Motivation affects your emotional state in determining whether you derive

positive experiences and satisfaction such as when most of your students are able
to solve the problems given.
If you are interested in creating change, influencing others and managing

performance and outcomes, you should understand the motivation behind a
personÊs behaviour.
2.2.1 Motivational Theories

Do you agree that motivational theories sound so textbookish? Is it really
applicable to the day-to-day operations of a nursing unit? Well, the answer is yes.
Motivation theories are useful because they help to explain why people act the
way they do and how managers can relate to individuals as human beings and
workers. Understanding these theories help us to develop better practices and gain
a better understanding of the people around us.
In this subtopic, four motivation theories are introduced. They are:
(a) Two-factor Theory by Frederick Herzberg (1923-2000)

The two factors in this theory are hygiene-maintenance and motivator
factors.
(i) Hygiene-maintenance factor  Working conditions, salary, status and
security, motivating workers to meet safety and security needs while
avoiding job dissatisfaction.

(ii) Motivator factor  Achievement, recognition and the satisfaction of the

work itself, and the promotion of job enrichment by creating job
satisfaction.
You can refer to Anne Bruce's (2002) book, How to Motivate Every
Employee: 24 Proven Tactics to Spark Productivity in the Workplace to
obtain more information on motivation-related productivity at:
https://goo.gl/MsENek.
(b) Theory X and Theory Y by Douglas McGregor (1906–1964)

Leaders must direct and control. Rewards and punishments can be used to
motivate employees. Theory X leads naturally to:
(i) An emphasis on the tactics of control procedures and techniques for
instruction people on what to do;
(ii) Determining whether they are actually performing the task; and
(iii) Administering rewards and punishment.
Theory X explains the consequences of a particular managerial strategy.

Because its assumptions are so unnecessarily limiting, it prevents managers
from seeing the possibilities inherent in other managerial strategies. As long
as the assumptions of Theory X influence managerial strategy, organisations
will fail to discover, let alone utilise, the potentialities of average human
beings.
As for Theory Y, its purpose is to encourage integration, to create a situation

in which an employee can achieve his or her own goals in the best manner
by directing his or her efforts towards the objectives of the organisation. It is
a deliberate attempt to link improvements in managerial competence with
the satisfaction of higher-level ego and self-actualisation needs.
In addition, Theory Y leads to a preoccupation with the nature of

relationships, with the creation of an environment which will encourage
commitment to organisational objectives and which will provide
opportunities for maximum exercise of initiative, ingenuity and self-
direction in achieving them.
Last but not least, leaders should remove obstacles because workers have
self-control and self-discipline, and their reward is their work involvement.

(c) Theory Z by William Ouchi (1943-Present)

This theory involves collective decision-making, long-term employment,
mentoring, holistic concern and use of quality circles to manage service and
quality. It is a humanistic style of motivation based on Japanese
organisations.
(d) Human Hierarchy of Needs Theory by Abraham Maslow (1908–1970)

Abraham Maslow, a developmental psychologist, described the human
hierarchy of needs and commented on how work helps to meet those needs.
Hierarchy of human needs begins with physiological needs, progressing to

safety, social, self-esteem and self-actualising needs. Lower-level needs will
always drive behaviour before higher-level needs are addressed.
Work helps to meet safety and security needs by providing pay, which can
help to provide food, shelter and clothing. Once the lower needs are met,
Maslow believed that humans would strive for self-esteem and
subsequently, self-actualisation. According to Maslow (1943), „Hard work
and total commitment to doing well on the job that you are called to do⁄is
one of the bricks on the road to self-actualisation or being all that you can
be.‰
In thinking about motivation from a management perspective, it is very

important to appreciate this point:
„You cannot motivate people; you can only influence what theyÊre
motivated to do.‰

Figure 2.3 shows how organisations motivate employees according to the

MaslowÊs hierarchy of human needs.
Figure 2.3: How organisations motivate their employees according to the hierarchy
of needs theory
Source: Kelly (2003)
When this theory is applied to employees, leaders should be aware that the
need for safety and security (for example, an adequate salary and a
comfortable working environment) will override the opportunity to be
creative and inventive (for example, in promoting a job change).

 There are three styles of leadership, namely autocratic, democratic and laissez-
faire.
 Leadership is a process of influence that involves the leader, the followers and
their interactions.
 There are three characteristics of a leader, namely guiding vision, passion and
integrity.
 Three qualities of the transformational leader are individual consideration,

charisma and intellectual stimulation.
 Developing the roles and responsibilities of a leader involve:
 Selecting an effective and willing mentor;
 Leading by example through role modelling;
 Sharing the rewards with the followers;
 Having a clear vision in which followers can support; and
 Being willing to grow and change to meet current needs.
 Motivation can be defined as „that which provides motive‰. It is a process that

occurs internally to influence and direct our behaviour in order to satisfy
needs.
 Some of the motivational theories are Two-factor Theory by Herzberg, Theory

X and Theory Y by McGregor, Theory Z by Ouchi and the Human Hierarchy
of Needs Theory by Maslow.

Autocratic leadership Intellectual stimulation

Charisma Laissez-faire leadership
Democratic leadership Motivation
Formal leadership Passion
Guiding vision Theory X
Human Hierarchy of Needs Theory Theory Y
Individual consideration Theory Z
Informal leadership Traditional view
Integrity Two-factor theory
1. Select the correct combination.

A. Scientific Management Theory  Max Weber
B. Two-factor Theory  Frederick Herzberg
C. Theory X, Y and Z  Douglas McGregor
D. Administrative Principles  Kelly Heidenthal
2. Which of the following characteristics describe an effective leader?

(i) Accepts responsibility
(ii) Shares rewards
(iii) Has a clear vision for the future
(iv) Takes advantage of others
A. i
B. i, ii
C. i, ii, iii
D. iv

3. Which of the following is NOT a leaderÊs characteristic.

A. Guiding vision
B. Passion
C. Integrity
D. Charisma
1. Describe the type of leader that you would want to be as an assistant medical
officer in a healthcare organisation. Identify specific behaviours that you
plan to adopt as a leader.
2. In what ways are transformational leadership and charismatic leadership

theories useful for your development as a leader?
Allen, G. (1998). Supervision. Retrieved from http://www.ollie.dcccd.edu/

mgmtl374/bookcontents/4directing/leadinu/lead.htm
Atchison, T. A. (1990). Turning healthcare leadership around. San Francisco, CA:

Jossey-Bass.
Bruce, A. (2002). How to motivate every employee: 24 proven tactics to spark

productivity in the workplace. New York, NY: McGraw-Hill.
Covey, S. R. (1989). The 7 habits of highly effective people. New York,

NY: Free Press.
Covey, S. R. (2004). The 8th habit: From effectiveness to greatness. New York,
NY: Free Press.
Earnshaw, G. (1995). Mentorship: The studentsÊ view. Nurse Education Today, 15,
274279.
Gurka, A. M. (1995). Transformational leadership: Qualities and strategies for the

CNS. Clinical Nurse Specialist, 9(3), 16974.
Kelly, P. (2003). Nursing leadership & management. Clifton Park,

NY: Thomson/Delmar Learning.
Herzberg, F. (1972). Work and the nature of man. London, England: Staples Press.
Hughes, R. L., Ginnett, R. C., & Curphy, G. J. (1999). Leadership: Enhancing the
lessons of experience. New York, NY: Irwin/McGraw-Hill.
Kerfoot, K. (1999). On leadership from mechanical to integrated organizations:

The leader's challenge. Nursing Economics, 17(2), 1067.
Lewin, K., & Lippitt, R. (1938). An experimental approach to the study of autocracy
and democracy: A preliminary note. Sociometry, 1, 292300.
Lussier, R. N. (1999). Human relations in organizations (4th ed.). Boston,

MA: McGraw-Hill.
Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50,

370396.
McGregor, D. (1960). The human side of enterprise. New York, NY: McGraw-Hill.
Motivation. (2018). In Merriam-WebsterÊs online dictionary. Retrieved from

https://www.merriam-webster.com/dictionary/motivation
Norila Mohd Daud. (2006, May 7). Our laws must keep pace with the times. The
Star Online. Retrieved from https://www.thestar.com.my/opinion/
letters/2006/05/07/our-laws-must-keep-pace-with-the-times/
Ouchi, W. G. (1993). Theory Z: How American business can meet the Japanese
challenge. New York, NY: Avon Books.
Stamps, P. L. (1997). NursesÊ and work satisfaction: An index of measurement

(2nd ed.). Chicago, IL: Health Administration Press.
Tomey, A. M. (2009). Nursing leadership and management effects work

environment. Journal Nursing Management, 17(1), 1525.
Yukl, G. (1998). Leadership in organizations (4th ed.). Upper Saddle River,

NJ: Prentice Hall.

Topic  Managing the
Emergency
3 Department
and Clinical
Area
LEARNING OUTCOMES
1. Identify two types of patient classification system (PCS);
2. Distinguish between the two patient classification systems and the
new model;
3. Point out the four issues of staff scheduling; and
4. Explain the importance of evaluation.
 INTRODUCTION
Let us start this topic with a quote from a living legend of the American
Academy of Nursing, Marie Manthey (see Figure 3.1).

42  TOPIC 3 MANAGING THE EMERGENCY DEPARTMENT
AND CLINICAL AREA
Figure 3.1: Marie Manthey

Source: https://www.nursing.umn.edu/sites/nursing.umn.edu/files/
marie-manthey.jpg
Do you agree with the statement in Figure 3.1? What is your definition of high
quality healthcare practice? Generally, the ability of an assistant medical officer
to provide safe and effective healthcare to a patient is dependent on the
knowledge, skills or competency level, attitude and experience of the staff, the
severity of the patientÊs illness, the number of patient care time available, the
model of the care delivery system, care management tools and organisational
support.
In this topic, we will explore the factors mentioned, how they affect the planning
for staffing and the results of staffing plans.
3.1 EFFECTIVE STAFFING

An assistant medical officer is a front-line staff who strives to achieve the health
ministry's aspirations through its key roles in promotion, preventive, curative,
rehabilitative and palliative care.
Since the medical and healthcare sector is dynamic, the emphasis on duties and
services change according to the suitability of time and condition. Let us look at
Figure 3.2, which demonstrates this situation.

TOPIC 3 MANAGING THE EMERGENCY DEPARTMENT  43
AND CLINICAL AREA
Figure 3.2: An example of dynamic changes in the medical and healthcare sector
Source: Mancini (2018)
Even though the initial approach to healthcare was the health-centric approach,
however, the latest development focuses on the community-centric approach.
Community-centric approach focuses on and develops the role of assistant
medical officer in the curative aspect, rehabilitative and palliative in accordance
with the requirements of the support services.
3.1.1 Determination of Staffing Needs

No matter how effective an organisation performs in its effort to retain existing
staff, some turnover is to be expected. Some staff will retire whilst others will be
stationed at different parts of the country.
Therefore, the most effective personnel strategy in a healthcare organisation is to

work at retaining the staff they currently have. Major efforts should be made to
reduce undesirable turnover. One major solution to staff retention is to maintain
a high level of healthcare provider satisfaction.
Surprisingly, very little is known about what leads to assistant medical officer
satisfaction. Many factors are believed to be relevant in keeping assistant medical
officer satisfied. The issue of financial payment is, of course, relevant. A higher
salary at another institution may cause staff to move from one organisation to
another.

AND CLINICAL AREA
Another key reason for the failure to retain healthcare providers is burnout.
Burnout will most likely cause healthcare providers to leave the healthcare
profession completely. Healthcare providers who are suffering from burnout
tend to be less productive, more error-prone, have low morale and accrue a
considerable number of sick days.
The most obvious cause of burnout is shortage of staff. When there are simply
not enough assistant medical officers to get the job done on a given day or week,
the existing staff may be required to take in the extra workload. It is very
common for staff in such instances to undertake double duty. Most staff tend to
be very tired at the end of the shift.
Other factors could be due to fewer opportunities for career development and
financial problems, leading healthcare providers to leave the organisation and
consequently causing even greater stress on those remaining.
Let us pause for a minute. What can be done to reduce burnout? Staff will be
more contented if they believe they have a caring manager who is interested in
their development. A manager should be supportive, fair and perceived to be
using staff time wisely. To some extent, the overall attitude and the support
system of the unit manager and administrators could offset the problems of
burnout.
The cost of coaching new staff is high. Increasing the retention of existing
employees decreases the need for orientation. As the staff remains comfortable in
the same position, he will begin to develop short and long-term professional
goals.
When staff is satisfied with the working environment and job role, they are more
likely to be motivated in their commitment to the organisation. When the staff
becomes a more experienced assistant medical officer, he will be required to
coach new staff, include them in decision-making and help them to become team
players. These will make a significant difference in the turnover rate. The
treatment of staff by seniors as well as superiors, the perception of fairness and
willingness to see each employee as an individual will contribute towards
reducing staff turnover.

AND CLINICAL AREA
3.1.2 Patient Classification System (PCS)

To identify how many staff is needed at any given time in the unit, it is necessary
to determine the patientsÊ actual needs. In order to do so, we need a patient
classification system (PCS).
A patient classification system (PCS) is a measurement tool that is used to

articulate the nursing workload for a specific patient over a period of time.
This is also called patient acuity.
As a patient becomes increasingly ill, the acuity level will rise. This means the
patient requires more nursing care.
On the other hand, if a patientÊs acuity level decreases, the patient requires less
nursing care. The criteria reflecting the care needed in bathing, mobilising,
eating, supervision, assessment and observation are based on the 14 activities of
daily living (ADL) as highlighted by Virginia Henderson (Current Nursing,
2017). This idea is then being matched with the latest clinical technology and
caregiver skills variables (Malloch & Conivaloff, 1999).
There are two different types of PCS (see Figure 3.3).
Figure 3.3: Two types of patient classification system (PCS)

AND CLINICAL AREA
The two systems are further explained in Table 3.1.
Table 3.1: Summary of the Types of PCS, and Their Respective Advantages
and Disadvantages
Type of PCS Advantages Disadvantages

Factor System
• Uses units of • Readily available data • Becomes an ongoing
measurement that for managers and staff workload for the
equate to nursing time. for their day-to-day assistant medical
operations. officer in having to
• Attempts to capture the classify patients on a
cognitive functions of • The data provides a
daily basis.
assessment, planning, basic information
intervention and against which one can • The system does not
evaluation of patient justify changes in capture the patientÊs
outcomes along with staffing requirements. needs for psychosocial,
written documentation environmental and
processes. health management
support.
• Considered as the most
popular type of • A novice may take
classification system. longer to perform the
activities as compared
• Able to project care to the average or more
needs for individual experienced assistant
patients as well as medical officer.
patient groups.
• The time assigned for
different nursing
activities can be
changed over time to
reflect the changing
needs of the patients or
hospital systems.
Prototype System
• Allocates nursing time • Reduces work for the • No ongoing measure of
to large patient groups assistant medical officer actual nursing work
based on similar because he is not required by individual
patients or known as required to classify the patients.
diagnostic-related patients on a daily basis.
• No ongoing data to
groups.
monitor the accuracy of
• Assumes that on pre-assigned nursing
average this will reflect requirements.
the standard routine
nursing care provided.

AND CLINICAL AREA
In addition to the two systems, there is a new model of PCS. The model attempts
to move away from tasks to indices that measure the professional components of
nursing care and patient outcome (Malloch & Conivaloff, 1999). The indicators
are measured during each shift by the staff as part of staff assessment.
There are seven domains of patient care needs for nursing intervention in this
new model. These domains are:
(a) Cognitive status;
(b) Self-care ability;
(c) Emotional, social or spiritual well-being;
(d) Family information needs or support status;
(e) Treatments;
(f) Interventions; and
(g) Interdisciplinary coordination and transitions.
As for the patient care outcome, the new model of PCS suggests:
(a) Clinical condition;
(b) Knowledge of the disease or process;
(c) Self-care management; and
(d) Healthy behaviour.
SELF-CHECK 3.1
1. State the factors that lead to assistant medical officer
dissatisfaction.
2. Describe the patient classification system (PCS).
3. State the patient care outcomes as suggested in the new PCS

model.

