LEADERSLE ADERHIP

Leader is a part of management and one of the most significant elements of direction. A leader
may or may not be manager but a manager must a leader. A manager as a leader must lead his subordinate
s and also inspire them to achieve organizational goals. Thus leadership is the driving force which gets
the things done by others.
Leadership represents an abstract quality in a man. It is a psychological process of influencing
followers or subordinates and providing guidance to them. Thus the essence of leadership is follower
ship. It is the followers who make a person as leader. An executive has to earn followers. He may get
subordinates because he is in authority but he may not get a follower unless he makes the people to follow
him only willing followers can and will make him a leader.
DEFINITON
LEADER

A person who demonstrates and exercise influence and power over others. Leaders have a vision and
influence others by their actions and comments.

LEADERSHIP
Leadership is the ability to influence other people
Lansdale
Leadership is the ability of a manager to induce subordinate to work with zeal confidence.
Koontz and O Donnell
Leadership as the ability to secure desirable actions from a group of followers voluntary, without the use
of coercion.
Afford and Beatty
Leadership is the activity to persuade others to seek defined objectives enthusiastically. It is the human
factor which binds a group together and motivate it towards goals
Keith Davis
Leadership is the lifting of man’s vision to higher sights, the rising of man’s performance to higher
standard, the building of man’s personality beyond its normal limitation.
Peter Drucker
 IMPORTANCE-

LEADERS MOTIVATES PEOPLE

A leader motivates employees for higher output through motivational techniques. The leader
himself acts as a motivating factor.

LEADER COUNSELS EMPLOYEES

In an organization people needs counseling to reduce the emotional disequilibrium
and to remove barriers to effective performance. A leader solves such types of problems and
makes employees happy. Thus, a leader acts as a counselor.

LEADER DEVELOPS TEAM SPIRIT

A leader creates confidence in his subordinates and gains their faith and cooperation. Besides,
the leader provides environment conductive to work which results in team spirit.

LEADERS AIMS AT TIME MANAGEMENT

Leader is in a position to utilize time productivity in an organization. A leader gets things done
by people by the proper time management.

LEADER STRIVES FOR EFFECTIVENESS

A leader brings effectiveness to an organization by providing the workers with the necessary
resources in terms of money, methods, climate, work environment, etc.

FUNCTIONS OF LEADERSHIP-

Executive, Planner, Policy maker, Expert, External group representative, Controller of internal
relation, Purveyor of rewards and punishment

TYPES OF LEADERSHIP
a) INTELLECTUAL LEADER
He is one who possesses rich knowledge and technical competence. All his subordinates listen
and follow his advice because of his specialized intellectual authority.

e.g. - financial advisor, legal advisor, etc.

b) CREATIVE LEADER
Creative leader uses the technique of ‗circular response ‘to encourage ideas to flow
from group to him and vice versa. He draws out the best in his followers and controls them
with zeal to attain the goals.
 c) PERSUASIVE LEADER
He gains faith and confidence from his followers. He possesses a magnetic
personality which attracts followers which helps to get work done by them effectively.

d) INSTITUTIONAL LEADER
When a person becomes a leader by virtue of his position, he is called an
institutional leader. e.g. - the principal of a college, managing director of a company

e) DEMOCRATIC LEADER
A democratic leader is one who does not lead but is led by his followers. In other words,
he follows the opinion of the majority of his followers and delegates most of his power to them.

f) AUTOCRATIC LEADER
He is one who dominates and drives his group through coercion and command. He
institutes a sense of fear among his followers. Such leaders love power and never delegate
their authority.

THEORIES:-

1. TRAIT THEORY/GREAT MAN THEORY-

This theory suggests that leaders have some inborn traits. They have certain set of characteristics
that are crucial for inspiring others towards a common goal. A successful leader is supposed to have the
following traits- good personality, tirelessness, capacity to read other‘s mind, ability to make quick
decision, courage, persuasion, intelligence, reliability, imagination

2. STYLE THEORY-
This focuses on what leaders do in relational and contextual terms. The achievement of
satisfactory performance measures requires supervisors to pursue effective relationships with their
subordinates, while comprehending the factors in the work environment that influence outcomes.

3. TRANSACTIONAL/TRANSFORMATIONAL THEORY

This theory describes the relationship between leaders and followers. New concepts such as
empowerment, inspiration motivation and social learning are present. This refers to a process whereby the
leader attends to the needs and motives of followers so that interaction raises to high levels of motivation
and morality.

4. SITUATIONAL THEORY

THIS THEORY believes that leadership effectiveness depended on the relationship among
the leaders task at hand, their interpersonal skills and the favorableness the work
Situation. This theory considers the challenge of situation and encourages an adaptive leadership style to
complement the issue being faced.

STYLES OF LEADERSHIP

1. AUTOCRATIC LEADERSHIP:
Leader assumes complete control over the decisions and activities of the group.

CHARACTERISTIC OF THE LEADER

 Firm personality, insistent, self-assured, highly directive, dominating.

 Has high concern for the work than for the people who performs task
 Shows no regards to the interests of the employees
 Set rigid standards and method of performance and expects the subordinates to obey
the rules and follow the same
 Makes all decision by himself or herself
 Minimal group participation or none from the workers

ADVANTAGES AND DISADVANTAGES

ADVANTAGES DISADVANTAGES

Efficient in time of crisis, easy to make Does not encourage the individuals growth and
decision by one group and less time does not recognize the potentials, imitativeness
consuming and creates less cooperation among members

It is useful when there is only leader who is Leader lacks supportive power that results in
experienced having new and essential decision made with consultation although he
information, while subordinates are in may be correct
experienced and new

It is useful when the workers are unsure of Less job satisfaction leads to less
taking decision and expect the leader to tell commitment to goals of the organization
what to do
2. DEMOCRATIC LEADER

Participative consultative style of leadership

CHARACTERISTIC OF THE LEADER

 Sense of equality among leader and followers

 Open system of communication prevails
 Interaction between the leader and group is friendly and trusting
 Leader works through people not by domination but by suggestions and
persuasions

ADVANTAGES AND DISADVANTAGES

ADVANTAGES DISADVANTAGES

Encourages all employee in decision It takes more time for taking decision by the
making group than the leader alone

Promotes personnel involvement, greater

commitment to work and enhance job
satisfaction

3. LAISSARE-FAIRE LEADERSHIP
Free- Rein, Anarchic and Ultraliberal style of leadership. The leader gives up all power
to the group.

CHARACTERISTIC FEATURES

 Encourages independent activity by the group member

 Group members are tree to set their own goals determine their own activities and
allowed to do almost what they desire to do
 Style effective in highly motivating professional growth

ADVANTAGES AND DISADVANTAGES

ADVANTAGES DISADVANTAGES

In limited situations creativity may be May lead to instability, disorganization,

encouraged for specific purposes inefficiency, no unity of action
 To try new method of action Lack of feeling responsible to solve the
problem that may arise. Individual will lose
interest, initiative and desire for achievement

4. BUREAUCRATIC LEADERSHIP

In this the leader function only with rules and regulations. Leader cannot be
flexible and does not like to take any risk out of the rules. E.g. defense leader

Characteristics of leadership
1. It is a personal quality of character and behavior in man which enables him to exert internal
personal influence.
2. It is concerned with the lying down group objectives and policies for the followers, motivating
them coordinating their efforts to accomplish the objectives.
3. It pre – supposes the existence of a group followers.
4. Its style may differ from situation to situation.
5. It is the ability to perused others and motivate them to work for accomplishing certain objectives.
6. It is process of influencing exercised by leader on members of a group.
7. It involves an unequal distribution of authority among leaders and groups.

LEADERSHIP SKILLS

A. SKILLS OF PERSONAL BEHAVIOUR

 Sensitive to the feeling of the group
 Identifies self with needs of the group
 Does not ridicule or criticize others suggestion
 Does not argue
B. SKILLS OF COMMUNICATION
 Listen attentively
 Make sure everyone understands
 Establish positive communication with the group
 Recognizes that everyone‘s contribution are important
C. SKILLS OF ORGANIZATION
 Develop short and long term objectives
 Break big problem into small ones
  Share responsibilities and opportunities
 Plan, act, follow-up and evaluate
D. SKILLS OF SEF EXAMINATION
 Aware of personal motivation
 Aware of group members
 Helps group to aware of their attitudes and values S-
Self reliant
E- Enthusiastic
L- Loyal
F- Factual

DIFFERENCE BETWEEN LEADERSHIP AND MANAGEMENT

Factors Leadership Management

Source of power Personal abilities Authority delegated

Focus Vision and purpose Operating results

Approach Transformational Transactional

Process Inspiration Control

Emphasis Collectively Individualism

Futurity Proactive Reactive

Type Formal and informal Formal

APPLICATION OF LEADERSHIP IN NURSING

1. Patient care coordination :
Even new graduate nurses have leadership responsibilities when they begin in nursing. Nursing
leadership begins with nursing care of the individual patient. The students are guide to organize
nursing care.
 Establish good and priorities for each day.
 Establish time
 Establish success and failure
2. Employee responsibilities:
 Nurses have specific tasks or duties to perform. These tasks are determined by the plan and
objective of the health care agency. It is important to read your job description carefully and to
continue to evaluate how institutional factor s influences your own practice of nursing. Factors
that compromise quality care should be noted and addressed in construction with experience
nurses.
3. Guidelines for delegating nursing care:
New graduate nurses use leadership techniques when they direct the work of nonprofessional
staff and volunteers and consider delegating tasks to nonprofessional staff.
4. Mentorship:
It is a relationship in which an experienced individual advise and assist a less experienced
individual. This is an effective way of easing a new nurse into leadership responsibilities
5. Preceptor ship:
An alternative model is preceptor ship. The preceptor is selected to introduce an employee to
new responsibilities through teaching and guidance. The relationship is limited by the new
employee s needs.
6. Continuing education : leadership , managerial and administrative skills are needed

GROUP DYNAMICS

INTRODUCTION
“Never doubt that a small group of thoughtful citizens can change the world. Indeed, it is the only thing
that ever has.‖ Margaret Mead

In today‘s explosion of information technology, communication continues to be a complex

process. Group dynamics can be very positive and helpful where team members support each other and
do what is best. It can alternately become destructive if individuals are allowed to continue with more
selfish behaviors such as never helping someone else, making
Their personal life and personal problems permeate their work, being negative about everything that
happens or complaining all the time. The nurse manager has an important role in this situation, because
it may be necessary to counsel individuals exhibiting negative behavior to achieve positive group
dynamics.