AND CLINICAL AREA
ACTIVITY 3.1
There are two different scenarios of patients in a clinical ward (see

Figure 3.4).
Figure 3.4: Two scenarios of patients in a clinical ward
Patient A just had a heart attack. However, his condition has already
stabilised. Patient B was involved in an accident. He has a broken his
left leg. Assuming you are the assistant medical manager, how would
you determine the allocation of staff for each patient? What are the
criteria that you would consider when making the decision?
Share your answer in the myINSPIRE online forum.
3.2 SCHEDULING
Scheduling of staff is the responsibility of the assistant medical officer head or
manager. He must ensure that the schedule places appropriate staff each day and
shift to achieve sufficient and effective patient care. Some issues to consider
when you schedule your staff are shown in Figure 3.5.

AND CLINICAL AREA
Figure 3.5: Four scheduling issues
There is also the aspect of self-scheduling. What does self-scheduling mean?
Self-scheduling is a process whereby staff within a unit collectively decide

and implement the monthly work schedule.
Dearholt & Feathers (1997)
Self-scheduling was implemented to boost staff morale by increasing staff control

over their work environment through self-governing activities. It provides
opportunities for staff to increase the communication amongst themselves and
promotes empowerment as well as professional growth. This form of scheduling
provides maximum flexibility for staff and serves to increase their sense of
ownership and shared responsibility in ensuring that their respective works are
adequately recognised (Shullanberger, 2000).
ACTIVITY 3.2
To ensure that patient care needs are met, there must be a structure to
the self-scheduling programme. What is your opinion of
self-scheduling? What would be the consequences if you introduce this
system into our local setting? Post your answer in the online
myINSPIRE forum.

AND CLINICAL AREA
SELF-CHECK 3.2
1. State the four scheduling issues.
2. Define self-scheduling and describe its advantages.
3.3 EVALUATION
Before we end this topic, let us take a look at evaluation. Providing feedback to
employees regarding their performance is one of the strongest rewards an
organisation can provide. Performance appraisals are individual evaluations of
work performance. Evaluations are usually done annually but may also be
required after a scheduled orientation period for a new employee.
The actual appraisal is sometimes viewed as a negative experience. For example,

many assistant medical officer heads or managers perceive appraisals as a time-
consuming process with endless paperwork. Emphasis should instead be placed
on:
(a) Role clarification;
(b) Evaluation of competency-based performance outcomes; and
(c) The employeeÊs contributions to the organisation.
Performance appraisals provide the basis for many administrative decisions

including promotions, salary increases and disciplinary actions.
Let us discuss evaluation based on competency and staff development. But first,
what is competency?
Competency refers to what an individual is capable of performing and

includes cognitive skills such as decision-making.
It also includes interpersonal skills as well as the psychomotor or technical skills

associated with nursing procedures. These skills may be acquired through formal
education, experiences and/or practices.

AND CLINICAL AREA
There are three standards of competency as expected of an assistant medical

officer:
(a) Applying the appropriate knowledge and skills during a particular
situation;
(b) Demonstrating responsibility and accountability in actual practice and
problem solving; and
(c) Restricting and/or accommodating the practice if the assistant medical
officer cannot safely perform the essential functions of the role due to
mental or physical disabilities.
How do you measure competency? According to the Joint Commission on

Accreditation for Healthcare Organizations (2002), competency can be validated
by two possible methods:
(a) Actual observable behaviour; and
(b) The absence of error.
To meet these requirements, it is necessary to formalise a process whereby a

supervisor documents these two points after observing the individualÊs day-to-
day performance.
 The patient classification system (PCS) predicts the nursing time required for
a specific patient or a group of patients.
 The two types of PCS are factor system and prototype system.
 The new model of PCS attempts to move away from tasks to indices to one
that measures the professional components of nursing care and patient
outcomes.
 The number of staff and patients in the staffing pattern determines the
amount of nursing time available for patient care.
 The scheduling of staff is the responsibility of the assistant medical officer

head or manager, who must take into consideration the patientÊs needs and
intensity, number of patients and the staffÊs experience.

AND CLINICAL AREA
 The four issues of staff scheduling are the type of patient and acuity, the total
number of patients, the staff experience and the support available to your
staff.
 Self-scheduling can increase staff morale and professional growth. However,

for it to be successful, it would require clear boundaries and guidelines.
 Providing feedback to employees regarding their performance is one of the

strongest rewards an organisation can provide.
 Performance appraisals are individual evaluations of work performance

which are generally conducted annually.
Community-centric approach Patient classification system (PCS)

Evaluation Prototype system
Factor system Self-scheduling
Health-centric approach Staffing pattern
New model of PCS
1. Florence Nightingale was also as known as the .

A. „Lady with the Lamp.‰
B. „Lady of the Lamp.‰
C. „Lady in the Mirror.‰
D. „Lady of Medicine.‰

AND CLINICAL AREA
2. The following statements are true about the patient classification system
(PCS) EXCEPT:
A. It is a measurement tool which is used to articulate the nursing
workload for a specific patient over a period of time.
B. It is necessary to determine the patient's needs.
C. It is useful for both individual patientsÊ as well large patient groups.
D. It is a process which is required for the implementation of the
monthly work schedule.
Current Nursing. (2017). Virginia HendersonÊs need theory. Retrieved from

http://currentnursing.com/nursing_theory/Henderson.html
Dearholt, S. L., & Feathers, C. A. (1997). Self-scheduling can work. Nursing

Management, 28(8), 4748.
Joint Commission on Accreditation for Healthcare Organizations (JCAHO).

(2002). Hospital accreditation standards. Oak Brook, IL: JCAHO.
Jones, C. L. (2002). Recruitment and retention. In P. G. Zimmermann (Ed.),

Nursing management secrets (pp. 8389). Philadelphia, PA: Hanley &
Belfus.
Mancini, M. (2018). 15 heroic facts about Florence Nightingale. Retrieved from

http://mentalfloss.com/article/63892/15-heroic-facts-about-florence-
nightingale
Malloch, K., & Conivaloff, A. (1999). Patient classification systems, part 1. Journal
of Nursing Administration, 29(7/8), 4956.
Manthey, M. (1980). A theoretical framework for primary nursing. The Journal of

Nursing Administration, 10(6), 1115.
Shullanberger, G. (2000). Nurse staffing decisions: An integrative review of the

literature. Nursing Economics, 18(3), 124136.

Topic  Models of Care
4 Delivery
System
LEARNING OUTCOMES
1. Explain the four models of care delivery systems; and
2. Formulate a standard care plan using clinical pathways and case
management.
 INTRODUCTION
There are many healthcare delivery models in the healthcare management. Each
healthcare delivery model has its own advantages and disadvantages. No one
model is ideal. Some methods are appropriate for large institutions, whereas
others may work best in a community setting.
As such, managers in any organisations must examine their organisational goals, unit
objectives, staff availability and budget when selecting a care delivery model.
In order to ensure that standard quality healthcare is provided to patients, the

work must be organised. The decision on which delivery model is to be used is
based on the needs of the patients and the availability of competent staff at
different skill set levels.
Thus, as a manager in your area, you are responsible for planning and
implementing the model and evaluating its outcomes. Firstly, you must make
sure that you have sufficient staff to execute the model. Secondly, you have to
use reinforcements to engage your staff in the implementation process. Lastly,
continuous monitoring should also be conducted to evaluate their performance.
Let us get to know the various models of care delivery system in this topic.
Happy reading!

TOPIC 4 MODELS OF CARE DELIVERY SYSTEM  55
4.1 OVERVIEW OF POPULATION HEALTH

The Care Continuum Alliance (2012) has developed a framework and a model to
conceptually and operationally illustrate the process and activities associated
with population health. They are:
(a) Population health conceptual framework; and
(b) Population health process model.
These frameworks have been developed as a guide for care delivery models
which seek to integrate and implement population health strategies, components
and processes.
4.1.1 Population Health Conceptual Framework

Let us look at the population health conceptual framework shown in Figure 4.1.
Figure 4.1: Population health conceptual framework

Source: Care Continuum Alliance (2012)

56  TOPIC 4 MODELS OF CARE DELIVERY SYSTEM
This model can be embedded into a primary care integrated system in various
ways, for example, integrated delivery systems and accountable care
organisations as well as patient-centred medical home practices.
The primary care integrated system can adopt the processes and key components
outlined in the framework to assess its own capabilities and to guide the
development of expanded and integrated care delivery models.
Next, let us look at the advantages and disadvantages of this framework in

Table 4.1.
Table 4.1: Advantages and Disadvantages of Population Health Conceptual Framework
Advantages Disadvantages
 The conceptual framework depicts the  To a patient, the care provided may
identification, assessment and appear to be disjointed.
stratification of patients.  In this model, the patient becomes
 The core of the model (central blue box) the sum of the tasks of care required
includes the continuum care as well as rather than holistic care.
patient-centred interventions.
 The patient is central in this model. He or
she is surrounded by various overlapping
sources of influence on of his or her
health.
4.1.2 Population Health Process Model

Now, let us move on to the population health process model as shown in
Figure 4.2.

Figure 4.2: Population health process model

Source: Care Continuum Alliance (2012)

The purpose of this model is to help us improve our understanding on the

essential and detailed elements of population health. In addition, this process
model also outlines the process flow associated with delivering the key
components of population health, beginning with monitoring the population and
identifying patients who are appropriate for an activity or intervention.
The advantages and disadvantages of this model are listed in Table 4.2.
Table 4.2: Advantages and Disadvantages of Population Health Process Model
 This model requires healthcare  Communication in this model can be
providers to assess the state of health, complex as there is shared
followed by risk stratification, the responsibility and accountability,
application of engagement strategies, which can cause confusion and lack of
the ability of multiple communication accountability.
and delivery modalities as well as the
 These factors are likely to contribute to
patient-centred interventions across
healthcare providersÊ dissatisfaction
the care continuum.
with this model.
 It includes a feedback loop that reflects
 This model can also lead to patients
the needs process and quality
feeling isolated and depersonalised.
improvements based on the impact
evaluation.
4.1.3 Health Assessment Model

Now, let us move on to the third model, which is the health assessment model.
The health assessment model represents efforts to assess the health of the
population. This assessment typically consists of a lot of information, including:
(a) Self-reported health questions;
(b) Health insurance claims;
(c) Laboratory and pharmacy data; and
(d) Clinician-documented information.
In health assessments, the primary healthcare providers need to:

(a) Analyse the combined data;
(b) Conduct initial assessment  repeated measures over time to demonstrated

changes in the health status of the patients and the population;

(c) Monitor results in a continuous feedback loop to facilitate the care team
(documenting the progress of the population); and
(d) Establish new baselines and adjusting care interventions in a continuous
cycle of quality for overall improvement.
In addition, primary healthcare providers have the authority, accountability and

responsibility to provide the best care for a group of patients.
What are the advantages and disadvantages of this model? Let us look at
Table 4.3 for the answers.
Table 4.3: Advantages and Disadvantages of Health Assessment Model
 This model offers information that  It is high cost because a higher healthcare
will be extremely helpful for the skills mix is involved.
clinicians in their efforts to engage
 The person allocating the assignments
with patients through the patient care
needs to be knowledgeable about all the
plan.
patients and staff in order to ensure the
 Effective enrolment and engagement appropriate matching of staff to patient.
is important in the healthcare of the
 Healthcare provider to patient ratio must
patient population.
be realistic to ensure there is sufficient
healthcare services time available to meet
the care needs of patient.
4.1.4 Patient-centred Care Model

Let us look at the fourth model, which is the patient-centred care model
(see Figure 4.3).

Figure 4.3: Patient-centred care model for a rehabilitation unit

Source: Kelly-Heidenthal (2003)
Take note that this last model focuses on patient needs rather than staff needs. In
this model, the required care and services are brought to the patient. The beauty
of this model is that all patient services are decentralised at the patient area
including the radiology and pharmacy services. Therefore, staffing is based on
patient needs.
In addition, efforts are in place to have the right person perform the proper
service. The care team includes other disciplines that are involved in the
planning of the patient care. Therefore, service providers have to collaborate to
ensure that the patient receives the care needed. The advantages and
disadvantages of this model are listed in Table 4.4.
Table 4.4: Advantages and Disadvantages of Patient-centred Care Model
 The most convenient model for  It can be extremely costly to decentralise
patients as it expedites services to major services in an organisation.
the patients.
 Some staff perceive the model as a way to
reduce assistant medical officers as well as
costs.

ACTIVITY 4.1
Each model of the care delivery system has its strengths and
weaknesses and should be taken into consideration when deciding
which model to implement. Based on the several different care delivery
models, choose the best model that you think can be implemented in
your area of work. Justify why you chose that model. Share your
answer in the myINSPIRE online forum.
SELF-CHECK 4.1
1. Why do we need a care delivery system?
2. Describe four models of the care delivery system.
4.2 CARE DELIVERY MANAGEMENT TOOLS

Based on the studies by Karen Zander (2017), it is important for the case
management professionals to know a little of the history and the important
models of the professions besides their own which they most interact. This is
especially true because case management is not in itself a profession, but rather a
negotiated role filled by a licensed professional in hospitals, health care systems,
medical homes, post-acute agencies and the community.
Take note that the hospitals looked for opportunities to reduce costs through the
reduction in the length of stay (LOS). Therefore, clinical pathways and case
management are the tools or strategies that can achieve this objective. These tools
are further explained in the next subtopics.
4.2.1 Clinical Pathways

What are the clinical pathways all about?
Clinical pathways are care management tools that outline the expected
clinical course and outcomes for a specific type of patient.

Pathways are often identified on a day-to-day basis. For each day, the expected
outcome is articulated and the patientÊs progress is measured.
In this management tool, the pathways consist of multidisciplinary orders of care

including orders from physicians and nurses as well as other healthcare
professionals such as physiotherapists and nutritionists for a group of patients
with a specific condition or treatment.
In addition, clinical pathways are widely used not only to enhance outcomes but
also to contain costs within a constrained length of stay (Lagoe, 1998). The
features of this tool are listed in Table 4.5.
Table 4.5: Features of Clinical Pathways
Feature Description
High volume Increased total number of patients admitted with the same
diagnosis.
High risk Need immediate treatments compared to other diseases.
High cost Higher cost for treatment, for example, total knee replacement.
High loss The standard care plan in the clinical pathway will shorten the
length of stay in the hospital.
Large variation in The data is used to identify opportunities for improvements in
practice hospital systems and in clinical practice.
For a homogeneous group of patients, they are identified by a medical diagnosis,

diagnostic-related group (DRG) or surgical procedures for which usual processes
of care are similar. Let us look at Table 4.6, which shows you an example of a
formulated clinical pathway.

Table 4.6: Clinical Pathway for Acute Asthma in Adults
Daily Outcomes
Emergency Medical Ward Medical Ward Medical Ward Medical Ward
Medicine on
Admission Day 1 Day 2 Day 3 Day 4
Patient will: Patient will: Patient will: Patient will: Patient will:
• Maintain • Maintain clear • Return • Have an • Have an
clear airway breathing effective effective
airway pattern and breathing breathing
• Maintain
rate to pattern pattern and
• Maintain oxygen
baseline cough
oxygen saturation • Able to cough
saturation >95% • Maintain effectively • Maintain PEF
>95% PEF post post nebuliser
• Achieve PEF • Maintain PEF
nebuliser >75%
• Achieve post nebuliser post nebuliser
>75%
PEF post >75% >75% • Have stable
nebuliser • Have stable vital signs
• Experience • Have stable
>75% vital signs
resolution of vital signs • Able to use
• Experience acute • Maintain inhaler /
• Understand
resolution respiratory hydration; aerochamber
inhaler
of acute distress good urine correctly
technique /
respiratory output,
• To restore lung aerochamber • Patient and
distress moist
function to the family
mucous
• Have best possible understand the
membranes
stable vital level as soon as medication
signs possible • Able to instructions,
practise the recognition
• Patient and • Have stable controlled of an acute
family vital signs breathing attack and
understand exercise and
• Maintain action taken
the coughing
hydration; during an
diagnosis technique
good urine attack
and
output, moist
ongoing • To prevent
mucous
treatment early relapse
membranes
• Understand
nature of
disease
• Able to use
peak flow
meter

Lastly, what are the advantages and disadvantages of this tool? Let us find out
the answer in Table 4.7.
Table 4.7: Advantages and Disadvantage of Clinical Pathways
• They are powerful tools for managing • It requires a significant amount of
care. They are very instructive for new work to gain consensus from various
staff and save significant amount of disciplines regarding the expected plan
time in the process of care. of care.
• The implementation of clinical
pathways will improve care and
shorten the length of stay for the
population on the pathways.
4.2.2 Case Management

Case management is a second strategy that can improve patient care and reduce
hospital costs through coordination of care. A case manager is responsible
for coordinating care and establishing goals from pre-admission through
discharge (Del Togno-Armanasco, Hopkin & Harter, 1995).
For example, in a case of a patient with post-surgery condition, if the patient has
not achieve the ambulation goal according to the clinical pathway, the case
manager would work with the physician and other healthcare professionals to
determine the factors that prevent the patient from achieving the goal. You can
visit the following websites to obtain more information on case management:
(a) http://www.ana.org
(b) https://www.nursingexplorer.com/careers/case-management-nurse
ACTIVITY 4.2
Formulate one clinical pathway for a small group of patients in your
hospital based on high risk, high volume and high cost. You are
required to show evidence of the statistical data before proceeding to
the clinical pathway. Post your answer in the myINSPIRE online
forum.

SELF-CHECK 4.2
1. State the importance of clinical pathways.
2. What is the method that is used in case management to improve

patient care and reduce hospital costs?
 Four models of care delivery systems are:
 Population health conceptual framework;
 Population health process model;
 Health assessment; and
 Patient-centred care model.
 Population health conceptual framework can be embedded into the primary

care integrated system in a various ways.
 The population health process model helps us to improve on the

understanding of the essential and detailed elements of the population
health.
 The health assessment section of the process model represents the efforts to
assess the health of the population. This assessment typically consists of
information.
 Patient-centred care model focuses on patient needs rather than staff needs.
In this model, the required care and services are brought to the patient.
 Case management and clinical pathways are care management tools that
have been developed to improve patient care and reduce hospital costs.
 Clinical pathways are care management tools that outline the expected
clinical course and outcomes for a specific type of patient.
 Case management improves patient care and reduce hospital costs through
the coordination of care.

Case management Population health conceptual

framework
Clinical pathway
Population health process model
Health assessment
Patient-centred care model
1. As an assistant medical manager in a new unit for stroke patients

(consisting of 10 patients), what would you take into consideration when
planning for the staffing of this unit?
2. Based on the above scenario, choose the most appropriate model of

delivery care system and explain the advantages and disadvantages of the
model in relation to the scenario.
Care Continuum Alliance. (2012). Implementation and evaluation: A population

health guide for primary care models. Retrieved from
http://www.exerciseismedicine.org/assets/page_documents/PHM%20G
uide%20for%20Primary%20Care%20HL.pdf
Del Togno-Armanasco, V., Hopkin, L. A., & Harter, S. (1995). How case
management really works. American Journal of Nursing, 95(5), 24I24L.
Kelly-Heidenthal, H. (2003). Nursing leadership and management. Florence,

KY: Thomson Delmar Learning.
Lagoe, R. (1998). Basic statistics for clinical pathway evaluation. Nursing

Economics, 16(3), 125131.
Zander, K. (2017). Case management models: Best practices for health systems
and ACOs (2nd ed.). Retrieved from https://hcmarketplace.com/
aitdownloadablefiles/download/aitfile/aitfile_id/1942.pdf

Topic  Managing Care
5
LEARNING OUTCOMES
1. Describe the five stages of the team process and the key components
of effective teams;
2. Explain the five general strategies of time management; and
3. Apply time management strategies to enhance personal
productivity.
 INTRODUCTION
Numerous studies have shown how healthcare providers use their time. Most
studies were conducted on acute care nurses as they represent the majority of
nurses. According to Scharf (1997), only 30 to 35 per cent of nursing time is spent
on direct patient care while 25 per cent is spent on charting and reporting. The
remaining time is spent on admission and discharge procedures, professional
communication, personal time and providing care that could be provided by
unlicensed personnel, for example, transportation and housekeeping (Upenieks,
1998).
Benner (1984) addressed the issues faced by new nurses as they struggle with time
management and explained the ways expert nurses deal with time management
using contingency planning. This contingency planning includes approaches such
as rapidly assessing patient needs as well as setting and shifting priorities. Routine
standards and procedures are continuously being evaluated. Standard priorities
include attending to radically abnormal vital signs, symptoms of respiratory or
circulatory compromise, intravenous medications running dry and intravenous
medication administration. In addition, expert nurses learn to anticipate and
prevent periods of extreme workload during a shift.

68  TOPIC 5 MANAGING CARE
How about assistant medical officers? What can an assistant medical officer do to
become an expert? Well, being an effective team member and utilising time
management strategies can be helpful to them. These two strategies are the main
focus of discussion in this topic.
5.1 EFFECTIVE TEAM BUILDING

There is a well-known quote that goes like this:
„The whole is greater than the sum of its parts.‰
Have you ever heard it? What does it mean? The quote clearly shows the
importance of effective team building in which each member is equally important,
everyoneÊs voices and opinions are heard, and progress is aimed at the same goals.
In addition, team members should know each otherÊs strengths and weaknesses,
and continually develop their knowledge and skills.
As for leaders, they also play a role in educating team members so that they know
what to do, enabling them so that they know how to do it and empowering them
by authorising them to do it (Harrington-Mackin, 1996).
There is also the interdisciplinary team. An interdisciplinary team is formed

comprising members with a variety of clinical expertise such as nurses, physicians
and social workers to look at care delivery from different viewpoints.
When working with different personnel from different backgrounds within a

team, the team leader should ensure that everyone contributes towards
accomplishing the goals. In an organisation, various types of committees are
developed to assist in the process of communication. There are two types of
committees:
(a) Ad-hoc committee which is usually temporarily formed for specific purposes
to achieve short-term goals.
(b) Standing committee that may be mandated by laws, for example, medical
staff meetings.

TOPIC 5 MANAGING CARE  69
5.1.1 Stages in the Team Process

Tuckman and Jensen (1977) and Lacoursier (1980) have identified five stages in the
team process (see Figure 5.1).
Figure 5.1: Five stages of the team process

Source: Tuckman & Jensen (1977); Lacoursier (1980)
The five stages of the team process are further explained in Table 5.1.
Table 5.1: Five Stages of the Team Process
Stage Activity
Forming  Expectations  Start when the first meeting begins.
 Interactions  Opinions are exchanged to define the groupÊs
expectations and boundaries.
 Boundary formations  The group establishes its identity with the
help of the group leader.
Storming  Tension  May occur due to statements or opinions made by team
members.
 Conflict  Sometimes it can be quite apparent as people often take
sides on certain concerns or issues.
 Confrontation  Difficult situation but it is important to ensure
resolution for the emerging problems.
Norming  Positioning  Members having a sense of belonging in the team.
 Goal setting  With positions now established, goals outlined in the
forming stage are set in accordance with expectations.
 Cohesiveness  Conflict has transformed into cohesiveness.
Performing  Actual work  Team members are now ready to implement the
actual work that will meet the groupÊs objectives.
 Relationships  Agreements are more likely to be achieved as everyone
knows what their roles are and what they are supposed to do.
 Group maturity  Obvious progress is made towards the plan to
achieve the overall group goals.

Adjourning  Closure  The process whereby team members review the groupÊs
progress.
 Evaluation  The group should evaluate whether the stated purpose
was accomplished.
 Outcome review  Closure activities to focus on groupÊs
accomplishments on stated and unstated objectives.
Source: Tuckman & Jensen (1977); Lacoursier (1980)
5.1.2 Key Components of Effective Teams

Did you know that the value of team building is to enhance the functions in any
one or in all of the management processes (Herman & Reichelt, 1998)? The
management processes involved are shown in Figure 5.2.
Figure 5.2: Some of the management processes that can be enhanced through effective
team building
Source: Herman & Reichelt (1998)
Lewin (1951), McGregor (1960) and Argyris (1964) are among the few people who
have discussed the theories of effective teams. A great team accomplishes the
objectives of the group through active participation of its team members.

What are the key components of effective teams? The six key components of
effective teams are shown in Figure 5.3.
Figure 5.3: Six key components of effective teams
The six components of effective teams are further elaborated in Table 5.2.
Table 5.2: Six Key Components of Effective Teams
Component Description
Clearly stated Team members need to know the purpose of the team, its goals
team purpose as well as targets to be achieved. The leader must ensure that
everyone in the unit understands the task and performs the
correct procedures.
Team composition The leader should recruit and hire talented people. Team
members should use their basic knowledge and experiences
gained from working in different areas.
Effective Clear communication between team members can resolve
communication conflicts that might occur.
Active The leader should ensure that each member participates and
participation contributes especially during a discussion or brainstorming
session.
Active plan The plan that everyone should agree on and feedback by team
members as well as others who will be affected by the teamÊs
decisions are necessary in maintaining team focus.

Ongoing Outcomes should be consistent with and up to expectations. Staff

assessment and who excels will be rewarded. In addition, special coaching and
evaluation reinforcement will be provided in order to overcome weaknesses.
Table 5.3 shows the attributes of effective and ineffective teams.
Table 5.3: Attributes of Effective and Ineffective Teams
Attribute Effective Team  Ineffective Team 

Working • Informal • Bored
environment  Comfortable • Tense
• Stiff
Objectives  Well understood • Unclear
 Accepted • Many personal agendas
Leadership  Shared • Autocratic
 Shifts from time to time • Remains clearly with the
committee chairperson
Conflict • Comfortable with • Uncomfortable with
disagreements disagreements
 Open discussion on conflict • One group aggressively
issues dominates
Criticism  Frank • Embarrassing
 Constructive
You can visit this website (https://goo.gl/FPNnJy) for more information on

effective teams.
5.2 TIME MANAGEMENT

The majority of new assistant medical officers find it impossible to meet all of their
patientsÊ needs as these needs tend to be limitless whilst time is limited. Effective
time management allows assistant medical officers to:
(a) Prioritise care;
(b) Decide on the outcomes; and
(c) Perform the most important interventions first.

Effective time management not only helps assistant medical officers to work well
but also improves the quality of their personal lives as it translates to more time
with family, friends and for leisure pursuits.
In addition, time management allows us to achieve more with the available

time by:
(a) Analysing which task is more important; and
(b) How the time is currently being managed.
Did you know that the Pareto Principle can be applied to time management?
Let us look at Figure 5.4 which demonstrates this principle.
Figure 5.4: The Pareto principle
Based on Figure 5.4, it states that 20 per cent of focused effort produces 80 per cent
of the results. Conversely, 80 per cent of unfocused effort produces only 20 per
cent of the results. What does this imply? This principle reminds us to focus on the
right activities so that we can achieve maximum results.
It sounds easy but why do some people find it hard to focus on the 20 per cent
effort? Well, there are several possible explanations on this matter. One reason for
losing focus is when you tend to execute too many tasks or projects
simultaneously.

To overcome this problem, you should run lesser projects at the same time so that
every project can get your undivided attention. It is even better to finish one project
first before you move on to the next one. Prioritising goals can also be helpful.
Another reason for suffering from work overload is due to our inability to say
„no‰. Learning to say „no‰ to requests is difficult and at times can be unpleasant
for others. You need to remember and consider how much time you have left in
order to complete the request. If your time is limited, you can consider delegating
your task to someone else negotiating for a longer due date or stating politely that
you are not able to complete the request based on your workload at hand.
5.2.1 Time Management Strategies

In general, there are five time management strategies. They are shown in
Figure 5.5.
Figure 5.5: Time management strategies
The strategies are further explained as follows:
(a) Goal Setting

The first step in any time management strategy is to shift from task
orientation to outcome orientation. Long-term goals cannot be achieved
overnight. Long-term goals are best when broken down to smaller realistic
steps. There may come a time when the outcome is no longer realistic or
should be shifted to a more realistic goal when circumstances change (Reed
& Pettigrew, 1999).

(b) Setting Priorities

After the goals have been decided, priorities are set. Goals that are more
urgent should be accomplished first.
However, life-threatening emergencies should come first. These emergencies

must be done no matter how much shortage of staff there is at that time. It is
imperative that assistant medical officers protect their patients and maintain
patient and staff safety as well as perform the activities essential to nursing
and medical care plans (Hansten & Washburn, 1998).
There are three stages of priority. Let us find out what the stages are in
Table 5.4.
Table 5.4: Three Stages of Priority
Stage Description
First priority: Life-threatening conditions include patients who are at risk
Life-threatening or to himself or to others, or patients whose vital signs and
potentially life- level of consciousness indicates potential respiratory or
threatening circulatory collapse (Hansten & Washburn, 1998). A patient
occurrence whose condition is life-threatening deserves the highest
level of priority and requires monitoring until he is
transferred or stabilised.
Second priority: Activities that are essential to safety include ensuring the
Activities essential availability of life-saving medications and equipment, and
to safety protecting patients from infections and falls. The activities
also include asking for assistance or providing assistance
while two people transfer, turn or move the heavy patient
(Hansten & Washburn, 1998).
Third priority: Activities that are essential to the care plan include those
Activities essential which lead to the relief of symptoms or healing. They are the
to the care plan activities that, if omitted, will hinder the patientÊs recovery.
The activities include nutrition and medication
administration, ambulation, positioning and so on.
(c) Organisation
Did you know that by having a few simple routines, you can save a lot of
time in a day and even enhance your efficiency? To do so, you need to be
organised. Examples of the routines include keeping a neat workspace,
arranging things in order or using „file management‰ rather than „pile
management‰.

Another matter that should be taken into consideration is the storage of

linens, supplies and medications. Nurses should give considerations to all
aspects of the unitÊs environment and work together with co-workers to
make a difference.
(d) Time Tools

Sometimes the events of the day can be very hectic as opposed to a planned
schedule. In such instances, you may find yourself responding to events
rather than prioritised goals.
Therefore, each assistant medical officer must devise a method for tracking
care and organising his time as well as delegating and monitoring the care
provided by others. One way to do so is by using a time log to list work-
related activities so that you can plan your activities ahead of time. The
activity log should be used for several days and the behaviour should not be
modified in the meantime. The assistant medical officer should record every
activity from the beginning of the shift until the end as well as periodically
noting their feelings while performing the activities.
After completing the log, the assistant medical officer should analyse
whether the time was spent wisely or whether some activities require some
adjustments.
(e) Dealing with Information

Did you know that the first step in managing information is to assess the
source? You will have a better idea on how to deal with the information once
you know the source of the data. Subsequently, you can interpret the data
and convert it into useful information by eliminating any unnecessary or
unneeded data.
5.2.2 Time Management Strategies to Enhance

Personal Productivity
Are you aware that time management is so flexible that not only can it help you to
organise your work life but also your personal life as well? Sometimes, assistant
medical officers feel that their work life is so hectic due to the rotating shifts,
weekend work and stressful work experiences that they have very little quality
time with family or even to spend a few minutes to exercise.
Let us consider the following three time management strategies that can help
enhance our personal productivity (see Table 5.5).