DEFINITION
GROUP:

 A group may be defined as a number of individuals who join together to achieve a goal. People
join groups to achieve goals that cannot be achieved by them alone.
Johnson & Johnson (2006)
 A collection of people who interact with one another, accept rights and obligations as members
and who share a common identity.
 A group is an association of two or more people in an interdependent relationship with shared
purposes.
GROUP DYNAMICS:

 A branch of social psychology which studies problems involving the structure of a group.
 The interactions that influence the attitudes and behavior of people when they are grouped with
others through either choice or accidental circumstances.
 A field of social psychology concerned with the nature of human groups, their development, and
their interactions with individuals, other groups, and larger organizations.
TYPE OF GROUPS
Formal groups: refers to those which are established under the legal or formal authority with the
view to achieve a particular end results. e.g.: trade unions.
Informal groups: refers to aggregate of personal contact and interaction and network of relationship among
individual. e.g.: friendship group.
Primary groups: are characterized by small size, face to face interaction and intimacy among
members of group. e.g.: family, neighborhood group.
Secondary groups: characterized by large size, individual identification with the values and
beliefs prevailing in them rather than cultural interaction.
e.g.: occupational association and ethnic group.
Task groups: are composed of people who work together to perform a task but involve cross-
command relationship. e.g.: for finding out who was responsible for causing wrong medication
order would require liaison between ward in charge, senior sister and head nurse.
Social groups: refers to integrated system of interrelated psychological group formed to
accomplish defined objectives. e.g.: political party with its many local political clubs. Friendship
group.
 Reference groups: one in which they would like to belong.
Membership groups: those where the individual actually belongs.
Command groups: formed by subordinates reporting directly to the particular manager are
determined by formal organizational chart.
Functional groups: the individuals work together daily on similar tasks.
Problem solving groups: it focuses on specific issues in their areas of responsibility, develops
potential solution and often empowered to take action.

OBJECTIVES OF GROUP DYNAMICS

 To identify and analyze the social processes that impact on group development and performance.
 To acquire the skills necessary to intervene and improve individual and group performance in an
organizational context.
 To build more successful organizations by applying techniques that provide positive impact on
goal achievement.

PRINCIPLES OF GROUP DYNAMICS

♪ The members of the group must have a strong sense of belonging to the group.
♪ Changes in one part of the group may produce stress in other person, which can be reduced only by
eliminating or allowing the change by bringing about readjustment in the related parts
♪ the group arises and functions owing to common motives.
♪ Groups survive by placing the members into functional hierarchy and facilitating the action
towards the goals
♪ The intergroup relations, group organization and member participation is essential for effectiveness of a
group.
♪ Information relating to needs for change, plans for change and consequences of changes must be
shared by members of a group.

ELEMENTS OF GROUP DYNAMICS

COMMUNICATION
One of the easiest aspects of group process to observe is the pattern of communication. The
kinds of observations we make give us clues to other important things which may be going on in
the group such as who leads whom or who influences whom.
♥ Who talks? For how long? How often?
♥ Who do people look at when they talk?
♥ Who talks after whom, or who interrupts whom?
 ♥ Style of communication used?
♥ How are silent people treated? Is silence due to disagreement, disinterest, fear, fatigue?

CONTENT VS PROCESS
When we observe what the group is talking about, we are focusing on the content. When
we try to observe how the group is handling its communication, i.e., who talks how much or who
talks to whom, we are talking about group process. In fact, the content of group discussion often
tells us what process issue may be on people's minds.
At a simpler level, looking at process really means to focus on what is going on in the
group and trying to understand it in terms of other things that have gone on in the group.

DECISION
Many kinds of decisions are made in groups without considering the effects these
decisions have on other members. Some try to impose their own decisions on the group, while
others want all members to participate or share in the decisions that are made. Some decisions are
made consciously after much debate and voting. Others are made silently when no one objects to
suggestion.

INFLUENCE
Some people may speak very little, yet they may capture the attention of the whole
group. Others may talk a lot—but other members may pay little attention to them

TASK VS RELATIONSHIPS
The group's task is the job to be done. People who are concerned with the task tend to:
♥ Make suggestions as to the best way to proceed or deal with a problem
♥ Attempt to summarize what has been covered or what has been going on in the group
♥ Give or ask for facts, ideas, opinions, feelings, feedback, or search for alternatives.
Relationships means how well people in the group work together. People who are concerned with
relationships tend to:
♥ Be more concerned with how people feel than how much they know
♥ Help others get into the discussion
♥ Encourage people with friendly remarks and gestures.
ROLES
Behavior in the group can be of 3 types:
♥ TASK ROLES (which helps the group accomplish its task)
  Initiator: proposing tasks or goals; defining a group problem; suggesting ways to solve a
problem.
 Information/opinion seeker: requesting facts; asking for expressions of feeling;
requesting a statement; seeking suggestions and ideas.
 Information or opinion giver: offering facts; providing relevant information; stating an
opinion; giving suggestions and ideas.
 Clarifier and elaborator: interpreting ideas or suggestions; clearing up confusion;
defining terms; indicating alternatives and issues before the group.
 Summarizer: pulling together related ideas; restating suggestions after the group has
discussed them; offering a decision or conclusion for the group to accept or reject.
 Energizer; who stimulates and prods the group to act and raise the level of their actions.
 Coordinator: who clarifies and coordinates ideas, suggestions and activities of the group
members.

♥ RELATIONSHIP ROLES (which helps group members get along better)

 Harmonizer: who mediates, harmonizes and resolve conflicts.
 Gate keeper: helping to keep communication channels open; facilitating the
participation of others; suggesting procedures that permit sharing remarks.
 Encourager; being friendly, warm, and responsive to others; indicating by facial
expression or remarks the acceptance of others' contributions.
 Compromiser: when one's own idea or status is involved in a conflict, offering a
compromise which yields status; admitting error.
 Follower: who accepts the group‘s ideas and listens to their discussion and decisions.

♥ SELF-ORIENTED ROLES (which contributes to neither group task nor group relationship)
 Dominator: interrupts others; launches on long monologues; is over-positive; tries to
lead group and assert authority; is generally autocratic.
 Negativist: rejects ideas suggested by others; takes a negative attitude on issues; argues
frequently and unnecessarily; is pessimistic, refuses to cooperate; pouts.
 Aggressor: tries to achieve importance in group; boasts; criticizes or blames others; tries
to get attention; shows anger or irritation against group or individuals; deflates
importance or position of others in group.
 Playboy: is not interested in the group except as it can help him or her to have a good
time.
  Storyteller: likes to tell long "fishing stories" which are not relevant to the group; gets
off on long tangents.
 Interrupter: talks over others; engages in side conversations; whispers to neighbor.

MEMBERSHIP
One major concern for group members is the degree of acceptance or inclusion they feel
in the group.
♥ Are there any sub-groupings? Sometimes two or three members may consistently agree
and support each other or consistently disagree and oppose one another.
♥ Do some people seem to be outside the group? Do some members seem to be "in"? How
those ―outside‖ are treated?
♥ Do some members move in and out of the group? Under what conditions do they move in
and out?

FEELINGS
During any group discussion, feelings are frequently generated by the interactions
between members. These feelings, however, are seldom talked about. Observers may have to
make guesses based on tone of voice, facial expressions, gestures and many other forms of
nonverbal cues.

NORMS
Standard or group rules always develop in a group in order to control the behavior of
members. Norms usually express the beliefs or desires of the majority of the group members as to
what behaviors should or should not take place in the group. These norms may be clear to all
members (explicit), known or sensed by only a few (implicit), or operating completely below the
level of awareness of any group members. Some norms help group progress and some hinder it.

GROUP ATMOSPHERE
Something about the way a group works creates an atmosphere which in turn is revealed
in a general impression. Insight can be gained into the atmosphere characteristic of a group by
finding words which describe the general impression held by group members.