Table 5.5: Time Management Strategies to Enhance Personal Productivity
Strategy Description
Create more There are three major ways to create time. The first method is to
personal time delegate work to someone else. The disadvantage is you cannot
control the outcome of the task, for example, when or how the task
will be completed. Therefore, you might only want to consider
delegating jobs that are boring and mundane.
Another method to make time is to eliminate chores or tasks that
add no value.
The last method is to get up earlier in the day. The extra time from
getting up an hour earlier can be used to enrich your life. At the
end of the day, you might feel tired and respond to the fatigue by
going to bed a little earlier. If a person does not try to go to sleep
earlier and the outcome of getting up early is fatigue, then the
strategy is not beneficial.
Use downtime Downtime is referred to as the time that is seldom used in a day,
effectively for example, waiting time. Calling ahead to verify appointments
and/or reduce and arriving no more than five minutes earlier can help you to
downtime avoid downtime. During unavoidable waiting time, the time can
be filled with productive pursuits such as reading or writing
handy materials.
Control There are always unwanted distractions that might disrupt your
unwanted schedule or personal life. A few examples of distractions include
distractions unplanned phone calls, low priority tasks and requests for
assistance.
How should we handle unwanted distractions? Table 5.6 will provide you with
some strategies to handle them.
Table 5.6: Strategies to Handle Unwanted Time Distractions
Distraction Strategies
Unplanned phone Use an answering machine or voicemail. Consider a humorous
call message. Set a time to return calls.
Low priority task Say no to jobs that have little value or which you have little
interest in.
Request for Encourage your staff to be more independent. Your decision
assistance to accede to the requested assistance should be a conscious
decision rather than a drop-in distraction.

You can visit these websites for more information on time management:
(a) http://www.daytimer.com
(b) http://www.mindtools.com
ACTIVITY 5.1
Based on your experience working in a busy ward and as the team leader
of the unit, discuss the strategies to plan for an effective use of time and
to prioritise your activities. Post your answer in the myINSPIRE online
forum.
SELF-CHECK 5.1
1. Describe the five stages of the team process.
2. Explain the key components of effective teams.
3. Explain five strategies of time management. What are the extra

strategies that can be applied in your line of duty with respect to
time management?
 In effective team building, each member is equally important. EveryoneÊs

voices and opinions are heard and progress is directed at the same goals.
 An interdisciplinary team is formed comprising members with a variety of

clinical expertise such as nurses, physicians and social workers, who look at
care delivery from different viewpoints.
 Five stages of the team process are forming, storming, norming, performing
and adjourning.
 The key components of effective teams include clearly stated team purpose,
team composition, effective communication, active participation, active plan
and ongoing assessment and evaluation.
 General time management strategies include goal setting, setting priorities,

organisation, time tools and dealing with information.

 Other time management strategies to enhance personal productivity include

creating more personal time, using downtime effectively and/or reducing
downtime, and control unwanted distractions.
Adjourning Performing
Distractions Personal time
Downtime Setting priorities
Forming Storming
Goal setting Team building
Information Team process
Norming Time management strategies
Organisation Time tools
1. Which is the normal sequencing of the team process?

A. Forming, norming, storming, performing, adjourning.
B. Norming, forming, storming, performing, adjourning.
C. Forming, storming, performing, adjourning, norming
D. Performing, adjourning, norming, forming, storming.
2. To maintain a conducive environment in team building, it is important to:

A. have an autocratic management style by the leader.
B. encourage creativity within the organisation.
C. reward employees who consistently revise the teamÊs objectives.
D. hold an evaluation session at the completion of the teamÊs duration.

3. All of the following are general time management strategies EXCEPT

.
A. waiting patiently.
B. analysing time.
C. focusing on priorities.
D. having an outcome orientation.
4. Personal productivity can be enhanced by .

A. analysing time, getting up an hour earlier and delegating unwanted
tasks.
B. getting up an hour earlier, answering your calls and inviting a friend
to have a friendly chat.
C. analysing the use of time, getting up earlier and waiting patiently.
D. waking up an hour earlier and accepting all responsibilities without
any negotiations.
Argyris, C. (1964). Integrating the individual and the organization. Oxford,

England: Wiley.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Menlo Park, CA: Addision-Wesley.
Hansten, R. I., & Washburn, M. J. (1998). Clinical delegation skills (2nd ed.).
Gaithersburg, MD: Aspen Publishers.
Harrington-Mackin, D. (1996). Keeping the team going: A tool kit to renew & refuel
your workplace teams. New York, NY: American Management Association
(AMACOM).
Herman, J., & Reichelt, P. (1998). Are first line nurse managers prepared for team
building? Nursing Management, 29(10), 6872.
Lacoursier, R. B. (1980). The life of groups: Group development stage theory.

New York, NY: Human Sciences Press.

Lewin, K. (1951). Field theory in social sciences. New York, NY: Harper & Row.
McGregor, D. (1960). The human side of enterprise. New York, NY: McGraw-Hill
Book Company.
Reed, F. C., & Pettigrew, A. C. (1999). Self-management: Stress and time. St Louis,
MO: Mosby.
Scharf, L. (1997). Revising nursing documentation to meet patient outcomes.

Nursing Management, 28(4), 3839.
Tuckman, B. W., & Jensen, M. A. (1977). Stages in small group development

revisited. Group and Organisation Studies, 2, 419427.
Upenieks, V. (1998). Work sampling: Assessing nursing efficiency. Nursing

Management, 29(4), 2729.

Topic  Decision-
6 making
LEARNING OUTCOMES
1. Identify the factors affecting decision-making;
2. Apply decision-making theories and process to make personal and
group decisions as well as solve complex problems;
3. Demonstrate critical thinking;
4. Explain change and conflict resolution; and
5. Apply the concept of quality assurance, quality management and
quality improvement.
 INTRODUCTION
Why is decision-making important? Decision-making is important because it is a
vital skill that every healthcare providers should have, especially healthcare
managers, since it does not only involve managing and delivering care but also
engaging in planned change. Healthcare institutions have already provided
certain guidelines in dealing with routine situations. However, exceptional
situations may occur at times and requires difficult decision-making involving a
mature sense of judgment.
As for critical thinking, it is a complex process that has many definitions. Most
agreed that critical thinking does entail an orderly investigation of ideas,
assumptions, principles and conclusions. What is critical thinking? Critical
thinking is the process that guides scientific reasoning in the healthcare process,
problem-solving and decision-making. The cognitive skills attributed to the critical
thinking process include divergent thinking, reasoning, reflection, creativity,
clarification and basic support (Green, 2000).

TOPIC 6 DECISION-MAKING  83
Organisational change is a type of change that often causes more stress and
concerns. Unfortunately, when organisational change is planned, employees are
often the last to know about the anticipated change when in reality they will likely
be the ones most affected by it.
Therefore, even though the assistant medical officers are expected to implement
the new care delivery system, they may also be the last persons to know about the
change until it is being implemented. In addition, conflict resolution is vital in
organisational change.
Thus, in this topic, you will learn about the process of decision-making, critical
thinking and conflict resolution, and relate them to your experience and daily
nursing practice. Last but not least, you will also be introduced to the concept of
quality assurance (QA), quality management (QM) and quality improvement (QI).
6.1 FACTORS AFFECTING DECISION-MAKING

Before we discuss further on decision-making, let us get to know the factors that
affect decision-making. Generally, there are two types of factors, namely external
and internal, which affect decision-making. Details of the factors are shown in
Figure 6.1.
Figure 6.1: Internal and external factors that affect decision-making

84  TOPIC 6 DECISION-MAKING
6.2 DECISION-MAKING THEORIES

There are several theories with regard to decision-making. These theories are
summarised in Table 6.1.
Table 6.1: Theories in Decision-making
Theory Key Idea Application to Practice

Normative or • Used when information is • Situations that fall under
prescriptive objective and routine this category can be
decisions are involved or handled using the agency
when the problem is policy, standard procedures
structured. or analytical tools.
• Options are known and
predictable.
Descriptive or • Used when information is • Situations that fall under
behavioural subjective, non-routine and this category are best
unstructured. handled by gathering more
data, relying on past
• Uncertainties exist because
experiences, applying
options or outcomes are
creative approaches or
either unknown or
following a group process.
unpredictable.
Satisficing • The decision maker selects • This process is most
the solution that minimally expedient and may be most
meets the objective or appropriate when time is
standard for a decision. an issue.
• It is a more conservative
method compared to an
optimised approach.
Optimising • The decision maker selects • This process is more likely
the solution that maximally to result in a better
meets the objective or decision. However, it takes
standard for a decision. a longer time to obtain the
result.
• This process usually involves
accessing the pros and cons of
each option as well as listing
the benefits and costs
associated with each option.
The goal is to select the most
ideal solution.
Source: Lancaster & Lancaster (1982)

6.3 DECISION-MAKING PROCESS

Did you know that the decision-making process involves five steps? The five steps
are listed in Figure 6.2.
Figure 6.2: Five steps in decision-making process
The five steps in decision-making are further explained in Table 6.2.
Table 6.2: Decision-making Process
Step Description
1. Identify the problem  Difficulties will arise if the assistant medical manager
and analyse the concentrates on the symptoms rather than the cause.
situation
 A questioning attitude will help to confirm the facts. For
examples, what is the desirable situation? Who is
involved? When? How?
2. Explore alternatives  Managers should firstly determine whether the situation
and consider their is covered by the policy. If it is not, they must use their
consequences discretion and experience to solve it.
 Healthcare goes through rapid changes and solutions
for yesterdayÊs problem may not work today.
 Thus, managers should look beyond their own
experiences and augment them by continuing their
learning (education), have professional meetings,
correspondences and brainstorming with their staff.

3. Choose the most  Examples of interference that might affect effective

desirable alternative solutions include avoiding the real problem, insufficient
data, lacking in staff commitment and eagerness to reach
a decision.
 Managers should balance factors such as patient safety,
staff acceptance, morale, public acceptance, costs and
risks of failure.
4. Implement the  A decision without action is useless.
decision
 The manager will need to select suitable staff and
educate them on how to implement the decision.
5. Evaluate the result  Audits, checklists, ratings and rankings can be used to
review and analyse the outcome.
6.4 GROUP DECISION-MAKING

Did you know that group decision-making is more likely to result in higher quality
decisions? Research findings suggest that groups are more likely to be effective if:
(a) Members are actively involved;
(b) The group is cohesive;
(c) Communication is encouraged; and
(d) Members demonstrate some understanding of the group process.
The group facilitator or leader should carefully select members on the basis of their
knowledge and skills to form an effective group. Individuals who are aggressive,
authoritarian or manifest self-oriented behaviours tend to decrease the
effectiveness of the group.
There are several advantages in utilising group decision-making. With membersÊ

diverse knowledge, skills and resources collaborating during the process, new
ideas can be generated. In addition, the implementation process will be easier to
be carried out when there is commitment from the team members.
In order to secure the support of the group, the leader should maintain open
communication with those who are affected by the decision and be honest about
the advantages and disadvantages of the decision.

Group decision-making also has disadvantages and may not be appropriate for all
situations. Group decision-making process requires more time and may not be
appropriate in some situations especially crisis situations which require prompt
decisions. Another disadvantage relates to unequal power among the team
members. Dominant personality types may influence more passive or powerless
group members to conform to their points of view.
SELF-CHECK 6.1
1. Describe the factors that affect decision-making.
2. What are some of the theories which relate to decision-making?
3. Describe the advantages and disadvantages of group decision-

making.
ACTIVITY 6.1
In groups of two, identify a current problem in healthcare. Use the
problem-solving process to find the solution. Post your answer in the
myINSPIRE online forum.
6.5 CRITICAL THINKING

Before we discuss critical thinking, let us get to know more about nursing. A
professional assistant medical officer has to learn about nursing with respect to
ideas, concepts and theories related to nursing in addition to the knowledge and
skills of how to become a disciplined, self-directed critical thinker.
What is critical thinking? Critical thinking is the disciplined, intellectual process of

applying skilful reasoning as a guide to belief or action (Paul, 1990; Norris & Ennis,
1989).
In nursing, critical thinking for clinical decision-making is the ability to think in a

systematic and logical manner with openness to questions, and to reflect on the
reasoning process used to ensure safe nursing practice and quality care.

For a better picture of critical thinking, let us have a look at the model shown in
Figure 6.3.
Figure 6.3: The critical thinking model
Critical thinking is a concept that interweaves and links to other concepts.

However, decision-making is not synonymous with problem-solving. Decision-
making is a purposeful and goal-directed effort that uses a systematic process to
choose among options. Take note that not all decision-making begins with a
problem, sometimes the individual just needs to identify and select options or
alternatives.
Problem-solving, on the other hand, includes a decision-making step and is

focused on trying to solve an immediate problem, which can be viewed as a gap
between „what is‰ and „what should be‰.
Critical thinkers strive to be clear, accurate and precise when they communicate,
and their thinking is adequate for their intended purposes. Thus, it is important
for managers to assess their staffÊs ability to think critically and enhance their
knowledge and skills through staff development programmes, coaching and role
modelling. In addition, establishing a positive and motivating work environment
can enhance the attitude and disposition to think critically.

6.5.1 Elements of Critical Thinking

Did you know that reasoning (if it is purposeful) comprises elements of thought?
These elements of thought are explained in Table 6.3.
Table 6.3: Eight Elements of Thought
Thought Element Description
Purpose or goal Reasoning has a purpose and requires clarity, significance,

achievability and consistency of purpose.
Central problem or Reasoning is an attempt to solve a problem, figure something
main question out or answer a question. To answer a question or to solve a
problem, one must understand what it requires.
Point of view or frame Reasoning is done from a point of view. Reasoning is
of reference improved when multiple relevant points of views are sought
and articulated clearly, with emphasis on logic and fairness as
well as applied consistently and dispassionately.
Empirical dimension Reasoning is only as sound as the evidence on which it is
based. The evidence should be clear, relevant, accurate,
adequate, fairly gathered and reported as well as consistently
applied.
Conceptual dimension Reasoning is only as relevant, clear and deep as the concepts
that form it. Concepts should be clear, deep, neutral and
relevant.
Assumptions Reasoning is based on assumptions. It can only be as sound as
the assumptions on which it is based. Assumptions should be
clear, consistent and justifiable.
Implications and Reasoning has implications, consequences and direction.
consequences Understanding the implications and consequences is
important to reason through a decision or issue. One must
consider the clarity, completeness, precision, reality and
significance of articulated implications.
Inferences and Reasoning has inferences whereby one draws conclusions and
conclusions gives meaning to the data. Reasoning is only as sound as the
inferences it makes and the conclusions in which it is arrives
at. Inferences should be clear and justifiable. Conclusions
should be consistent, profound and reasonable.
Source: Paul (1990)

6.5.2 Holistic Approach to Critical Thinking

There are five holistic approaches to critical thinking as explained in Table 6.4.
Table 6.4: Five Holistic Approaches to Critical Thinking
Approach Description
Critical listening  It is a mode to monitoring how we listen so as to maximise
our understanding of what another person is saying.
 Critical thinkers listen empathetically and analytically with
respect to one who is speaking.
Critical thinking  It is disciplined, self-directed thinking which implies the

perfection of thinking that is appropriate to a particular
mode or domain of thinking.
 It is the art of reflecting on your thoughts in order for you to
make a better, clearer and more accurate or more defensible
decision.
Critical writing  To express oneself in languages, one has to arrange ideas in
relation to other ideas.
 When accuracy and truth are at issue, writing helps us to
support ideas, and elaborate them in order to make them
intelligible to others and raise objections on other points of
view.
 Disciplined writing requires disciplined thinking as it
enhances the writing process.
Critical reading  It is an active, intellectually engaged process in which the
reader participates in an inner dialogue with the writer.
 A critical reader actively looks for assumptions, key concepts
and ideas, reasons and justifications, supporting examples,
parallel experiences, implications and consequences as well
as any other structural features of the written text in order to
interpret and assess it accurately and fairly (Paul, 1990).
Critical speaking  It is an active process of verbally expressing a point of view,
ideas and thoughts so that others can gain an in-depth
understanding of the speakerÊs personal perspective on the
issue.
 Monitoring how we express ourselves verbally will ensure
that we maximise the accurate understanding of what we
mean through active dialogue and openness to feedback on
our views (Heaslip, 1993).

Last but not least, you can visit the following websites for more information on
critical thinking:
(a) http://www.critical-thinking.org
(b) http://www.insightassessment.com
ACTIVITY 6.2
Let us suppose that the shortage of staff is the biggest problem in your
hospital. Applying critical thinking, how would you solve the problem
with respect to recruiting and retaining staff?
SELF-CHECK 6.2
1. Describe the five steps in the decision-making process.
2. What are the elements of thought?
3. Explain the five holistic approaches to critical thinking.
6.6 CHANGE AND CONFLICT RESOLUTION

Now, let us move on to change and conflict resolution. There are many definitions
of change. For simplicity sake, change can be defined as „making something
different from what it was‰ (Sullivan & Decker, 1997).
Remember that generally change is implemented for a reasonable purpose. Most

organisational change is planned and most of the time, change is purposeful
(Sebastian, 1999). There are three types of change as explained in Table 6.5.

Table 6.5: Three Types of Change
Change Description
Personal change  Made voluntarily according to oneÊs own
reasons, usually for self-improvement.
 For example, changing oneÊs diet or
exercising more and attending seminars on
self-improvement.
Professional change  Can be a change in relation to oneÊs job

position.
 May affect both personal life and professional
life.
Organisational change  Often causes the most stress and concern.

 Usually planned in order to improve
efficiency or financial standing.
Source: Sebastian (1999)

6.6.1 The Change Process

The change process consists of five steps as shown in Figure 6.4.
Figure 6.4: Five steps in the change process
The steps in the change process are further explained as follows:
(a) Assessment
The purpose of and the need for change can be identified from the collection
and analyses of data. There are several sources for data collection and
analysis, namely structural, technological and people.
However, these sources have their own respective problems as can be seen
in the following:
(i) Structural problems  Problems may arise in the form of physical space
or configuration of the space involved;
(ii) Technological problems  Problems may include the lack of wall

outlets for the necessary equipment, poorly selected computer
locations and limited computer system interface ability; and

(iii) People problems  Problems may come in the form inadequate training
to accomplish the goals, unwillingness to meet the goals, lack of
commitment to the organisation or lack of understanding regarding the
need for change.
In this step, we need to analysis data in order to identify the need for change
and to support the potential solutions.
(b) Planning
The most successful plan for change is one where the most affected
individuals are involved in, satisfied with and committed to the process. It is
also important to explain how the change will be implemented, although this
may require some modifications as the implementation begins.
Expected outcomes must be identified and the plan to evaluate those

outcomes must be evident.
(c) Implementation of Change Strategies

Bennis, Benne and Chin (1969) identified three strategies to promote change
in groups or organisations:
(i) Power coercive approach  Uses authority and the threat of job loss to
gain compliance with the change;
(ii) Normative re-educative approach  Uses social orientation and the

need for satisfactory relationships in the workplace as a method for
inducing support for the change; and
(iii) Rational-empirical approach  Uses knowledge as a power base. Once

workers understand the organisational need for change or understand
the relevance of the change to them as individuals and the organisation
as a whole, they will change.
(d) Evaluation of Change

The effectiveness of the change is evaluated according to the outcomes
expected in the planning process. Therefore, the time interval for evaluation
should be identified and allowed to elapse before modifications are made
and declarations of failure are asserted.
(e) Stabilisation of Change

The stabilisation of the change is completed once the evaluation is
determined. Subsequently, re-evaluation is planned after the first six months
or one year of implementation to ensure that stabilisation of the change has
occurred.
6.6.2 Conflict
An important part of the change process is the ability to resolve conflict. Conflict
allows for a healthy discussion of different views and values, and adds another
dimension to quality patient care. Conflict can also be seen as a disagreement about
something of importance to two or more parties. Each party may or may not be
aware of the otherÊs conceptualisation of the meaning of the conflict, thus both
parties need to sit down to determine the existence and nature of the conflict as
well as the reasons for it.
There are essentially seven methods in conflict resolution. These methods are
explained in Table 6.6 together with their respective advantages and
disadvantages.
Table 6.6: Advantages and Disadvantages of Conflict Resolution Methods
Method Description Advantage Disadvantage

Avoiding  Ignoring the  Does not make a  Conflict can become
conflict. big deal out of bigger than
nothing. anticipated.
 Conflict may be  The source of the
minor in conflict may be
comparison to more important to
other priorities. one person or group
than the other.
Accommodating  Smoothing  One party is more  One party holds
or concerned with an more power and
cooperating. issue than the can force the other
other. party to give in.
 One party
gives in to  Stakes are not high  The importance of
the other enough for one the stakes are not as
side. group, causing the apparent to one
other party to party as to the
willingly give in. other.
 Can result in the
party feeling „used‰
if he/they is/are
always pressured to
give in.

Competing  Forcing.  Produces a winner.  Produces a loser.

 The two or  Good when time is  Results in anger and
three parties short and stakes resentment for the
are forced to are high. losing party.
compete for
the goal.
Compromising  Each party  No one should win  May cause a return
gives up or lose but both to the conflict if
something should gain what is given up
and gains something. becomes more
something important than the
 Good for
in return. original goal.
disagreements
between
individuals.
Negotiating  High-level  Stakes are very  Agreements are
discussion high and solution permanent even
that seeks is rather though each party
agreement permanent. has gains and
but not losses.
 Often involves
necessarily
powerful groups.
consensus.
Collaborating  Both parties  Best solution for  Takes a lot of time.
work the conflict and  Requires
together to encompasses all commitment for
develop an important goals to success.
optimal each party.
outcome.
Confronting  Immediate  Does not allow  May leave the
and obvious conflict to take impression that
move to root. conflict is not
stop conflict tolerated.
 Very powerful.
at the very
 May make
start.
something big out
of nothing.
Aside from these seven methods, you can also consider five other approaches to
conflict resolution from the perspective of negotiation. The five approaches of
negotiation according to Lewicki, Hiam and Olander (1996) are shown in
Figure 6.5.

Figure 6.5: Five approaches of negotiation

Source: Lewicki, Hiam & Olander (1996)
The five approaches of negotiation are influenced by the importance of

maintaining the relationship relative to the importance of achieving oneÊs desired
outcome. This relationship is shown in Figure 6.6.
Figure 6.6: The importance of relationship versus the importance of outcome

Source: Lewicki, Hiam & Olander (1996)
The success rate of the selected approaches depends on several factors. Any issues
can have an enormous impact on the approach selected and the level of success
that will be achieved. The guide for the assistant medical leader or manager is to
determine which conflict requires intervention and which approach stands the
best chance of success.

ACTIVITY 6.3
Let us assess a conflict situation. Reflect on your daily tasks at the ward. Select
one problem that occurs during your shift. Based on the following assessment
format, answer all the following questions:
(a) What is (are) the issue(s) in the conflict?
(b) Are the issues based on facts? Based on values? Based on interests in the
resources concerned?
(c) Are the issues realistic?
(d) What are the goals of each conflicting party?
(e) What conflict management strategies, if any, have been used to manage
the conflict to date?
(f) What are the alternatives to managing the conflict?
(g) What are you doing to stop the conflict from continuing?
6.7 MANAGING QUALITY

Before we end this topic, let us look at quality management. Did you know that
quality management philosophy in healthcare differs from others with respect to
its evaluation techniques? This is because it focuses on:
(a) The customer instead of the provider;
(b) Prevention instead of inspection; and
(c) Process instead of the person.
Successful quality management anchors on the organisation and the values of a

continuous process of improved patient outcomes. These values will determine
the survival and competitiveness of healthcare providers.
When we talk about quality, there are three terms that relate to it. The terms are:
(a) Quality assurance (QA);
(b) Quality management (QM); and
(c) Quality improvement (QI).

Quality assurance (QA) emerged in healthcare practice in the 1950s, about the
same time in which hospital-accrediting organisations were founded (Albany
Medical Center, 1998). QA was first aimed at inspecting healthcare institutions,
mainly hospitals, to achieve minimum standards of care. The function of QA grew
over time and became the organisational mechanism for measuring performance
against standards, and reporting incidents and errors such as mortality and
morbidity rates.
QAÊs methods consist primarily of chart audits of various patient diagnoses and
procedures. The method was thought to be punitive with its emphasis on „doing
it right‰ and did little to sustain change or proactively identify problems before
they occur. However, it did help to achieve the minimum standards of
performance.
Next came quality management (QM) and quality improvement (QI) concepts.
These two terms evolved from the business philosophy known as total quality
management (TQM).
TQM began in the manufacturing industry with W. Edwards Deming and Joseph
Juran in the 1950s. The approach was integrated into the healthcare industry in the
1980s when costs and quality of care from health maintenance organisations and
other third-party providers increased along with the competition for patients
(Albany Medical Center, 1998).
What does QM and QI mean? Let us look at Table 6.7 for the answer.
Table 6.7: Quality Management (QM) and Quality Improvement (QI) Definition
Quality Management (QM) Quality Improvement (QI)

A philosophy that defines a corporate An ongoing process of innovation,
culture which emphasises customer prevention of error and staff
satisfaction, innovation and employee development. It is used by corporations
involvement. and institutions that adopt the quality
management philosophy.
This proactive approach emphasises „doing the right thing‰ for customers and the
end goal of this approach is to satisfy customers.
However, many healthcare organisations prefer to use the term „quality

management‰ or „continuous quality improvement‰ because total quality
improvement can never be achieved.

There is another term that you need to know  performance management (PI).
For your information, the term „performance improvement‰ is sometimes used
interchangeably with quality improvement but it usually emphasises improving
the activities of individuals or groups and not the systems.
Let us look at Table 6.8 which shows the differences between QA and QI.
Table 6.8: Differences between Quality Assurance (QA) and Quality Improvement (QI)
Aspect Quality Assurance (QA) Quality Improvement (QI)

Philosophy  „Doing it right.‰  „Doing the right thing.‰
Goal  To improve quality.  To improve quality.
Focus  Discovery and correction of  Prevention of errors.
errors.
Major tasks  Inspection of nursing  Review of nursing activities.
activities.
 Innovation.
 Chart audits.
 Staff development.
Quality  QA personnel or department  Multidisciplinary team.
team personnel.
Outcomes  Set by QA team with input  Set by QI team with input from
from staff. staff and patients/customers.
Source: Gurung (2016)
SELF-CHECK 6.3
1. State the focus of quality management philosophy in

healthcare.
2. Define quality assurance (QA) and quality improvement (QI).

6.7.1 Benefits of Quality Management (QM)

Quality management (QM) provides benefits to healthcare providers in several
ways. Firstly, QM provides benefits for organisations because QM is based on:
(a) The philosophy of being better;
(b) Things to be done right the first time;
(c) Improvement is always possible; and
(d) Being better than the competitors.
Therefore, the application of the QM philosophy can increase an organisationÊs

chances of survival during highly turbulent and competitive times.
Secondly, QM helps in terms of customer loyalty by maintaining quality in every

interaction with the patient or customer. Customer satisfaction is rooted in the way
health professionals treat their patients or customers and in the quality of their
outcomes.
Thirdly, QM motivates health professionals to give their customers more than the
basics so that customers will recommend the services to others and create demand
for the services. This is achieved by:
(a) Proactively seizing opportunities to perform better;
(b) Aiming for quality consistently; and
(c) Continuously improving and not waiting for a problem to be highlighted or
pressure from competitors.
Fourthly, QM involves everyone in the improvement team and encourages

everyone to contribute. This style of participative management enhances job
satisfaction. Employees feel valued as team members who can really make a
difference.
6.7.2 Quality Improvement (QI) Process

Generally, the quality improvement (QI) process is structured to plan, implement
and evaluate changes in healthcare activities. It involves six steps and can easily
be applied to clinical situations. The six steps are explained in Table 6.9.

Table 6.9: Six Steps in the Quality Improvement (QI) Process
Step Description
1. Identify the most  Assistant medical managers or staff nurses may
important patient or conduct interviews or survey patients about their
consumer needs for experiences during nursing care.
healthcare services
 The studies should not only focus on physical tasks but
also on interpersonal care as well.
2. Assemble a  Teamwork is important in order to develop an effective
multidisciplinary QI team.
team to review the
identified consumer  Consider briefing or educating team members about
needs and services their roles before starting the QI process.
3. Collect data to  Various data tools can be used such as flowcharts, line
measure the current graphs, histograms, Pareto charts and fishbone
status of the services diagrams.
4. Establish  Benchmarking is one way to evaluate the quality of
measurement outcomes in your healthcare institution.
outcomes and quality
indicators  It is done by comparing one institutionÊs performance
against that of similar organisations.
5. Select and implement  Change strategies should emphasise open
a plan to meet the communication and training for staff who are affected
outcomes by the new standards or outcomes.
6. Collect data to  If an outcome is not met, revisions on the
evaluate the implementation process are needed.
implementation of
the plan and the  The assistant medical manager must also evaluate the
achievement of the work of the team members and the ability of individual
outcomes team members to work together effectively.
ACTIVITY 6.4
You are the change agent of the unit tasked with implementing a new
healthcare approach and maintaining the quality of care. Choose one
issue in your clinical practice and relate it with the quality
improvement process (refer to Table 6.9). Post your answer in the
myINSPIRE online forum.

 Generally, there are two types of factors that affect decision-making, namely
external factors and internal factors.
 Decision-making theories that can be applied to our decision-making are

normative or prescriptive, descriptive or behavioural, satisficing and
optimising.
 The decision-making process involves five steps:
 Identifying the problem;
 Exploring alternatives and considering their consequences;
 Choosing the most desirable alternative;
 Implementing the decision; and
 Evaluating the results.
 Group decision-making is more likely to result in higher quality decisions.
 Critical thinking is the disciplined, intellectual process of applying skilful

reasoning as a guide to belief or action. It involves examining situations from
every viewpoint.
 Conflict management and resolution are important parts of the change process.
 Change can be defined as making something different from what it originally was.
 There are three types of change, namely personal change, professional change
and organisational change.
 The change process involves assessment, planning, implementation,

evaluation and stabilisation.
 To resolve conflicts, parties need to identify their differences, priorities and

common goals. They also need to determine which conflict resolution is the
most appropriate and to implement it.
 Quality management (QM) strives to prevent errors through effective

planning. It refers to a philosophy that defines a corporate culture emphasising
customer satisfaction, innovation and employee involvement.

 Quality assurance (QA) is the organisational mechanism for measuring

performance against standards and reporting incidents and errors such as
mortality and morbidity rates.
 Quality improvement (QI) is a continuous process which focuses on

maintaining regulatory compliance and improving patient care processes and
outcomes.
Conflict Organisational change

Critical thinking Personal change
Decision-making Professional change
Descriptive or behavioural Quality assurance (QA)
Group decision-making Quality improvement (QI)
Normative or prescriptive Quality management (QM)
Optimising Satisficing
1. Decision-making is best described as

A. the process one uses to solve a problem.
B. the process one uses to choose between alternatives.
C. the process one uses to reflect on a certain situation.
D. the process one uses to generate ideas.
2. What is the most desirable conflict resolution technique?

A. Avoiding
B. Competing
C. Negotiating
D. Collaborating

1. Decision-making process is a vital skill that every assistant medical manager

should have. Using an example, briefly describe how the decision-making
theories can be implemented in your healthcare practice.
2. Discuss the benefits of quality improvement (QI) process in your healthcare

activities.
Albany Medical Center. (1998). AMC Q series curriculum. Albany, NY: Author.
Bennis, W., Benne, K., & Chin, R. (1969). The planning of change. New York: Holt,
Rinehart & Winston.
Green, C. (2000). Critical thinking in nursing. Upper Saddle River, NJ: Prentice
Hall Health.
Gurung, N. (2016). Quality assurance in nursing. Retrieved from

https://www.slideshare.net/NirsubaGurung/quality-assurance-in-
nursing-60403730
Heaslip, P. (1993). Critical thinking and nursing. Retrieved from

https://www.criticalthinking.org/pages/critical-thinking-and-nursing/834
Lancaster, J., & Lancaster, W. (1982). Concepts for advanced nursing practice:
The nurse as a change agent. St Louis, MO: Mosby.
Lewicki, R. J., Hiam, A., & Olander, K. W. (1996). Think before you speak:
A complete guide to strategic negotiation. Hoboken, NJ: Wiley.
Norris, S. P., & Ennis, R. H. (1989). Evaluating critical thinking. Pacific Grove, CA:
Midwest Publications, Critical Thinking Press.
Paul, R. W. (1990). Critical thinking: What every person needs to survive in a

rapidly changing world. Rohnert Park, CA: Center for Critical Thinking and
Moral Critique.