GROUP MATURITY
Group maturity is defined as the ability and willingness of group members to set goals
and work toward their accomplishment. Characteristic of mature group:
♥ an increasing ability to be self-directed (not dependent on the leader).
♥ An increased tolerance in accepting that progress takes time.
 ♥ An increasing sensitivity to their own feelings and those of others.
♥ Improvement in the ability to withstand tension, frustration and disagreement.
♥ An increased ability to change plans and methods as new situations develop.
Assessing group maturity is especially important for a group leader. An immature group
needs direction. Directive leadership is usually best. If a group is very mature, nondirective
leadership is usually best. In between the extremes of very mature and very immature, democratic
leadership will be the best bet depending on the situation.

STAGES OF GROUP DEVELOPMENT

I.BRUCE W TUCKMAN is a respected educational psychologist who first described the four stages of
group development in 1965. The four-stage model is called as Tuckman's Stages for a group. Tuckman's
model states that the ideal group decision-making process should occur in four stages:
Stage 1: Forming (pretending to get on or get along with others)

Individual behavior is driven by a desire to be accepted by the others, and avoid

controversy or conflict. Serious issues and feelings are avoided, and people focus on
being busy with routines, such as team organization, who does what, when to meet, etc.
But individuals are also gathering information and impressions - about each other, and
about the scope of the task and how to approach it. This is a comfortable stage to be in,
but the avoidance of conflict and threat means that not much actually gets done.

Stage 2: Storming (letting down the politeness barrier and trying to get down to the issues even if
tempers flare up)

Individuals in the group can only remain nice to each other for so long, as important
issues start to be addressed. Some people's patience will break early, and minor
confrontations will arise that are quickly dealt with or glossed over. These may relate
to the work of the group itself, or to roles and responsibilities within the group. Some
will observe that it's good to be getting into the real issues, whilst others will wish to
remain in the comfort and security of stage 1. Depending on the culture of the
organization and individuals, the conflict will be more or less suppressed, but it'll be
there, under the surface. To deal with the conflict, individuals may feel they are
winning or losing battles, and will look for structural clarity and rules to prevent the
conflict persisting.
Stage 3: Norming (getting used to each other and developing trust and productivity)
As Stage 2 evolves, the "rules of engagement" for the group become established, and
the scopes of the group‘s tasks or responsibilities are clear and agreed. Having had
their arguments, they now understand each other better, and can appreciate each
other's skills and experience. Individuals listen to each other, appreciate and support
each other, and are prepared to change pre- conceived views: they feel they're
part of a cohesive, effective group. However, individuals have had to work hard
to attain this stage, and may resist any pressure to change - especially from the outside
- for fear that the group will break up, or revert to a storm.

Stage 4: Performing (working in a group to a common goal on a highly efficient and cooperative basis)

Not all groups reach this stage, characterized by a state of interdependence and
flexibility. Everyone knows each other well enough to be able to work together, and
trusts each other enough to allow independent activity. Roles and responsibilities
change according to need in an almost seamless way. Group identity, loyalty and
morale are all high, and everyone is equally task- orientated and people-orientated.
This high degree of comfort means that all the energy of the group can be directed
towards the task(s) in hand.

Ten years after first describing the four stages, Bruce Tuckman revisited his original work
and described another, final, stage in 1977:
Stage 5: Adjourning (mourning the adjournment of the group)

This is about completion and disengagement, both from the tasks and the group
members. Individuals will be proud of having achieved much and glad to have been
part of such an enjoyable group. They need to recognize what they've done, and
consciously move on. Some authors describe stage 5 as "Deforming and Mourning",
recognizing the sense of loss felt by group members.

In the real world, groups are often forming and changing, and each time that happens, they can move
to a different Tuckman Stage. A group might be happily Norming or Performing, but a new member
might force them back into Storming. Seasoned leaders will be ready for this, and will help the group get
back to Performing as quickly as possible. Many work groups live in the
Comfort of Norming, and are fearful of moving back into Storming, or forward into Performing. This will
govern their behavior towards each other, and especially their reaction to change.
II. M. SCOTT PECK developed stages for larger-scale groups (i.e., communities) which are similar to
Tuckman's stages of group development. Peck describes the stages of a community as:
► Pseudo-community
► Chaos
► Emptiness
► True Community
GROUP DYNAMICS PROCESS
A. GROUP FORMATION
A group is able to share experiences, to provide feedback, to pool ideas, to generate insights, and
provide an arena for analysis of experiences. The group provides a measure of support and
reassurance. Moreover, as a group, learners may also plan collectively for change action. Group
discussion is a very effective learning method.
► Participation
Participation is a fundamental process within a group, because many of the other processes
depend upon participation of the various members. Levels and degrees of participation vary. Some
members are active participants while others are more withdrawn and passive. In essence,
participation means involvement, concern for the task, and direct or indirect contribution to the group
goal. If members do not participate, the group ceases to exist.
Factors which affect member’s participation are;
◘ The content or task of the group- is it of interest, importance and relevance?
◘ The physical atmosphere - is it comfortable physically, socially and psychologically?
◘ The psychological atmosphere - is it accepting, non-threatening?
◘ Member‘s personal preoccupations - are there any distracting thoughts in their mind?
◘ The level of interaction and discussions - is adequate information provided for everyone to
understand? - is it at a level everyone understands?
◘ Familiarity - between group members- do members know each other from before?
► Communication
Communication within a group deals with the spoken and the unspoken, the verbal and the
non-verbal, the explicit and the implied messages that are conveyed and exchanged relating to
information and ideas, and feelings.
Two-way communication implies a situation where not only the two parties talk to each other, but
that they are listening to each other as well. It helps in clarification of doubts, confusions and
misconceptions, both parties understanding each other, receiving and giving of feedback.
 Helpful hints for effective communication
◘ Have a circular seating arrangement so that everyone can see and interact with everyone else
◘ If there are two facilitators, they should sit apart so that communication flow is not in one
direction
◘ Respect individuals- let everyone call everyone else by name respectfully
◘ Encourage and support the quiet members to voice their opinions
◘ Try and persuade the people who speak too much to give others a chance
◘ Ensure that only one person speaks at a time or no one else will be heard
◘ Discourage sub groups from indulging in side talk

► Problem solving
Most groups find themselves unable to solve problems because they address the problem at a
superficial level. After that they find themselves blocked because they cannot figure out why the
problem occurred and how they can tackle it.

An effective problem solving procedure would be to:

◘ Clearly define the problem: Is it what appears on the surface or are there deep hidden aspects?
◘ Try to thoroughly explore and understand the causes behind the problem
◘ Collect additional information, from elsewhere if necessary, and analyze it to understand the
problem further
◘ The group should suspend criticism and judgment for a while and try to combine each other's
ideas or add on improvements. The objectives should be to generate as many ideas and
suggestions as possible. This is called "brainstorming" in a group, when individuals try lateral
thinking.

► Leadership
Leadership involves focusing the efforts of the people towards a common goal and to enable
them to work together as one. In general we designate one individual as a leader. This individual may
be chosen from within or appointed from outside. Thus, one member may provide leadership with
respect to achieving the goal while a different individual may be providing leadership in maintaining
the group as a group. These roles can switch and change.

B. DEVELOPMENT OF GROUPS
The developmental process of small groups can be viewed in several ways. Firstly, it is useful to
know the persons who compose a particular small group.
◘ People bring their past experiences
◘ People come with their personalities (their perceptions, attitudes and values)
◘ People also come with a particular set of expectations.
 The priorities and expectations of persons comprising a group can influence the manner
in which the group develops over a period of time
Stages
Viewing the group as a whole we observe definite patterns of behavior occurring within a group.
These can be grouped into stages.

► FIRST STAGE
The initial stage in the life of a group is concerned with forming a group. This stage is
characterized by members seeking safety and protection, tentativeness of response, seeking
superficial contact with others, demonstrating dependency on existing authority figures. Members at
this stage either engage in busy type of activity or show apathy.

► SECOND STAGE
The second stage in this group is marked by the formation of dyads and triads. Members seek
out familiar or similar individuals and begin a deeper sharing of self. Continued attention to the
subgroup creates a differentiation in the group and tensions across the dyads /triads may appear.
Pairing is a common phenomenon.

► THIRD STAGE
The third developmental stage is marked by a more serious concern about task performance.
The dyads/triads begin to open up and seek out other members in the group. Efforts are made to
establish various norms for task performance. Members begin to take greater responsibility for their
own group and relationship while the authority figure becomes relaxed.

► FOURTH STAGE
This is a stage of a fully functional group where members see themselves as a group and get
involved in the task. Each person makes a contribution and the authority figure is also seen as a part
of the group. Group norms are followed and collective pressure is exerted to ensure the effectiveness
of the group. The group redefines its goals in the light of information from the outside environment
and shows an autonomous will to pursue those goals. The long-term viability of the group is
established and nurtured.

C. FACILITATING A GROUP
A group cannot automatically function effectively, it needs to be facilitated. Facilitation can be
described as a conscious process of assisting a group to successfully achieve its task while functioning as
a group. Facilitation can be performed by members themselves, or with the help of an outsider.
To facilitate effectively the facilitator needs to:
◘ Understand what is happening within the group
◘ Be aware of his/her own personality and
◘ Know how to facilitate

POWER AND POLITICS

INTRODUCTION
Power was once considered a taboo in nursing. In the earliest years, the exercise of power was
considered inappropriate, unladylike, and unprofessional. Many decisions about nursing education and
practice were often made by persons outside of nursing. Nurses began to exercise their collective power
with the rise of nursing leaders and the development of organizations that evolved into the American
Nurses ‘Association and the National League for Nursing. Power gives one the potential to change the
attitudes and behaviors of individual people and groups. Power has a positive and a negative face. The
negative face of power is the ―I win, you lose‖ aspect of dominance versus submission. The positive face
of power occurs when someone exerts influence on behalf of rather than over someone or something.
Politics is the art of using power wisely. It requires clear decision making, assertiveness, accountability,
and the willingness to express one‘s own views.
DEFINITIONS:
1) Power is derived from the Latin verb pottered (to be able); thus power may be appropriately
defined as that which enables one to accomplish goals.
2) Power can also be defined as the capacity to act or the strength and potency to accomplish
something.
3) Power is the ability to influence others through the use of energy and strength.

THE NEED FOR POWER:

 To provide competent, humanistic, and affordable care to people
 To participate in health care policy development
 To gain leverage proportionate with their numbers
 To ensure that nursing is an attractive career choice for all who want to provide care, influence, and
improve nursing, heath care, and health policy.

LEVELS OF POWER:
The power to be (being) - The maintenance of a purely vegetative existence requires
minimum force (exist).
The power of self-affirmation- Efforts to define self and establish significance require greater
force than that required for existence.
 The power of self-assertion- Compelling others to reckon with one‘s individuality and rights requires
greater force than that needed for self-affirmation.
The power of aggression- Moving into and taking possession of another‘s territory requires force
beyond that needed to define personal identity and rights
The power of violence-Application of harmful force against another person or property reflects a
disturbed definition of self, other, and property.

POWER PRINCIPLES:
There are principles to guide a nurse manager in obtaining power and preventing its seizure by others.
1. Power is dynamic and elusive and must be continuously replenished.
2. Power can be obtained only through active means; that is, it must be expressed against resistance
and wrested from opponents.
3. A power oriented manager uses any means of control that will manipulate circumstances in her/his
favor.
4. To win in the game of organizational politics requires a person’s total commitment to goals.
5. Restraint is needed to use power appropriate. A person should use only as much force as needed to
achieve desired objectives.
6. Power relations in an organization are situational, that is, a person‘s ability to apply force to
another is contingent on specific circumstances that would not exist at another place or time. For
example, a subordinate‘s power over a superior may result from the subordinate‘s having held a
leadership position in the past; having publicly defended the superior against attack; or having
knowledge of the superior‘s unwise or unsafe behavior in a situation that is unknown to others. A
superior‘s power over a subordinate may result less from their respective positions in the official table
of organization than from the superior‘s membership on the subordinate‘s thesis committee or office
in a professional organization that the subordinate has recently joined.
7. Power has spatial dimensions. That is, the amount of a person‘s power is relative to other powers
extant in the situation. A nurse manager who attempts to wield power forcefully will encounter strong
resistance from peers and subordinates, because excessive force engenders counterforce as employees
struggle for personal control and control over work life. This counterforce limits the direction and
distance through which the manager‘s power attempts are effective.
8. All agency employees desire clear definitions of power and control relationships among staff
members but are reluctant to discuss power and control issues publicly; especially in the presence of
persons with high authority. Consequently, health workers are unlikely to ventilate dissatisfaction
about power distribution and use during regular staff meetings. Resentments concerning power abuse
are likely to accumulate, fester, and explode unexpectedly.
TYPES OF POWER:
According to French and Raven (1959), the following are the types of power.
1. Reward power:
Reward power is obtained by the ability to grant favors or reward others with whatever they
value. The arsenal of rewards that a manager can dispense to get employees to work toward meeting
organizational goals is very broad. Positive leadership through rewards tends to develop a great deal of
loyalty and devotion toward leaders. Nurse Managers have a strong reward power base.
2. Punishment or coercive power:
This is the opposite of reward power and is based on fear of punishment if the manager‘s
expectations are not met. The manager may obtain compliance through threats of transfer, layoff,
demotion, or dismissal. The manager who shuns or ignores an employee is exercising power through
punishment, as is the manager who berates or belittles an employee. The focus of coercive power is not to
assist others to improve or contribute more to the work team, but instead specifically to hurt and punish
others. This manager has reward power but chooses to use it in a negative way. This is an unhealthy
power base and must be avoided by nurse managers who wish to be successful.
3. Legitimate power:
Legitimate power is position power. Authority is also called legitimate power. It is the power
gained by a title or official position within an organization. Legitimate power has inherent in it the ability
to create feelings of obligation or responsibility. The socialization and culture of subordinate employees
will influence to some degree how much power a manager has due to his/her position.
4. Expert power:
Expert power is gained through knowledge, expertise, or experience. Having critical knowledge
allows a manager to gain power over others who need that knowledge. This type of power is limited to a
specialized area. For example, someone with vast expertise in music would be powerful only in that area,
not in another specialization.
5. Referent power:
Referent power is power a person has because others identify with that leader or with what that
leader symbolizes. Referent power also occurs when one gives other person feelings of personal
acceptance or approval. It may be obtained through association with the powerful. People may also
develop referent power because others perceive them as powerful.
Some theorists distinguish charismatic power from referent power. Willey (1990) state that charisma is a
type of personal power, whereas referent power is gained only through association with powerful others.
 6. Informational power:
This source of power is obtained when people have information that others must have in order to
accomplish their goals. The person with the most information is listened and respected. We need to
determine if it is legitimate information coming from the person who is sharing it. The information
coming from someone in a management position should be valued and recognized as a source of power as
opposed to information from someone who does not have legitimate right to the information.

SOURCES OF POWER

Type source
Association with others
Referent
Position
Legitimate
Fear
Coercive
Ability to grant favors
Reward
Knowledge and skill
Expert
Personal
Charismatic
The need for information
Informational
Maturity, ego strength
Self

WAYS TO ACHIEVE POWER:

There are multiple ways to accumulate, or gain power. Methods to acquire power include the following:
☻ Broad human networks: the more networks and the more extensive they are, the more power potential.
☻ Broad information networks: the more diverse types of information controlled the more power.
☻ Multiple formal and informal leadership roles: high engagement and visibility bring
increased power.
☻ Ability to assess situations accurately and to solve problems.
☻ Authority over others and resources via legitimate work organizational roles.
☻ Vision for the future and creativity
☻ Ability to grant services to others, which builds debts.
☻ Expertise that is sought by others.
WAYS TO INCREASE EXPERT POWER:

 Participate in interdisciplinary conferences to broaden knowledge, develop skills, and build networks.
 Keep knowledge and skills current to maintain and extend power. Continuing education offerings,
books, and journals are effective means.
 Earn higher degrees; education brings expertise and enhances credibility.
 Participate actively in professional associations such as the ANA, state nurses‘ associations, and
specialty groups to broaden networks, hone expertise, and develop legitimate and referent power.
 Participate in nursing research to develop knowledge and increase expertise
 Problem-solve with colleagues in nursing and other disciplines to develop expertise and networks and
to polish skills.
 Participate in nursing and interdisciplinary committees to develop and enhance expert, referent, and
legitimate power.
 Publish to develop expert power.
 Learn from mentors; be a mentor to develop expertise and connections or referent power.

EXERCISING POWER AND INFLUENCE IN THE WORKPLACE AND OTHER ORGANIZATIONS:

To use influence effectively in any organization, one must understand how the system works and develop
organizational strategies. Developing organizational savvy includes identifying the real decision makers
and those persons who have a high level of influence with the decision makers. Recognize the informal
leaders within any organization.

Collegiality and collaboration:

An empowering attitude:
Developing coalitions:
Negotiating:

EMPOWERMENT:

Definition: Empowerment is a sense of having both the ability and the opportunity to act effectively.

Empowerment is a process or strategy the goal of which is to change the nature and distribution of power
in a specific context. It is a group activity that increases political and social consciousness, is based on the
need for autonomy, and is accomplished with continuing cycles of
 Assessment and action. Nursing organizations seek to empower nurses; nurses endeavor to empower
patients to seek and adopt healthy lifestyles.

Empowered nurses have three required characteristics that enable them to participate in policy
development:-
1. The first is a raised consciousness of the social, political, and economic realities of their situation or
environment and society. They are aware of culture and diversity and of gender, race, and class biases,
prejudices, discrimination, and stereotyping that produce the need for policy development or change.
Such nurses can evaluate and understand the dynamics of a situation or issue in which they themselves
can more readily find or help to find remedies.
2. The second quality empowered nurses to have a positive sense of self and self-efficacy regarding their
ability to effect, or facilitate, change. They value themselves and have voice to articulate and effect
change. They can also contribute to the resolution of problems that affect health at the community,
state, and national levels.
3. Development of skills that allow active participation in change processes is the third important
characteristics. Empowered nurses know how to use traditional methods of power and politics in
policy making. Concrete knowledge and information are necessary, as is understanding interpersonal
communication skills, politics, and power and how to use them.
Empowerment ladder:
 Self-confidence
 Ability to control life situations
 Refuse to be a victim
 Value self and others
 be a risk taker
 be creative
 Resolve conflict
 Show initiative
 Become empowered.