Sebastian, J. G. (1999). Organizational theory and the change process. In J.

Lancester (Ed.), Nursing issues in leading and managing change. St Lois,
MO: Mosby-Times Mirror.

nursing (4th ed.). Menlo Park, CA: Addison-Wesley.

7 Law
LEARNING OUTCOMES
1. Identify the sources of law in Malaysia;
2. Explain the structure of the Malaysian courts;
3. Identify the various types of law in Malaysia; and
4. Define tort law and explain how it affects healthcare practice.
 INTRODUCTION
The role of professional assistant medical officers has expanded rapidly within the
past few years to include increased expertise, specialisation, autonomy and
accountability from the legal and ethical perspectives. This has raised new
concerns amongst assistant medical officers and has heightened the awareness of
the interactions between legal and ethical issues. The areas of concern include legal
issues, professional acts and regulations, employment rules and ethical principles.
This topic provides an overview of the legal system and specific doctrines used by
the courts to define the legal boundaries of the nursing practice.
However, take note that this topic is not meant to be a complete legal guide to the
healthcare practice. You are advised to seek other legal textbooks for further
information on legal matters.

108  TOPIC 7 INTRODUCTION TO LAW
7.1 DEFINITION OF LAW

Did you know that the earliest notion of law was the pronouncement of a ruler
who was acting according to what he thought was his „divine right‰? How can we
define law? Well, a workable definition would be in relation to the rules of human
conduct, established and enforced by authority, which prohibit extremes in
behaviour so that one can live without fear for oneself or oneÊs property
(Ramachandran, 2012).
7.1.1 Sources of Law

Many different laws affect healthcare providers and their practice. Some laws
affect assistant medical officers personally such as constitutional amendments,
whereas other laws such as administrative law regulates the assistant medical
officersÊ professional acts.
In a democratic country like Malaysia, who formulates and enforces the laws? The
ruling government in Malaysia, who is elected by the people, is the one tasked to
formulate and enforce laws. Article 160 of the Federal Constitution provides a
three-fold classification of the different types and sources of Malaysian laws as
shown in Figure 7.1.
Figure 7.1: Different types of Malaysian law

Source: Commissioner of Law Revision (2006)

TOPIC 7 INTRODUCTION TO LAW  109
The three different types of law are further explained in Table 7.1.
Table 7.1: Types of Malaysian Law
Type Description
Written law The written law consists of the Federal Constitution (which is the
(statutory law/ supreme law of the land) and the Constitution of each state of the
public law) Federation of Malaysia. Acts are passed by the Parliament and the
various State Assemblies. Subsidiary rules and regulations are
made by the ministers and other persons, by virtue of the powers
vested in them according to the Acts of Parliament or State
enactments.
Common law This is a body of law that was developed from an accumulation of
judgments arising from past cases or precedents. The body of case
laws, which developed from adjudication of kings and later of
judges, is known as the common law. Common law or judge-made
law is to be contrasted from statutory law.
Whenever a case comes up before a court, a decision is made by

the court upon the facts of the case before it. This legal decision
may contain a principle which would be used in subsequent cases
as a guide or precedent. Most of these precedents are recorded in
volumes known as case reports. These recorded precedents are
referred to as the common law. Precedents are created by the
power of judges to interpret the existing law, whether it is a
previous precedent or some legislation. By doing so, they create
new precedents and so the common law grows.
Customs or Customs or practices deal with any customs or practices having
practices the force of the Federation law. This includes practices derived
from personal laws of different communities. For example, the
adat of the Malays as well as the Hindu and Chinese customary
laws.
ACTIVITY 7.1
Discuss the following questions in the myINSPIRE online forum:
(a) What is your interpretation of law?
(b) Why must laws exist?

SELF-CHECK 7.1
Describe the three types of Malaysian law.
7.1.2 Hierarchy of Malaysian Courts

Figure 7.2 which shows an overview of the hierarchy of the Malaysian courts.
Figure 7.2: The judicial system in Malaysia

Source: http://www.kehakiman.gov.my/en/court/appeal-court/hierarchy
The system of courts throughout Malaysia was established via Article 121 of the
Federal Constitution, the Courts of Judicature Act (revised 1972) and the
Subordinate Courts Act (revised 1972).

What is a court?
A court is a gathering, presided over by a judge or other person invested with

judicial power, which follows the rules of procedure prescribed for that court
and in some cases, it is assisted by a jury.
Commissioner of Law Revision (2006)
The judge, or where there is a jury (the judge and jury), determines such matters as:
(a) Whether certain facts have been established or otherwise;
(b) Where required, the legal obligations and rights of a party or parties;
(c) The punishment that is appropriate for criminal or other offences; and
(d) The interpretation of statutory provision, the provisions of a will or of a
contract.
Take note that every court has a specific jurisdiction or power to hear cases. In fact,
the word „jurisdiction‰ covers two aspects:
(a) The subject matter before the court; and
(b) The geographical area in which the court covers.
The courts have the power to deal with matters concerning the law that have been
specifically stated within a certain geographical area. Furthermore, each court has
certain civil and criminal powers as highlighted in the following:
(a) On the civil side, the courts can only try cases involving the subject matter of
a certain value; and
(b) On the criminal side, the courts are limited by the punishment that they can
impose.
Courts are arranged in a hierarchy, from the lowest courts to the highest courts
(see Figure 7.2). Decisions made in the higher courts have precedence over
decisions made in the lower courts. This means that when one has received a
judgment from a lower court, one can appeal to a higher court to have the lower
courtÊs judgment quashed so that either a different judgment is made or a new
hearing is granted. The decision of the higher court then applies, and is binding on
all courts that are lower in the hierarchy within the same jurisdiction. The system
in which the common law is passed on to influence later decisions is called
precedent.

SELF-CHECK 7.2
1. Give the definition of a court.
2. State two aspects of jurisdiction.
7.1.3 Jurisdictions of the Malaysian Courts

Now, let us look at the specific jurisdictions of the various Malaysian courts.
(a) The Federal Court

In Malaysia, the Federal Court is the highest court of the land. It is essentially
an appellate court hearing appeals from the Court of Appeal and the High
Court. It also has the original jurisdiction to hear disputes between the States
in the Federation or between any States and the Federation. It can decide
whether any State or Federal law, which was made by the State or Federal
government, exceeds their authority. In addition, it can decide on any
question on the Federal Constitution referred to it by the Yang di-Pertuan
Agong.
(b) The High Court

The High Court has an original, appellate and supervisory jurisdiction. In its
original jurisdiction, it has the power to hear all civil and criminal matters
regardless of the amount or sentence involved.
However, for civil matters, only those above the jurisdiction of the
Subordinate Courts are filed in the High Court.
For criminal cases, the cases normally have to be heard first in the
Magistrates Courts by way of a preliminary hearing before they can be
brought to the High Court.
However, the Public Prosecutor may issue a certificate requiring the court
before which the case is pending to send the case to the High Court directly
for trial.
In its appellate jurisdiction, the High Court hears appeals from the
Subordinate Courts. By virtue of its supervisory jurisdiction, the High Court
may require any case in the Subordinate Courts to be brought before the
High Court for hearing.

(c) Sessions Court

A Sessions Court has the power to try all civil proceedings where the amount
in dispute or value of the subject matter does not exceed RM100,000.
However, the parties may have an agreement in writing to state that the
Sessions Court shall have jurisdiction over any amount. Take note that the
Sessions Court has no jurisdiction on matters relating to immovable property
(with some exceptions), specific relief, administration and probate,
legitimacy and guardianship of infants and divorce. In its criminal
jurisdiction, the Sessions Court can try all offences other than those
punishable by death.
(d) Magistrates Court

First Class Magistrates have the power to hear civil proceedings where the
amount in dispute or value of the subject matter does not exceed RM25,000.
A First Class Magistrate may also hear and determine appeals from the
PenghuluÊs Court. In his criminal jurisdiction, the judge can hear all offenses
for which the maximum term of imprisonment does not exceed 10 years or
which are only punishable with a fine. He is empowered to try offenses
under Section 392 (robbery) and Section 457 (trespass) of the Penal Code. The
First Class Magistrate may pass any sentence allowed by law not exceeding:
(i) 10 years of imprisonment;
(ii) A fine of RM10,000;
(iii) Whipping of up to 12 strokes; or
(iv) Any sentence combining any of the sentences above.
An appeal on the decision of the Magistrates Court is dealt with by the High
Court.
As for the Second Class Magistrates, they have the power to try original
actions or suits of a civil nature where the plaintiff seeks to recover a debt or
specific amount of money not exceeding RM300.
On the criminal side, a Second Class Magistrate may try offenses where the
maximum term of imprisonment for those offences does not exceed 12
months of imprisonment or which are only punishable with a fine. In
addition, a Second Class Magistrate may pass any sentence allowed by law
not exceeding:
(i) Six months imprisonment;
(ii) A fine of not more than RM1,000;

(iii) Any sentence combining either of the above; or

(iv) Any sentence combining any of the sentences above.
An appeal from a decision of the Magistrates Courts is dealt with by the High
Court.
(e) Juvenile Court

This is a special court under the Juvenile Act of 1947 (Revised 1972), which
deals with offenders below the age of 18. The President of the Sessions Court
presides with the help of two assessors who are chosen from the public.
Hearings are conducted in an informal atmosphere and are not open to
members of the public. The court has the power to try all offenses except
those punishable by death. Guilty offenders may be sent to an approved
institution or discharged upon a bond, with or without sureties. Any person
aggrieved by any findings of the court may appeal to the High Court.
(f) PenghuluÊs Court

Did you know that the PenghuluÊs Courts are peculiar to West Malaysia? A
PenghuluÊs Court has the power to hear civil proceedings where the amount
sought to be recovered does not exceed RM50 and in which all the parties are
persons of the Asian race and they can speak and understand the Malay
language.
On the criminal side, the PenghuluÊs Court may only try offenses of a minor
nature which are specifically enumerated in his Kuasa (empowering
document) and which can be adequately punished by a fine not exceeding
RM25. A person charged in a PenghuluÊs Court may elect to be tried by a
Magistrate Court. An appeal against the decision of the PenghuluÊs Court
may be made to the First Class Magistrate.
(g) Native Courts

Native Courts are part of the judicial system in Sabah and Sarawak. They
have the power to deal with matters concerning native customs where the
parties are local natives. The Native Courts have the power to try civil and
criminal cases arising from a breach of the native law or custom whereby all
the parties are natives or, in respect of a breach relating to religious,
matrimonial or sexual matters in which one of the parties is a native.
(h) Tribunals
Apart from the main system of courts, there are various bodies which are
often referred to as tribunals. These tribunals have varying functions and
procedures which are set out in the legislation that formulates them.

(i) Industrial Court

The Industrial Court is a special court that was set up to deal exclusively with
trade disputes. What does a trade dispute mean?
A trade dispute is defined as „any dispute between employers and

workmen or between workmen and workmen or between employers and
employees which is associated with the employment of any person.‰
Trade Disputes Ordinance 1949
However, parties cannot directly approach the Industrial Court. They have
to approach Minister of Human Resources, who may refer such a dispute to
the Industrial Court. Though the Industrial Court is not part of the main
system of courts, the High CourtÊs supervisory powers may be invoked to
examine the decisions of the Industrial Court. If an employee is dismissed or
terminated and chooses to challenge such a dismissal or termination he or
she, as an employee, can take the matter up to the Industrial Court.
The Industrial Court deals with matters referred to it in a less formal way
than the High Court. Rules of evidence are applied rather liberally. The court
pursues a nebulous ideal known as social justice when deciding upon the
cases brought before it.
7.1.4 Types of Laws

There are a number of ways to classify law. The different types of law are
illustrated in Figure 7.3.

Figure 7.3: Types of law

As you can see in Figure 7.3, the two major classifications of law are substantive
law and procedural law.
(a) Substantive Law

Substantive law is that part of the law which tells us what we can do, must
do or must not do, as well as the interpretation of the law, setting out rights
and obligations and others. It determines the specific wrong, harm, duty or
obligation that causes an action to be brought to trial. It is divided into two
sub-branches, namely:
(i) Civil law  Have many sub-branches such as constitutional law,

commercial law, contract law, bankruptcy law, administrative law and
family law. It recognises and enforces the rights of individuals and
organisations.
(ii) Criminal law  Defines crimes and punishments.
Civil law and criminal law will be further explained in Subtopic 7.1.5.

(b) Procedural Law

Procedural law includes the various legal procedures required to bring a
dispute to trial and determines the rules that parties must follow to litigate a
matter before a court.
In other words, it regulates the statute of limitations and the process for
administrating evidence at a trial. This includes sub-branches such as the law
of evidence and court rules.
In a nutshell, we can conclude that the legal system is a complex combination of

laws, rules and regulations that are created at both the federal and state levels.
Assistant medical officers must stay informed within the legal scope of their
healthcare practice in the society.
Moreover, the healthcare profession is bound to undergo changes from time to

time. Basic knowledge of the law and how it works would certainly help assistant
medical officers and nurses to avoid litigation while giving them the confidence to
practice without fear or uncertainty.
7.1.5 Differences between Civil Law and Criminal Law

Criminal actions are instigated by the Penal Code (Kanun Keseksaan) (in the guise
of the State, through the police) claiming a person has committed a wrong by
committing a crime.
On the other hand, civil action is instigated by an individual, who claims that
another person has wronged (harmed) him either physically, mentally or
economically, or is likely to cause such harm by the proposed actions.
Criminal cases are prosecuted by the State. They are officially designated. If the
prosecution is successful, the convicted person is punished. The Penal Code is not
interested in compensating the victim in these cases, only in punishing the offender.
On the other hand, civil cases are brought about mainly by:
(a) One person against another, claiming damage that was wrongfully inflicted
on him or a debt owing to him, and seeking compensation from that person.
In this case, the first person is suing (not prosecuting) the other. The person
suing is called the plaintiff while the person being sued is called the
defendant; or

(b) A person seeking endorsement of a claim to certain rights and privileges as

against another. That person is called an applicant of the court and any
person or body opposing the claim is called the respondent.
The Penal CodeÊs only interest here, through the judges, is that the contest in
court be carried out according to the established procedures and rules of
evidence and acts as a referee in both types of cases (the judges of course have
the added role of interpreting the law and determining the facts). Civil cases
are designated as per the name of the plaintiff or applicant first, followed by
that of the defendant or respondent.
In criminal cases, the prosecution has to convince the jury, beyond a reasonable
doubt, that the accused is guilty. This means that unless the prosecution has left
no reasonable doubt in the juryÊs mind as to the accusedÊs guilt, despite the
accuserÊs attempts to create that doubt, they must acquit.
In a civil case, the burden on the plaintiff or applicant amounts to convincing the
court on the balance of probabilities. This is not as difficult as the standard of proof
for a criminal case. The court must find a defendant not liable unless the plaintiff
has proved his case to that standard. The defendant does not have to prove his
case, only to throw doubt on the plaintiffÊs arguments.
Criminal law deals with wrongs which are committed against the State rather than
against individuals. This is reflected in the fact that offenders are prosecuted by
the State. The interest of criminal law is in the punishment of the perpetrator, not
in the fate of the victim, who must pursue remedies in civil actions.
It is rare for a charge of criminal negligence to be laid against a health worker. It

may, however, be found that where something has gone horribly wrong, with
unintended results, and it is established that the healthcare worker in question
either intended some degree of harm to occur or was so reckless with regard to
human life or safety that a jury finds his actions serious enough to amount to a
criminal act.
Take note that there is no definition of criminal negligence in the legislation (where
it involves an unintended death, it may be termed as involuntary manslaughter).
Therefore, we must look carefully to case law or reference for it.