The key factors contributing to one’s power image:-

 Self-image: Thinking of one‘s self as powerful and effective
 Grooming and dress: Ensuring that clothing, hair, and general appearance are neat, clean, and
appropriate to the situation
 Good manners: Treating people with courtesy and respect
 Body-language: Maintaining good posture, using gestures that avoid too much drama, maintaining
good eye contact, and being confident in your movement.
 Speech: Using a firm, confident voice; good grammar and diction; an appropriate vocabulary; and
strong communication skills
 Belief in power as a positive force
 Belief in value of nursing to society
 Career commitment: Having a career commitment does not preclude leaving employment
temporarily for family, education, or other demands. Having a career commitment implies that a nurse
views himself or herself first and foremost as a member of the discipline of nursing with an obligation
to make a contribution to the profession.
 Continuing professional education: Valuing education is one of the hallmarks of a profession. The
continuing development of one‘s professional skills and knowledge is an empowering experience,
preparing the nurse to make decisions with the support of an expanding body of knowledge. Returning
to school for advanced degrees is also a powerful growth experience and reflects commitment to the
profession of nursing.

Additional personal power strategies:

 be honest
 always be courteous; it makes other people feel good
 Smile when appropriate; it puts people at ease
 Accept responsibility for your own mistakes and learn from them
 be a risk taker
 Win and lose gracefully
 Learn to be comfortable with conflict and ambiguity; they are both normal states of the human condition.
 Give credit to others when credit is due.
 Develop the ability to take constructive criticism gracefully; learn to let destructive criticism
―roll off your back‖.
 always follow through on promises

TOOLS FOR IMPROVING POWER IMAGE:

Communication skills- The most basic tool is effective verbal communication skills, which help
define a power image. These are same communication skills nurses learn to ensure effective
interaction with patients and families. Listening skills are essential leadership skills. Manager who are
good listeners develop reputations for being fair and consistent. Verbal and non-verbal skills are
important personal power strategies; the ability to assess these messages is a critical power strategy.
Experts in communication estimate that 90% of the messages we communicate to others are
nonverbal. When nonverbal and verbal messages conflict, the nonverbal message is more powerful.
Networking: Networking is an important power strategy and political skill. A network is a system of
contacts that is developed, nurtured, and maintained as sources of information, advice, and moral
support. Networking supports the empowerment of participants through interaction and the refinement
of their interpersonal skills...
Mentoring: Mentors are competent, experienced professionals who develop a relationship with a
novice for the purpose of providing advice, support, information, and feedback to encourage the
development of another individual. Mentoring has become a significant power
 Strategy for women in general and for nurses in particular during the last 20 years. Mentoring provides
novices with expanded access to information, power, and career opportunities. Effective mentoring in
nursing can be characterized by certain attributes (Stewart & Kruger, 1996):-
Goal setting: Goal setting is another power strategy. Every nurse knows about setting goals. Nurse may
be expected to write annual goals for performance reviews at work. Goals help one to know if what was
planned was actually accomplished.
Developing expertise: must not be limited to clinical knowledge. Leadership and communication skills
are essential to the effective exercise of power in a range of nursing roles. Education and practice
provide the means for developing such expertise in any of the domains of nursing: clinical practice,
education, research, and management.
High visibility: the strategy of high visibility within an organization also requires volunteering to serve
as a member or the chairperson of committees and task forces. High visibility can be nurtured by
attending the open meetings of committees and other groups of which you are not a member in the
workplace, professional associations, or the community. Use opportunities both before and after
meetings to share your expertise, providing valuable information and ideas to members and leaders of
such groups. Share this expertise at open meetings when appropriate. Speak up confidently, but have
something relevant to say. Be concise and precise.

ABUSE OF POWER:
Abuse of power is the control of people by some kind of force. It is the use of power for one‘s
own benefit and can be present in families, organizations, and all levels of domestic and international
government. It is always unethical. Poor developing nations around the world are obvious examples.
Dictators abuse their people often to the point of genocide. Industrialized nations engage in unfair trade
and often exploit workers.
POWERLESSNESS:
Powerlessness is a horrible state. Personal powerlessness is a personal nightmare. It brings about
feelings of frustration that generally lead to anger; it saps energy levels and leaves the person in a constant
state of exhaustion from fighting to alter the balance of power; it defeats the spirit and soul of a person. A
person who exhibits powerless behavior is someone who needs immediate attention. Powerless people do
not function well in their jobs, they lose their motivation and drive to do well, and they are a negative
influence in any work environment. Such people should not be eliminated from the environment; they
should be assessed and worked with in an effort to alter the situation.
A person becomes powerless when:

 Being threatened by the competence of others

 Accepting a job without sufficient training or experience
 Depending on others to meet own needs
 Transferring feelings of inferiority to others while demanding perfection from subordinates.
 ―Nitpicking‖ over small things
 Wanting to keep things predictable
 Being trapped by roles and stereotypes
 Devaluing the group process

POLITICS:
Definition: It is a process through which one tries successfully or unsuccessfully to reach a goal.
Political nursing: Political nursing is defined as the use of knowledge about power processes and
strategies to influence the nature and direction of health care and professional nursing.
Anderson, Anderson & Glaze, 1998
Political Action Spheres:
The process of influencing others in order to achieve ends can be seen in relation to four arenas, spheres
or domains. These spheres are-
The workplace Professional
organizations Community
Local, state and federal governments

The workplace:
Nurses work in organizations with varied characteristics- private or public; profit, non- profit, or
charitable; large, small or medium; and in large or small cities, towns, small towns, or rural areas. In the
work place, there are many issues with which nurses are involved. Power and politics may be necessary to
resolve issues. Some issues that may be found in some workplace include the following:
1. Mandatory overtime work requirements
2. A nursing clinical ladder program that rewards excellence with promotions and pay incentives.
3. Work scheduling length of shift, evening and night rotation, vacation priority.
4. A smoking ban in the entire facility; designation of smoking areas.
5. Visiting hours in special care units.
6. Identification and security procedures.
7. Authority to delay discharge from or admission to special care units based on professional nurse
assessment.
8. Decisions regarding substation of unlicensed personnel for Registered Nurses to provide care.
 Professional organizations:
Professional organizations have been essential to the ―professionalization‖ of nursing. The modern
nursing movement began in 1873 in response to the changing role of women. Pioneers of this movement
worked for a new profession for women and for better health for the public. These women used political
power to open nurse training schools, organize professional associations, and participate in social issues
such as women‘s suffrage, public health, and integration. Professional organizations have made
significant contributions in developing nursing practice. They have set standards of practice, advocated
for change in the scope of practice and passage of nurse practice acts, and advocated for nurses in
collective action in the workplace. Such organizations have an ever-increasing role in the health policy
development. A strong professional or organization needs to be a visible force. Organizations can identify
issues that concern nursing and health care, bring them to public, and take a leadership role in advocating
for development of policies that improve health and ensure high-quality nursing care. To achieve this,
organizations need support of nurses through their membership and through their political acumen.
Community:
Community is defined as a population, a neighborhood, a state, a nation, and the world. Nurses are
members of a community with the responsibility to promote the wellbeing of the community and its
members. In exchange, the community provides important resources for nurses ‘work in health promotion
and health care-delivery. Many of the people who live in a community, such as health-care administrators,
corporate managers, industrial leaders, elected and career government officials, and patient have power.
These people can, and do, participate in community activities; they have status, expertise, and
connections. By building relationships with community members, nurses can gain supporters to achieve
goals. The connections they make can transform into networks, and the people in the networks can be
asked to support agendas. In exchange, nurses should support community agendas to work to improve
community life. Nurses can help mobilize communities on issues such as recycling, environmental clean-
up, safety, energy conservation, health screening, and the like. This can affect professional life with
increased skills, knowledge, experience, and power development. In addition, nurses who are active and
form connections in their communities become role models and represent the whole profession.
Government:
Government affects most aspects of our lives. We must document births, deaths, marriages; and
mandatory childhood immunizations. Government is needed to ensure that what we need to get done is
accomplished. Government plays an essential role in nursing and in health care. Government influences
and supports the current managed care arrangement, which provides for reimbursement for health and
nursing care. To a great extent, government determines who has access to care and to what type of care.
Federal, state, and local governments make decisions about major health issues in our society. Recent
decisions include:
 1) The kinds of foods and snacks available to children at schools.
2) Prohibition of smoking in some public places
3) Provision of meals for the poorest children
4) The health services available at schools and whether schools may provide sexual and
reproductive information.
5) Whether public funds can be used to distribute clean needles to intravenous drug users to
reduce the spread of HIV and AIDS.
6) Whether women can receive full information about reproductive rights and who can
provide that information.
7) Whether violence is treated only as a crime or also as a public health issue and whether to
regulate the use of hand guns.
8) Allocation of funds for housing development and maintenance.

THE FOUR STAGES OF POLITICAL DEVELOPMENT FOR THE PROFESSION

OF NURSING: (a model by - Cohen, Mason, Kavner, Leavitt, Pulcini, and
Sochalski, 1996)

1. Buy- in: Recognizing the importance of activism.

2. Self-interest: Developing and using political expertise to further the profession‘s self-
interests.
3. Political sophistication: Moving beyond self-interests, recognizing the need for activism on
behalf of the public.
4. Leading the way: Providing true leadership on broad healthcare interests.