7.1.6 Tort Law

The law of negligence, also known in the healthcare context as malpractice law, is
part of what is known as the tort law (Syed Ahmad S. A. Alsagoff, 2017). The term
is derived from an old French word meaning „wrong‰ and this branch of the law
deals with injuries caused by one person onto another. Disputes of law arise when
a person or body claims that another party has done them wrong.
Therefore, the doctrine of negligence applies to all areas of human activity but its
operation in relation to healthcare has some special features.
Tort law is one of the ways in which assistant medical officers and health visitors
are held accountable. It differs from other types of law in a number of ways.
Criminal law established standards on behalf of society and when the rules are
broken, the society punishes the wrongdoer irrespective of the victimÊs position.
The wrong is committed against society as a whole. However, this is different in
tort law as it is concerned with the relationship between individuals.
In tort law, when mishaps occur, victims can choose if they wish to sue the person
who caused the action. If they decide to sue, and in their case, they will receive
compensation. The compensation is designed, so far as possible, to put them in the
position in which they would have been if nothing had happened to them. The
major function of negligence actions in healthcare as in elsewhere, is to provide
compensation for the victims of the accidents.
The second main function of negligence is to provide an incentive to practitioners

to attain a high standard of care. The fact that falling short of the proper standards
of care may lead to being sued and paying out money for compensation is thought
to deter poor practice.
However, the negligence of the standard of care does not represent the quality of
care that assistant medical officers, nurses, midwives and health visitors should
aspire to provide since it only establishes the basic or minimum standard of
practice that patients are entitled to expect.
SELF-CHECK 7.3
1. Describe two major classifications of law.
2. What is tort law?
3. When does disputes of law happen?

 Law refers to the rules of human conduct, established and enforced by

authority, which prohibits extremes in behaviour so that one can live without
fear for oneself or oneÊs property.
 There are three types of Malaysian law, namely the written law (statutory
law/public law), common law and customs or practices.
 A court is a gathering, presided over by a judge or other person who is vested

with judicial power, which follows the rules of procedures prescribed for that
court and is in some cases, assisted by a jury.
 The judicial system in Malaysia can be divided into superior courts and
subordinate courts.
 Courts are set out in a hierarchy, from the lowest courts to the highest courts.
 Generally, there are two types of law, namely substantive law and procedural
law.
 Under substantive law, there are the civil law and criminal law. Meanwhile,
under procedural law, we have procedural rules and rules of court.
 The law of negligence, also known in the healthcare context as malpractice law,
is part of what is known as tort law, which deals with injuries caused by one
person to another.
 Tort law is one of the ways in which assistant medical officers, nurses and
health visitors are held accountable in their profession.

Appeal Plaintiff
Case law Procedural law
Common law Subordinate courts
Contract Substantive law
Court Superior courts
Customs or practices Tort law
Legislation Written law
Negligence
1. Common law refers to:

A. The law that societies have in common.
B. Ethical ideas only.
C. Statutes.
D. Case law.
2. The First Class Magistrate may pass any sentence allowed by law not
exceeding the following EXCEPT:
A. 10 years of imprisonment.
B. A fine of RM10,000.
C. A fine of not more than RM1,000.
D. Whipping of up to 12 strokes.

Commissioner of Law Revision. (2006). Laws of Malaysia. (2006). Retrieved from

http://www.oit.org/wcmsp5/groups/public/---ed_protect/---protrav/---
ilo_aids/documents/legaldocument/wcms_125966.pdf
Ramachandran, V. (Ed.). (2012). Encyclopedia of human behaviour (2nd ed.). New

York, NY: Elsevier.
Syed Ahmad S. A. Alsagoff. (2017). The law of torts in Malaysia. Petaling Jaya,
Malaysia: LexisNexis.
Trade Disputes Ordinance 1949.

8 Ethics
LEARNING OUTCOMES
1. Identify the standardisation of professional conduct;
2. Recognise the laws that can affect the assistant medical officer in
discharging his duty;
3. Apply basic ethical concepts; and
4. Solve ethical dilemmas using the five-step ethical decision-making
process.
 INTRODUCTION
This last topic is divided into four sections. Having learnt the types of law and the
differences between various types of law in the previous topic, you may now study
the standards of professional conduct set by the Medical Assistant Board. You will
also learn about the laws that apply to assistant medical officers.
The first subtopic examines the role of medical assistant acts and regulations, and
the employment rules in professional licensure and discipline. The second
subtopic deals with legal implications and assistant medical officersÊ duties and
responsibilities. Basic ethical concepts will be introduced in the subsequent
subtopic. The last subtopic deals with ethical issues and dilemmas in healthcare
practice.
The law works through the four following ways in order to maintain healthcare
standards:
(a) Criminal law is involved whenever harm was deliberately or recklessly
caused. For example, it is a case of manslaughter when a patient dies as a
result of recklessness or when healthcare practitioners intentionally commit
an unlawful act that causes death;

124  TOPIC 8 INTRODUCTION TO ETHICS
(b) The Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977
requires the Medical Assistant Board to conduct professionalism at all times;
(c) Under the contracts that employers have with each assistant medical officer,
employers may discipline and dismiss the assistant medical officer; and
(d) The law of negligence allows patients to sue assistant medical officers and
their employers for compensation, should they suffer loss through their
carelessness.
Let us learn more about these standards in the following subtopics.
8.1 STANDARDISATION OF PROFESSIONAL

CONDUCT
One of the primary functions of the Medical Assistant Board is to protect the public
from unqualified persons who attempt to practise the profession of an assistant
medical officer or who pose potential harm to a patient through unsafe practices.
Through such mechanisms as the Laws of Malaysia, Act 180, Medical Assistants
(Registration) Act 1977, the standards of care and the code of ethics for medical
assistants can ensure a degree of public safety where healthcare is concerned. The
Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977 is a legal
code and although it is stated in very general terms, it does have the force of law
and mechanisms for enforcement. Take note that the standards of care and code of
ethics are not laws but they have their own means of enforcement.
When an assistant medical officer violates the standards of care or the code of
ethics (or both) frequently and with disregard, that person is not acting in a
professional manner. Therefore, the Medical Assistant Board has the authority to
discipline assistant medical officers who are not acting in a professional manner.
This discipline can range from a reprimand to licensure suspension or even
revocation.

TOPIC 8 INTRODUCTION TO ETHICS  125
8.1.1 Licensure
What is licensure?
Licensure is the process in which an agency of a government grants permission

to an individual to engage in a given occupation.
There must be evidence that the applicant has attained a minimal degree of
competency to ensure that public health, safety and welfare are reasonably
protected. It defines not only the scope of practice and the requirements for entry
into practice but also the penalties for prescribed actions and for practising without
a requisite license.
8.1.2 Medical Assistant Board

In order to regulate the healthcare practice in Malaysia, the Medical Assistant
Board Malaysia was created. The Medical Assistant Board Malaysia comes under
the Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977.
Assistant Medical Officer Registration is a statutory body for assistant medical
officers. It controls the training, registration and discipline of assistant medical
officers in Malaysia.
The aims of the Board are to:

(a) Establish and improve the standards of education and professional conduct
for assistant medical officers at hospitals and public health practices;
(b) Provide policy advice to organisations representing assistant medical officers
and other organisations which are relevant to hospitals and the general
public; and
(c) Develop and promote the healthcare plan and processes for patients in
institutions as well as the community.

As for the functions of the Medical Assistant Board Malaysia, they are shown in
Table 8.1.
Table 8.1: Functions of Medical Assistant Board Malaysia
Function Description
Training • Approves training schools for medical assistants.
• Approves the curricula for training.
• Reviews the training curricula from time to time.
Registration • Registers trained assistant medical officers in the general part of the
Register for assistant medical officers.
• Registration of assistant medical officers is compulsory in order to practise
healthcare and provide general public services.
Discipline • The Board has disciplinary jurisdiction and is empowered to take action
against any registered assistant medical officers for breach of discipline
as provided in the Regulations.
Board meetings • The Examination Board meetings grant approval of the assistant
medical officersÊ registration examination results.
• The Medical Assistant Education Committee Meetings will consider
matters pertaining to training, curricula and examinations.
Examination • Sets questions for examinations.
• Appoints examiners.
• Conducts assessorsÊ meetings.
• Releases the examination results.
Practising • Issues annual practising certificate.
certificates • Issues temporary practising certificate to foreign assistant medical
officers.
Professional • Provides guidance to the professionals on the standards of professional
conduct conduct.
• Supports assistant medical officersÊ relationship with their patients.
Responsibility • Provides and maintains a high standard of healthcare at all times.
for standards of • Always practise high standards of professionalism, caring attitude and
healthcare be an effective member of the healthcare team.
• Must be competent, efficient and diligent in recording the history,
examining, carrying out diagnostic investigations, diagnosing and
treating the patient.
Use of • Assistant medical officers shall not use any titles relating to public
descriptions, title award and professional qualification. The use of public honours and
and publicity qualifications must be approved by the Board.
• Publicity (referring to all means of giving publicity) by assistant medical
officers is forbidden but he may provide information in relation to his
work.
Source: Lembaga Pembantu Perubatan (2009)

8.1.3 Contract of Employment

The relationship between parties may determine the limitations of liability in a
legal action aimed at recovering damages caused by wrongful or negligent acts. In
some employment situations, assistant medical officers may be employees while
in others, they may be independent contractors. It is important to know the
difference.
(a) Employer and Employee

Each person is personally liable for his or her own negligent acts. In addition,
an employee may make the employer liable as well. Generally speaking, the
employer has the „right to control‰ and to direct another employee in the
performance of the work including the details and means by which the work
is to be done. It is not necessary that the employer actually directs or controls
the way in which the services are performed, it is sufficient that the employer
is legally entitled to do so.
Generally speaking, a person becomes an employee when he or she performs

services for another who has the „right to control‰ what is done and how it
is done. An employee is one who works for wages or salary in the service of
an employer. The power to discharge belongs to that of the employer's.
Respondent superior (literally, „let the master answer‰) is a legal principle

that makes an employer liable for the wrongful acts of any employee. Also
called the master-servant rule, it can apply to the relationship between a
principal and an agent as well.
For example, whenever a person (patient) is injured by an employee

(assistant medical officer) as result of negligence in the course of the
employeeÊs (assistant medical officer) work, the employer (hospital) is
responsible towards the injured person (patient). In this situation, the injured
person (patient) may sue both the employee (assistant medical officer) and
the employer (hospital), and thus, has a better chance of being compensated
for his injury. However, double recovery is not allowed.
(b) Employer and Independent Contractor

Who is an independent contractor? The law defines an independent
contractor as a person contracting with another to do something but not
controlled by the other, nor subject to the otherÊs „right to control‰ with
respect to his physical conduct in the performance of the undertaking (work
or service).

Applying this definition to the assistant medical officers, it becomes apparent

that if an assistant medical officer is subject to be controlled by another
merely for the result of the work and not for the means by which the research
is reached, he may be an independent contractor. Private duty assistant
medical officers are independent contractors, answerable for any wrongs
they may commit and the hospitals in which they are working is not liable.
SELF-CHECK 8.1
1. What are the standards of care and the code of ethics for assistant
medical officers ?
2. What are the aims and functions of the Medical Assistant Board?
8.2 LAWS THAT APPLY TO ASSISTANT

MEDICAL OFFICERS
Assistant medical officers are citizens and are subject to as well as entitled to take
advantage of the law under Laws of Malaysia, Act 180, Medical Assistants
(Registration) Act 1977, Ministry of Health, Malaysia. For example, they may use
the law to protect themselves against their employers – perhaps against
discrimination and unfair dismissals, not providing a safe place and system of
work as well as adequately trained colleagues. They may also use the law against
patients who assault them or sue those who defame them.
Assistant medical officers can be, and have been, prosecuted for committing
crimes. These range from assaults and theft of patientÊs property to manslaughter
where a healthcare providers recklessness may have caused a patientÊs death.
While patients sue using the civil law, it is normal for the police to bring
prosecutions under criminal law.
In criminal law, the prosecution must prove their case „beyond all reasonable
doubts‰. That is why some prosecutions are not able to progress further because
of insufficient evidence to convict. This can occur in cases where healthcare
providers are accused of abusing patients and there is insufficient supporting
factual evidence.
In civil cases relating to the professional and employerÊs disciplinary procedures,

the court of tribunal only has to be satisfied „on a balance of probabilities‰
although they will take into account the seriousness of the consequences for the
people involved, for example, the loss of employment.

Thus, the same assistant medical officer may not be prosecuted for abusing a
patient or may not be found guilty. Nevertheless, his dismissal from employment
may be approved by the industrial tribunal and/or his registration as a healthcare
providers may be withdrawn by the Malaysian Medical Assistant Board, thus
making him liable to be sued by the patient for assault or negligence.
An assistant medical officer will only be liable for negligence if he had negligently
caused a loss to someone whom he owed a duty of care. To be liable for negligence,
it is not sufficient that there was duty of care but there must have also been a breach
of the standard of care.
The standards of care govern the actions of healthcare professionals. Thus, an

assistant medical officer is not considered to be negligent when he acts in the way
that any reasonably competent members of his profession would act. The court
would listen to the expert witness from the profession concerned, who would
describe the appropriate standard of care that any reasonable competent nurse
would have done in such circumstances. Harm or loss must be experienced and it
must have been caused by the negligent act. The law requires that the breach of
the standard of care must have caused the loss. The particular negligent conduct
does not have to be the sole main cause. It is sufficient that its effect was not
insignificant or trivial.
Let us look at an example of case of negligence shown in Example 8.1.
Example 8.1:
A female patient was admitted to hospital after having taken an overdose of
drugs. Her stomach was pumped out and she was transferred to a psychiatric
ward where she was diagnosed as having a depressive illness with paranoid
features. She had delusions about snakes, God and death. The information was
not recorded in the nursing notes. A few days later, she took out some matches
in the toilet and set fire to her shirt, even though her condition seemed to have
improved at that time. She was badly burned.
In this case, the assistant medical officer was found to be negligent as:
(a) The healthcare providers owed the woman a duty of care while she was
in the hospital;
(b) There was a breach of standard of care as relevant information was not
documented; and
(c) There was a loss, that is, physical injuries from the burn.

Example 8.1 is a negligence case because of the following three aspects:

(a) The assistant medical officer must owe the patient a duty of care;
(b) There was a breach in the care; and
(c) The patient had suffered some kind of loss.
8.2.1 Intentional and Unintentional Tort

Professional negligence can be considered as an unintentional tort while assault,
battery and defamation are intentional torts.
What do assault and battery mean? There are several definitions for these two
terms. The general definitions are shown in Table 8.2.
Table 8.2: General Definitions for Assault and Battery
Assault Battery
An intentional attempt, using violence or An intentional offensive or harmful
force, to injure or harm another person. touching of another person without his or
her consent.
Source: FindLaw (2018)
How do assault and battery differ? Let us look at the differences between assault
and battery in Table 8.3.
Table 8.3: Differences between Assault and Battery
Assault Battery
• Issue of consent does not arise. • The defendant's act is done without the
plaintiffÊs consent.
• Plaintiff experiences reasonable • There is physical contact between
apprehension of a force upon defendant and plaintiff.
himself or herself.
• Tort law protects one from the • Tort law protects one from physical
threat of any physical violence as contact, be it violent or otherwise, as long
well as to maintain a personÊs as it is an unnecessary and unauthorised
mental well-being. contact.