With the addition of an initial stage identified by Kalisch and Kalisch (1982), this model
can also be applied to the political development and activism of individual nurses related to
both professional and legislative political arenas:
1. Apathy: no membership in professional organizations; little or no interest in legislative
politics as they relate to nursing and healthcare.
2. Buy-in: recognition of the importance of activism within professional organizations and
legislative politics related to critical nursing issues.
3. Self-interest: involvement in professional organizations to further one‘s own career; the
development and use of political expertise to further the profession‘s self-interest.
4. Political sophistication: high level of professional organization activism (e.g., holding office
at the local and state level) moving beyond self-interests; recognition of the need for activism
on behalf of the public.
5. Leading the way: serving in elected or appointed positions in professional organizations at
the state and national levels; providing true leadership on broad healthcare interests within
legislative politics, including seeking appointment to policy-making bodies and election to
political positions.
POLITICAL ANALYSES
Effective use of power and politics to facilitate strategy development for the policy process
requires systematic analysis of the issues.
COMPONENTS OF POLITICAL ANALYSIS:
☻ Identify and analyze the problem:
Identification and analysis of the problem or issue is the first step. The problem must be
understood in order to frame it in ways that will move elected officials to action. It must be
carefully crafted in terms that make sense. To frame the problem adequately, state the scope,
duration, and history of the problem. An important point is to be explicit about whom this
problem affects. Then collect all data that are available to describe the issue and its
implications. Identify any gaps in the data. Identify whether more research might be useful and,
if so, what types would help.
☻ Outline and analyze proposed solution:
Present possible solutions to public officials along with the identified problem. It is best to
develop more than one solution because costs, effectiveness, and durability differ from
approach to approach
☻ Understand the background, including its history and attempts to solve the problem:
It is important to understand what attempts have been made to address an issue. The history,
including why and how previous attempts failed, will provide an estimation of the potential
success of the current proposal. Even in a workplace context, understanding the background of
an issue is important. If one believes that the staffing on a unit needs to be changed to improve
patient care, efficiency, and nurse satisfaction, one must assess how the staffing was structured,
why it was done in that particular way, and why and how that format is outdated before one
present one‘s proposal to the nurse manager or appropriate committee.

☻ Locate the political situation and its structure:

After the problem and solutions have been delineated, assess and choose the appropriate
political venues. The choice is between the private sector and government. If the decision made
is to approach government, decide on the level and branch. There are times when both the
public and private sectors are involved, but in that case, only one has the decision making
responsibility. When all sectors have equal power, no one sector has the responsibility to make
decision nor the vested interest to prevent a decision. Be sure to identify the political setting
accurately, because making an error can cause you a loss of credibility and a loss of power. For
example, if nurse are concerned about an aspect of patient care, the employer must be
approached through the organization structure. It is unfair and impolitic to go to public officials
before internal mechanisms have been exhausted. It is also imprudent to exclude the nurse
 Manager and go directly to the chief nurse executive or a supervisor. Again, so doing will
cause loos of face, credibility, and power.
☻ Evaluate the stakeholders:
The next step is to identify the stakeholders. Stakeholders are those who are affected by or have
influence over an issue or who could be recruited to care about it. Stakeholders include policy
makers who have proposals related to the issue, special interest groups, and those with a
position on the issue.
☻ Conduct a values assessment:
All political issues have or moral aspects. Human rights, international health law, the right to
health, genetic engineering, embryonic stem cell research, genetic technologies, terrorism,
abortion, and the death penalty are among the most visible moral issues today. Issues
necessitate that stakeholders assess their own values and those of their opponents.
☻ Ascertain financial and personnel needs to attain goals:
Any effective political strategy must include assessment of resources needed to reach goals. In
addition to money, other needed resources include time, connections or network, volunteers,
contributors, and intangibles, such as people who are strategists and those with creative ideas.
The budget structure within an organization or government agency must be considered. It is
important to understand the budget process, including how money is allocated to a cost center
or line budget, who makes decision regarding expenditures, how use of funds is evaluated, and
how an individual or group can influence budget development and implementation.
☻ Analyze power bases:
In any setting, assessment of power bases of both proponents and opponents is essential.

POLITICAL STRATEGIES:

After the political analysis is completed, a plan of action with strategies is developed. Strategies are
the plans to achieve political and policy goals. To achieve goals it is useful to follow these tactics.
 Persistence- Change takes time; conflict is almost always part of policy change. Policy change
or new policy development and implementation is a long-term commitment and requires
commitment and endurance.
 Look at big picture: Always prepare for the political process of policy development by
clarifying aspects of the issue. This includes knowing your position and possible solutions
supported by data, assessing your power base and that of others involved, planning strategies,
and knowing the opposition and their plans and rationales. Understand the context of the issue.
  Frame issue adequately: Understand the stakeholders and target audience to present the issue in
ways that are congruent with their values.
 Develop and use networks: Use power that accrues through persona; connections, which
requires keeping track of what you have done for others and asking them to reciprocate.
 Assess time: Consider carefully when the most opportune time to act is. Knowing when the time
is right requires accurate assessment of the values, concerns, goals, and resources of those you
have to convince that your way is best.
 Collaborate: Work with others to achieve policy goals. Collaboration usually achieves goals
more effectively than does individual action.
 Prepare to take risks: Do a risk – and –benefit analysis of an action. This analysis entails
considerations of the benefits gained or goals achieved in relation to the expenditure of all
resources, including personnel, money, time spent that could have been used on another
endeavor, and coherence with values.
 Understand the opposition: Put aside emotional positions, focus on the issues, and try to
understand the fears and concerns of the opposition. Educate the opposition to appreciate the
nursing position.

POLITICAL TACTICS
The effective functioning of an organization depends on the relationship between individuals and
groups. Effective use of politics in the workplace can facilitate achievement of goals.
SKILLS AND TACTICS IN THE WORKPLACE:
The effective functioning of an organization depends on relationships between individuals and
groups. Often, problematic conflicts arise that are threatening to groups. Resolution of these conflicts
requires significant managerial skill. Effective use of politics can facilitate conflict resolution and
achieve goals. The following skills and tactics are useful and have a high probability of success-
 Build your own team: Executives, administrators, and managers are often defeated in their roles
because persons from the previous team are unhappy, jealous, and disgruntled and do not support,
or actively sabotage, the work of the new boss.
 Choose your second-in command carefully. ―An aggressive, ambitious, upwardly mobile number
two man (or woman) is dangerous and often difficult to control‖ (McMurray, 1973).
 Establish alliances with superiors and peers. Determine expectations and motivations of others
before you form true friendships. Alliances with superiors and peers are needed to achieve goals.
  Use all possible channels of communication. Develop and maintain open, effective channels of
communication to avoid isolation, pre-emption, and loss in power struggles. Be fair, but learn to
recognize aggressive, manipulative people.
 do not be naive about how decisions are made. Learn and understand the preferences and the
way powerful people act in the organization in order to predict how they will make a decision;
then plan accordingly.
 Know priority. Know what the goals are and how the organization generally works to achieve
those goals. In other words, know the modus operandi.
 be courteous. Treat others with respect. Respect can prevent feelings that can lead to sabotage and
retaliation.
 Maintain a flexible position and maneuverability. Identify what is ethically important and
nonnegotiable. Then you can maneuver confidently to change power.
 Disclose information judiciously. In order to work effectively, it may be necessary not to disclose
how power strategies are used.
 Use passive resistance when appropriate to gain time. Delay can be useful when time is needed for
gathering information.
 Project an image of confidence, status, power, and material success. The image of weakness
conveys a lack of power and decreases ability to act and achieve goals.
 Learn to negotiate and collaborate. Do not be ingratiating or conciliatory.

Meier (1999) recommended some basic strategies for political action-

 Join political organizations
 Build a working relationship with a single legislator
 Invite a legislator to a professional organization meeting
 Invite a legislator or staff person from the legislator‘s office to spend a day with you at work.
Brendon and Schwerin offered additional strategies for political action to shape policy: Use
power effectively
Always appear self-confident
Empower others to work on policy issues
Build your visibility
Build relationships through coalitions and networks
Identify resources, human and physical, that can support your efforts. Enhance
the image of nursing in all policy efforts
Communicate message effectively and clearly
Develop expertise in shaping policy
Seek appointive positions or elective office to shape policy more effectively.
 LOBBYING

Nurses can take an active role in the legislative and political process to affect change. They may
become involved in influencing one specific piece of legislation or regulation, or they can become
involved more universally and systematically to influence health care legislation on the whole.

DEFINITION-
LOBBYING:
 Lobbying is the deliberate attempt to influence political decisions through various forms of
advocacy directed at policymakers on behalf of another person, organization or group.

 Lobbying is the practice of private advocacy with the goal of influencing a governing body by
promoting a point of view that is conducive to an individual's or organization's goals.

LOBBYIST:
1) A lobbyist is an individual who attempts to influence legislation on behalf of others, such as
professional organizations or industries.
2) Lobbyists are advocates. That means they represent a particular side of an issue.
3) A person who receives compensation or reimbursement from another person, group, or entity to
lobby.

TYPES OF LOBBYING:
 Direct
 Grassroots

DIRECT LOBBYING
Is communicating your views to a legislator or a staff member or any other government employee
who may help develop the legislation
To be lobbying, one must communicate a view on a "specific legislative proposal." Even if there is no
bill, one would be engaged in lobbying if one asked a legislator to take an action that would require
legislation, such as funding an agency. Asked one‘s members to lobby for this bill is also considered
as direct lobbying.
GRASSROOTS LOBBYING
Is simply citizen participation in government?
The key to successful grassroots lobbying efforts is assembling people who share common goals
and concerns. Grassroots communications are vital in educating legislators to the concerns of the voting
population in their state. If you do not share your views with your representative, then your views will not
be considered by your state representative when he votes on an issue which affects you. You can make a
difference by simply writing, calling, meeting, or faxing your representative.

TYPES OF LOBBYISTS
The Lobbyists Registration Act identifies three types of lobbyists:
The consultant lobbyist:
The consultant lobbyist is a person who is gainfully employed or not and whose occupation is to
lobby on behalf of a client in exchange for money, benefits or other forms of compensation. Consultant
lobbyists may work for public relations firms or be self-employed. For example, he or she might be a
public relations expert, a lawyer, an engineer, an architect.

The enterprise lobbyist:

This is a person who holds a job or has duties in a profit-making organization, whose duties
include, for a significant part, lobbying on behalf of the firm.

The organization lobbyist:

This is a person who holds a job or has duties in a non-profit organization. Like the enterprise
lobbyist, this lobbyist is affected by the Act if a significant part of his or her duties is to lobby on behalf
of this organization.

PREPARING FOR LOBBYING CAMPAIGN:

An effective lobbying initiative takes background work.
1. Develop plan of action. Consider, rework, revamp, and define the plan in advance of the trip to
the legislator‘s office.
2. Be sure one is fully aware of all similar initiatives on the same topic and the position of those
opposing one‘s idea.
3. Check with other nursing organizations to determine their positions and if they have information
to help support one‘s position.
 4. Fine-tune one‘s presentation to several key points because time will be limited.
5. Follow up after the meeting with a call or correspondence outlining the points.

PREPARING FOR AN EFFECTIVE LETTER-WRITING CAMPAIGN:

 Define the goals of this grass-roots campaign.
 Develop a plan
 Assess the knowledge level of the participants concerning the legislative process and the issues that
impact the organization. Use this information to plan educational sessions with the goal of improving
the political sophistication of the group.
 Give interested participants information about the bill in question and how this bill would directly
affect their practice. Clearly state what action the legislative body needs to take to meet the goal, and
include the specific bill number and name.
 Set up effective telephone or e-mail networks that can contact key members quickly. Often legislative
issues are scheduled and moved up quickly on that schedule, requiring an immediate change of plan.
 Identify and set up contacts with the key legislators involved in your issue.
 Set numerical goals for how many letters or mailings will be generated.
 On large issues, focus groups or polls may be used to acquire information that can be analyzed and
send to the legislators.
 Get the timing right. The time to begin your campaign is just before the committee hearings begin or
just prior to the vote on the floor. Too early is ineffective; too late is wasted effort. You must follow
the progress of your issue closely so as to mobilize your members at the right time.

USEFUL TIPS-
Dos:
a. Do write legibly or type. Handwritten are perfectly acceptable so long as they can be read.
b. Do use persona stationary. Indicate that you are a registered nurse. Sign your full name and address.
If you are writing for an organization, use that organization‘s stationary and include information
about the number of members in the organization, the services you perform, and the employment
setting you are found in.
c. Do state if you are a constituent. If you campaigned for or voted for the official, say so.
d. Do identify the issue by number and name if possible or refer to it by the common name.
e. Do state your position clearly and state what you would like your legislator to do.
f. Do draft the letter in your own words and convey your own thoughts.
g. Do refer to your own experience of how a bill will directly affect you, your family, your patients, and
members of your organization or your profession. Thoughtful, sincere letters on issues that directly
affect the writer receive the most attention and are those that are often quoted in hearings or debates.
h. Do contact the legislator in time for your legislator to act on an issue. After the vote is too late. If
your representative is a member of the committee that is hearing the issue, contact him/her before the
committee hearings begin. If he/she is not on the committee, write just before the bill is due to come
to the floor for debate and vote.
i. Do write the governor promptly for a state issue, after the bill passes both houses, if you want to
influence his/her decision to sign the bill into law or veto it.
j. Do use e-mails to state your points.
k. Do be appreciative, especially of past favorable votes. Many letters legislators receive feedback from
constituents who are unhappy or displeased about actions taken on an issue. Letters of thanks are
greatly appreciated.
l. Do make your point quickly and discuss only one issue per letter. Most letters should be one page
long.
m. Do remember that you are the expert in your professional area. Most legislators know little about the
practice of nursing and respect your knowledge. Offer your expertise to your elected representative as
an advisor or resource person to his or her staff when issues arise.
n. Do ask for what you want your legislator to do on an issue. Ask him/her to state his/her position in
the reply to you.
Don’ts:
a. Do not begin a letter with ―as a citizen and a taxpayer.‖ Legislators assume that you are a citizen,
and all of us pay taxes.
b. Do not threaten or use hostility. Most legislators ignore ―hate‖ mail.
c. Do not send carbon copies of your letter to other legislators. Write each legislator individually. Do
not send letters to other legislators from other states-they will refer your letter to your congressional
representative.
d. Do not write House members while a bill is in the Senate and vice versa. A bill may be amended
many times before it gets from one house to the other.
e. Do not write postcards; they are tossed.
f. Do not use form letters. In large numbers these letters get attention only in the form that they are
tallied. These letters tend to elicit a ―form letter response‖ from the legislator.
g. Do not apologize for writing and taking their time. If your letter is short and presents your opinion on
an issue, they are glad to have it.
KEEP ABREAST OF LEGISLATION AND REGULATION:
When issues are important to your professional, contact the legislator and provide the important facts that
support your position and be sure to follow up routinely so your opinions stay fresh in his/her mind.
Legislation: To keep in contact with the legislature, it is important to identify key committees and
subcommittees in the legislative bodies, and to identify and develop communication with the members of
those committees. Ways to keep abreast of new information include the following:
Volunteer for campaign work and develop contacts with legislators.
Obtain pertinent government documents using online resources.
Get the general telephone number for the state government and the mailing addresses for
correspondence.
Develop liaisons with other health professionals and utilize them as information sources and allies in
lobbying for health care issues.
Register a member of your group as a lobbyist- the fee is generally small. If
possible, hire a lobbyist
Once you have notified your legislator about your interest in a particular issue, the legislator‘s office
may routinely send literature outlining his or her activities throughout the sometimes arduous process.
Regulation: Because lobbying activities can significantly affect individuals and industry, regulation is
essential to avoid abuse. Lobbyists have created ethics codes, guidelines for professional conduct and
standards. The following will help you keep abreast of the newest regulations and standards:
Subscribe to the state register (which contains all state regulations under consideration).
Identify and develop contacts with state agencies that exert control on or impact your practice and ask
to be added to their mailing lists. A limited list includes the following:
i. Nurse practice act: rules and regulations
ii. Medical practice act: rules and regulations
iii. Pharmacy act: rules and regulations
iv. Dental practice act: rules and regulations
 v. Hospital licensing act: rules and regulations
vi. Ambulatory surgical center licensing act: rules and regulations
vii. Insurance statute: rules and regulations
viii. Trauma center statute: rules and regulations
ix. Department of Health
x. Podiatric Act: rules and regulations
CRITICAL THINKING

You assist an evil system most effectively by obeying its orders and decrees. An evil system never
deserves such allegiance. Allegiance to it means partaking of the evil. A good person will resist an evil
system with his or her whole soul. --Mahatma Gandhi

Meaning:

"Critical" as used in the expression "critical thinking" connotes the importance or centrality of the
thinking to an issue, question or problem of concern. "Critical" in this context does not mean
"disapproval" or "negative." There are many positive and useful uses of critical thinking, for example
formulating a workable solution to a complex personal problem, "Critical" as used in the expression
"critical thinking" connotes the importance or centrality of the thinking to an issue, question or problem of
concern. "Critical" in this context does not mean "disapproval" or "negative." There are many positive
and useful uses of critical thinking, for example formulating a workable solution to a complex personal
problem,

Definition:

Critical thinking is the intellectually disciplined process of actively and skillfully

conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or
generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and
action.

National Council for Excellence in Critical Thinking, 1987

"Critical thinking in nursing practice is a discipline specific, reflective reasoning process that
guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and
professional concerns. -

Critical thinking is the skillful application of a repertoire of validated general techniques for deciding the
level of confidence you should have in a proposition in the light of the available evidence.
-- Tim van Gelder
Critical thinking is reasonable, reflective thinking that is focused on deciding what to believe or do.
-- Robert Ennis
Levels of Critical Thinking According To Bloom

Bloom identified six thinking levels:

1. Knowledge (knowing things)
2. Comprehension (understanding things)
3. Application (being apply to apply knowledge in the real world)
4. Analysis (ability to pull things apart intellectually)
5. Synthesis (ability to see through the clutter to the core issues)
6. Evaluation (the ability to make good judgments)
Levels 4, 5 and 6 are the most important one for mid and higher levels of management.
Stages of Critical Thinking

 Stage One: We Begin as Unreflective Thinkers. We all begin as largely unreflective thinkers,
fundamentally unaware of the determining role that thinking is playing in our lives. We don‘t
realize, at this stage, the many ways that problems in thinking are causing problems in our lives.
We unconsciously think of ourselves as the source of truth. We assume our own beliefs to be true.
We unreflectively take in many absurd beliefs merely because they are believed by those around
us. We have no intellectual standards worthy of the name. Wish fulfillment plays a significant
role in what we believe.