According to Table 8.3, we can see that the key point of difference is patient
consent. Therefore, assistant medical officers should make a checklist to ensure
that informed consent is obtained, which includes the following aspects in
Table 8.4.
Table 8.4: Four Aspects of Patient Consent
Aspect Description
Disclosure Patient is informed of current medical status, course of treatment,
risks involved, benefits, alternatives and other related matters.
Comprehension Patient understanding.
Competence The patient is competent enough to understand, reason and
deliberate on the information provided and make decisions.
Voluntariness The patient was not subjected to force, coercive influence or
manipulation.
There are two types of defamation:
(a) Libel  The statements are in permanent form (written or printed

statements); and
(b) Slander  It is usually in transitory form (speech or gestures).
Thus, slander may not be actionable as compared to libel as proof of damage must
be available.
In addition, patient confidentiality is very important too. Therefore, assistant

medical officers owe a duty of confidentiality in respect of the patientÊs
information acquired in their capacity as an assistant medical officer and may only
disclose information in certain circumstances such as case discussion for
management of patient and statutory requirement.
SELF-CHECK 8.2
1. State the differences between assault and battery.
2. What are the four aspects of patient consent?
3. Contrast the two types of defamation.

8.3 BASIC ETHICAL CONCEPTS

Everyone in general agrees that doing good and avoiding harm are relevant in the
study and practice of ethics. Thus, the special emphasis accorded to ethics amongst
healthcare professionals. In the Laws of Malaysia, Act 180, Medical Assistants
(Registration) Act 1977, there are three provisions stating the ethical obligations
and duties of assistant medical officer. The provisions describe matters such as:
(a) The assistant medical officerÊs fundamental commitment and values;
(b) Duties associated with duty and loyalty; and
(c) Collaborative efforts with other healthcare professions.
Although they are not legally enforceable as laws, consistent violations of a

professional code indicate unwillingness by the individual to act in a professional
manner, which often results in disciplinary actions ranging from reprimands and
fines to suspension and revocation of licensure.
Most assistant medical officers envisage ethics as dealing with the principles of
morality  what is right and wrong. So, what is ethics? In a broad conceptual
definition, ethics is concerned with motives and attitudes, and the relationship of
these attitudes to the good of the individual. Ethics may be distinguished from the
law in that ethics concern the good of an individual within a society while the law
concerns the society as a whole. Laws can be enforced through the courts and
statutes while ethics are enforced via the ethics committee and a professional code
of conduct. Let us look at Table 8.5, which further explains the distinctions between
law and ethics.
Table 8.5: Distinctions between Law and Ethics
Aspect Law Ethics

Source External to oneself; rules and Internal to oneself; values, beliefs
regulations for society. and individual interpretations.
Concerns Conduct and actions  what did Motives and attitudes  why did
the person do. the person act the way he did.
Interests Society as a whole. Individuals within a society.
Enforcement Courts, statutes, Medical Assistant Ethics committee, professional
Board. organisation.

8.3.1 Ethical Theories

There are many different ethical theories that have evolved and most are
considered as normative approaches to ethics. The theories are generally divided
into two broad categories:
(a) Deontological theories  Emphasises the dignity of the human being; and
(b) Teleological theories  Governed by the consequences of our actions.
Take note that ethical theories are important because they form the essential basis
of knowledge from which to proceed. In addition to ethical theories, there are
several key principles of ethics, which will be discussed in the next subtopic.
8.3.2 Ethical Principles

There are four major ethical principles that should be considered, as shown in Figure
8.1, and explained in Table 8.6.
Figure 8.1: Four major ethical principles

Source: Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977

Table 8.6: Four Major Ethical Principles
Principle Description
Autonomy This principle addresses personal freedom and the right to choose
what will happen to oneÊs own person. The legal doctrine of
informed consent is a direct reflection of this principle.
However, autonomy is not an absolute right. Under certain

circumstances, the individualÊs rights do not prevail over the rights of
others. For example, a nurse has the right to refuse care to a patient
because of religious belief. However, if the safety of the patient is
jeopardised because of the lack of care, the nurse may suffer legal
consequences if care is not provided. The principle of autonomy
underlies the first statement in the Professional Code of Conduct.
Beneficence and Beneficence is the duty to help others by doing what is best for
non-maleficence them. This also applies to the principle of non-maleficence or do
no harm. Thus, not only does one have the duty to do good but
also the duty not to inflict harm or to risk harming others.
However, many assistant medical officers find it difficult to follow

these principles when performing treatments and procedures that
bring discomfort and pain to patients. The principle of beneficence
may be applied because even pain and suffering can bring about
good for the patient.
Veracity Veracity concerns truth telling and incorporates the concern that
individuals should always tell the truth. Lying or deception
creates a barrier between people and prohibits both meaningful
communication and the development of relationships.
Recognising that communication is the cornerstone of healthcare
and patient relationship, it is obvious that assistant medical
officers must be truthful in order to communicate effectively with
their patients.
Justice Justice is the obligation to be fair to all people. The concept is often
expanded to what is called distributive justice, which specifically
states that individuals have the right to be treated equally
regardless of race, sex, marital status, medical diagnosis, social
standing, economic level or religious belief. It requires that the
person or patient be treated according to what is fair. The
implication is that patients with the same diagnosis should receive
the same level of care.
However, it can sometimes be a challenge for assistant medical

officers to do so because of the constraints of scarce resource and
supplies allocation.

In a nutshell, ethics deals with the right and wrong doings in situations and has
no mechanism of enforcement, whereas laws are man-made rules that regulate
society and are enforceable. All ethical principles presuppose a basic respect for
human beings.
ACTIVITY 8.1
Read the following hypothetical case and discuss the answers to the
questions in the online forum.
Madam A is 75 years old and has terminal ovarian cancer. During the
course of her radiotherapy, she sustained third degree radiation burns
to her lower abdomen. Her wounds were extensive and deep, requiring
frequent wound irrigation. Despite being given pain relief before each
course of treatment, Madam A finds it very painful. She wants to
discontinue the treatment.
(a) Discuss the situation in terms of beneficence and non-maleficence.
(b) What is the assistant medical officerÊs responsibility in assisting
the patient to maintain autonomy?
(c) How should the assistant medical officer deal with the conflicting
principles?
8.4 ETHICAL DILEMMAS

Before we end this topic, let us have a discussion on ethical dilemmas. Firstly, what
does ethical dilemma stand for?
Ethical dilemmas can be defined as having to choose between two equally

desirable or undesirable alternatives.
Marquis & Huston (1994)

According to Curtin (1982), for a problem to be an ethical dilemma, it must have

three characteristics:
(a) The problem cannot be solved using empirical data;
(b) The problem must be so perplexing that deciding which facts and data to be
used in making the decision becomes difficult; and
(c) The results of the problem must have more effect than the immediate
situation. In other words, there should be far-reaching effects.
By the very nature of ethical dilemmas, there is no good solution, and the decision
made often has to be defended against those who disagree with it. Therefore, the
ethical decision-making process provides a way for assistant medical officers to
answer key questions about ethical dilemmas and to organise their thinking in a
more logical and sequential manner.
8.4.1 Ethical Decision-making Process

Did you know that the main goal of the ethical decision-making process is to
determine right from wrong in situations where clear demarcations do not exist or
are not apparent to the assistant medical officers who are faced with the decision.
The following five-step ethical decision-making process is presented as a tool for

you to resolve ethical dilemmas (see Figure 8.2).
Figure 8.2: Five-step ethical decision-making process


The five-step ethical decision-making process is further explained in Table 8.7.
Table 8.7: Five-step Ethical Decision-making Process
Step Description
1. Collect, analyse and • Obtain as much information as possible.
interpret data
• Obtain information regarding the patientÊs wishes,
the familyÊs wishes and the extent of the physical
or emotional problems which caused the dilemma.
• After collecting the information, bring the pieces of

information together in a manner that provides the
clearest and sharpest focus on the dilemma.
2. State the dilemma • The dilemma needs to be stated as clearly as
possible in terms of the key ethical issues.
3. Consider choices of • List all possible courses of action that can resolve
action the dilemma without considering the
consequences.
4. Analyse the advantages • By considering the advantages and disadvantages,
and disadvantages of the assistant medical officers should be able to pare
each course of action the choices down to the few realistic choices of
action.
5. Make the decision • This is the most difficult part of the process. The
decision should be based on sound ethics.
Last but not least, what can we conclude about ethical dilemmas? In a nutshell,
there are no clear or ideal solutions in any ethical dilemma. Differences of opinion
often exist because an individual is forced to choose between two equally
favourable alternatives. At some point, assistant medical officers need to undertake
the task of clarifying their own values in consideration as well.
SELF-CHECK 8.3
1. Define ethical dilemma and its characteristics.
2. Explain the five-step ethical decision-making process.

ACTIVITY 8.2
Answer the following questions and share your answers on myINSPIRE.
Mr Z, who is 90 years old, was hospitalised due to dehydration, vomiting

and urinary tract infection. He has senile dementia and has a tendency to
wander. He is at high risk for falls (he already has a history with a broken
hip last year). In addition, he was found wandering in the neighbourhood
on two separate occasions this year.
An intravenous line was inserted to correct his dehydration. Concerned

that he might fall, dislodge the line or wander off somewhere, the staff
believes it is best to restrain him. However, Mr Z refuses and is adamant
that he does not want to be restrained.
(a) State the ethical dilemma.
(b) What are the choices of action and how do these choices relate to
ethical principles?
(c) What decisions can be made?
 The law works through several ways to maintain healthcare standards, namely
criminal law, Laws of Malaysia  Act 180 Medical Assistants (Registration) Act
1977, contract law and law of negligence.
 One of the primary functions of the Medical Assistant Board is to protect the
public from unqualified persons who attempt to practise the profession of
assistant medical officers or who pose potential harm to a patient through
unsafe practices.
 Licensure is the process in which a government agency grants permission to

an individual to engage in a given occupation.
 The Medical Assistant Board Malaysia comes under the Laws of Malaysia Act
180 Medical Assistants (Registration) Act 1977. Assistant Medical Officer
Registration is a statutory body for assistant medical officers.
 In the contract of employment, the relationship between parties may determine

the limitations of liability in a legal action which serves to recover damages
caused by wrongful or negligent acts.

 In the Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977,
Ministry of Health, Malaysia, three provisions are listed, stating the ethical
obligations and duties of assistant medical officer.
 There are four major ethical principles that should be considered, namely
autonomy, beneficence and non-maleficence, veracity and justice.
 Ethical dilemmas can be defined as having to choose between two equally

desirable or undesirable alternatives.
 The five-step ethical decision-making process can be applied to an ethical

dilemma. The five steps are:
 Collect, analyse and interpret data;
 State the dilemma;
 Consider choices of action;
 Analyse the advantages and disadvantages of each course of action; and
 Make the decision.
Autonomy Malaysian Code of Professional

Conduct
Battery
Medical Assistant Board
Beneficence
Negligence
Criminal law
Non-maleficence
Defamation
Plaintiff
Duty of care
Tort
Ethical dilemmas
Veracity
Justice
Laws of Malaysia, Act 180, Medical
Assistants (Registration) Act 1977

1. An intentional attempt, using violence or force, to injure or harm another

person is
A. assault
B. defamation
C. malpractice
D. false imprisonment
2. Ethics can be defined as

A. rules and regulations for society.
B. conduct and actions  what did the person do.

C. values, beliefs and individual interpretations.
A. concerns with motives and attitudes, and the relationship of these
attitudes to the good of the individual.
Discuss the importance of the Medical Assistant Board in enforcing and

monitoring healthcare practice in Malaysia.
Curtin, L. L. (1982). Autonomy, accountability and nursing practice. Topics in

Clinical Nursing, 4(2), 714.
FindLaw. (2018). Assault and battery overview. Retrieved from

https://criminal.findlaw.com/criminal-charges/assault-and-battery-
overview.html
Kementerian Kesihatan Malaysia. (2009). Fungsi Lembaga Pembantu Perubatan.

Retrieved from http://medicalprac.moh.gov.my/v2/modules/mastop_
publish/?tac=Fungsi_Lembaga_Pembantu_Perubatan

Laws of Malaysia, Act 180, Medical Assistants (Registration) Act 1977.
Lembaga Pembantu Perubatan. (2009). Kod etika pembantu perubatan (penolong

pegawai perubatan). Putrajaya, Malaysia: Author.
Marquis, B. L., & Huston, C. J. (1994). Management decision making for nurses:
118 case studies. Philadelphia: PA: Lippincott Williams & Wilkins.

MODULE FEEDBACK
MAKLUM BALAS MODUL
If you have any comment or feedback, you are welcome to:
1. E-mail your comment or feedback to modulefeedback@oum.edu.my
OR
2. Fill in the Print Module online evaluation form available on myINSPIRE.
Thank you.
Centre for Instructional Design and Technology

(Pusat Reka Bentuk Pengajaran dan Teknologi )
Tel No.: 03-27732578
Fax No.: 03-26978702


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NBHS4142

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Module Writers: Assoc Prof Raijah A Rahim

Moderators: Prof Dr T K Mukherjee

Enhancers: Assoc Prof Raijah A Rahim

Developed by: Centre for Instructional Design and Technology

First Edition, December 2018

Copyright © Open University Malaysia (OUM)

Topic 1 Introduction to Management in Healthcare 1

Topic 2 Leadership and Motivation 21

Topic 3 Managing the Emergency Department and Clinical Area 41

Copyright © Open University Malaysia (OUM)

Topic 4 Models of Care Delivery System 54

Topic 5 Managing Care 67

Copyright © Open University Malaysia (OUM)

6.7 Managing Quality 98

Topic 7 Introduction to Law 107

Topic 8 Introduction to Ethics 123

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

COURSE GUIDE DESCRIPTION

As an open and distance learner, you should be acquainted with learning

Copyright © Open University Malaysia (OUM)

Table 1: Estimation of Time Accumulation of Study Hours

COURSE LEARNING OUTCOMES

1. Explain management and leadership in the context of healthcare practice;

2. Describe the principles and processes of management;

3. Discuss the management and motivation theories in relation to healthcare

4. Differentiate the various models of care delivery system;

5. Apply time management strategies to work and personal life; and

Copyright © Open University Malaysia (OUM)

Topic 1 introduces management in healthcare. Managers tend to focus their

Topic 2 describes leadership and motivation. Leadership relies more on

Topic 3 focuses on ward and clinical area management. A healthcare providerÊs

Topic 6 explores decision-making. Decision-making and critical thinking are vital

Copyright © Open University Malaysia (OUM)

TEXT ARRANGEMENT GUIDE

Self-Check: This component of the module is inserted at strategic locations

Activity: Like Self-Check, the Activity component is also placed at various

Copyright © Open University Malaysia (OUM)

Daft, R. L., & Marcic, D. (2001). Understanding management. Fort Worth,

Huber, D. (2006). Leadership and nursing care management. Philadelphia,

Copyright © Open University Malaysia (OUM)

Kelly-Heidenthal, H. (2003). Nursing leadership and management. Florence,

Roussel, L., Swansburg, R. C., & Swansburg, R. J. (2006). Management and

Sullivan, E. J., & Decker, P. J. (2005). Effective leadership and management in

Yoder-Wise, P. (2003). Leading and managing in nursing (6th ed.). Philadelphia,

TAN SRI DR ABDULLAH SANUSI (TSDAS)

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Figure 1.1: Managers versus leaders

Copyright © Open University Malaysia (OUM)

Which do you prefer to be – a manager or a leader? Well, generally it is difficult to

„Management is efficiency in climbing the ladder of success; leadership

Is it desirable to have both management and leadership skills? Well, according to

Copyright © Open University Malaysia (OUM)

1.1 MANAGEMENT PROCESS

Figure 1.2: Five stages of the management process

Figure 1.3: Oliver Wendell Holmes JrÊs quote

Copyright © Open University Malaysia (OUM)

Assistant medical officers have the opportunity to make a difference by planning

In addition, planning can have a positive impact on organisational and individual