 Stage Two: We Reach the Second Stage When We Are Faced with The Challenge Of
Recognizing the Low Level at Which We and Most Humans Function as Thinkers. For
example, we are capable of making false assumptions, using erroneous information, or jumping to
unjustifiable conclusions. This knowledge of our fallibility as thinkers is connected to the
emerging awareness that somehow we must learn to routinely identify, analyze, and assess our
thinking.

 Stage Three: We Reach the Third Stage When We Accept the Challenge and Begin to
Explicitly Develop Our Thinking
Having actively decided to take up the challenge to grow and develop as thinkers, we become
"beginning" thinkers, i.e., thinkers beginning to take thinking seriously.

 Stage Four: We Reach the Fourth Stage When We Begin to Develop A

Systematic Approach to Improving Our Ability to Think. At this stage, we now know that
simply wanting to change is not enough, nor is episodic and irregular "practice." We recognize
now the need for real commitment, for some regular and consistent way to build improvement of
thinking into the fabric of our lives.

 Stage Five: We Reach the Fifth Stage When We Have Established Good Habits
of Thought Across the Domains of Our Lives. We know that we are reaching the stage we call
the Advanced Thinker stage when we find that our regimen for rational living is paying off in
significant ways. We are now routinely identifying problems in our thinking, and are working
successfully to deal with those problems
 Rationally. We have successfully identified the significant domains in our lives in which we need
to improve (e.g. professional, parenting, husband, wife, consumer, etc.), and are making
significant progress in all or most of them

 Stage Six: We Reach the Sixth Stage When We Intuitively Think Critically at a Habitually
High Level Across all the Significant Domains of Our Lives. The sixth stage of development,
the Master Thinker Stage, is best described in the third person, since it is not clear that any
humans living in this age of irrationality qualify as "master" thinkers. It may be that the degree of
deep social conditioning that all of us experience renders it unlikely that any of us living today
are "master" thinkers. Nevertheless, the concept is a useful one, for it sets out what we are
striving for and is, in principle, a stage that some humans might reach.

Components of the Critical Thinking

The eight components that have been identified as part of the critical thinking process include:

1. Perception
2. Assumption
3. Emotion
4. Language
5. Argument
6. Fallacy
7. Logic
8. Problem Solving

1. Perception: Perception refers to the way we receive and translate our experiences – how and what
we think about them. For some, plain yogurt is delicious, while for others it is disgusting. For the
most part, perception is a learned process. e.g.: In the workplace, one employee will perceive a co-
worker to be a constructive decision-maker, while at the same time, another sees the same
employee as an adversarial roadblock to progress.

2. Assumptions: Trying to identify the assumptions that underlie the ideas, beliefs, values, and
actions that others and we take for granted is central to critical thinking. Assumptions are those
taken-for-granted values, common-sense ideas, and stereotypical notions about human nature and
social organization that underlie our thoughts and actions. Assumptions are not always bad. For
example, when you buy a new car, you assume that it will run without problems for a while. When
you go to sleep at night, you assume that your alarm will wake you up
in the morning. Remember, assumptions depend on the
notion that some ideas are so obvious and so taken for granted that they don‘t need to be explained.
Yet, in many cases, insisting on an explanation reveals that we may need more factual evidence in
order to develop well- supported viewpoints and to come to sound decisions. The problem with
assumptions is that they make us feel comfortable without present beliefs and keep us from
thinking about alternatives.
 3. Emotion: Emotions/feelings are an important aspect of the human experience. They are a critical
part of what separates humans from machines and the lower animals. They are part of everything
we do and everything we think. Emotions can affect and inspire thought, stated William James, but
they can also destroy it. We all have personal barriers enculturation, ego defenses, self-concept,
biases, etc.—shaped by our exposure to culture and genetic forces. But to the critical thinker,
personal barriers are not walls, merely hurdles. Critical thinkers don‘t ignore or deny emotions; as
with other forces of influence on our thinking, they accept and manage them.

4. Language: Some say that language is the landscape of the mind. Others say that language is the
software of our brain. Whatever the metaphor, it is clear that thinking cannot be separated from
language. Furthermore, for the multitude that define thinking itself as
―expressed thought,‖ language carries the content and structures the form of the entire
thinking process.

5. Argument: Many people think that arguing means fighting or quarreling. In the context of critical
thinking, however, this definition does not fit. An argument is simply a claim, used to persuade others,
that something is (or is not) true and should (or should not) be done. When someone gives reasons for
believing something hoping that another person will come to the same conclusion by considering
those reasons the discourse is geared toward persuasion. An argument contains three basic elements:
an issue, one or more reasons called premises in logic, and one or more conclusions. Arguments can
be valid or invalid, based on how they are structured. Arguments are not true or false only premises
and conclusions are true or false. The goal of a critical thinker is to develop sound arguments that have
both validity (are structured properly) and true premises. When we have a validly structured argument
with true premises, we have a sound argument. In sound arguments the conclusion must be true and
therein lies the beauty and usefulness of logic.

6. Fallacy: Since we use language for the three primary purposes of informing, explaining, and
persuading, we must be careful how we use it. We must make every effort to apply sound reasoning,
particularly when language is used to persuade. To be sound, reasoning must satisfy three conditions:

1. it must be valid (structured properly);

2. the premises must be true; and
3. All relevant information must be included.

If the reasoning fails to satisfy any of these three criteria, it is said to be fallacious. A
fallacy, then, is an incorrect pattern of reasoning.

Remember, finding a fallacy in your own or someone else‘s reasoning does not mean that the
conclusion is false. It means only that the conclusion has not been sufficiently supported because one
or more of the above three conditions were not satisfied. Fallacies can be
committed through any of our communication methods, especially in the print, visual, and
 Sound media.

7. Logic: Traditionally, philosophy has distinguished between two methods of reasoning: deductive
logic and inductive logic. In logic, moving from observations to conclusions is called induction.
Moving from conclusions to predictions that something will follow, given a set of circumstances and
then verifying the prediction is called deduction. Inductive reasoning is characterized by reasoning
from diverse facts, probability, generalizations, hypotheses, and analogies, leading to inductive
strength. Deductive reasoning is characterized by reasoning from known facts, certainty, syllogisms,
validity, and truth of premises, leading to sound arguments and conclusions.

8. Problem Solving: Solving ―logic‖ problems is like solving any problem that we encounter or identify
in life. The following general model for problem solving is suggested:

1. Read and heed the problem. What is it telling you? What is it asking? Define terms that you
do not understand.

2. Identify the unknown(s). It is helpful to name these with a symbol. Math uses a letter known
as a variable, but any symbol will do.

3. Identify the known‘s. Write down all the information that the problem tells you. Even if you
just repeat the givens in the problem, list them.

4. Start to identify the relationships between the known and the unknowns. This is the critical
and creative part of solving a problem. Create a visual aid like a diagram, sketch, table, etc.,
that allows you to ―see‖ the relationships.

5. Use the relationships identified in step (4) to generate a problem-solving strategy.

6. Apply the strategy and solve.

7. If something doesn‘t seem to work, repeat steps 1-6. The secret to problem solving is
continuing to try and learning something new on each successive iteration. The solution will
ultimately be reached.

METHODS OF CRITICAL THINKING

a. Debate: it involve enquiry, advocacy, and reasoned judgment on a proposition. A person or

group may debate or argue the pros and cons of a proposition in coming to a reasoned
judgment.
b. Individual decision: an individual may debate a proposition in his or her mind using problem
solving or decision making process. When consent or cooperation of others is needed, the
individual may use group discussion, persuasion, propend, coercions or a combination of this
method
c. Group discussion: five conditions for reaching decision through group discussion are group
members agree that a problem exist, have comparable standard of value, have
 Comparable purposes, are willing to accept consensus of the group, and relatively few in
number
d. Persuasion: it is communication to influence the acts, beliefs, attitude, and value of others by
reasoning, urging or inducement. Debate and advertising are two forms of communication
which intent is to persuade
e. Propend: it can be good or bad; it is multiple media communication designed to persuade or
influence a mass audience.
f. Coercion: threat or use of force is coercions. An example of coercions is brainwashing in
which subjects are completely controlled physically controlled for an indefinite period of
time.
g. Combination of method: Some situation requires a combination of foregoing communication
techniques to reach a decision.

PROCESS OF CRITICAL THINKING

 The critical thinking process, as described by Wolcott and Lynch, includes four steps.
Students generally begin their critical thinking at step one and, with practice, progress to step
2 and up the ladder.

Identify the problem, the relevant information, and all uncertainties about the
Step 1: problem. This includes awareness that there is more than one correct solution. (low
cognitive complexity)

Explore interpretations and connections. This includes recognize one's own bias,
Step 2: articulating the reasoning associated with alternative points of view, and organizing
information in meaningful ways. (moderate cognitive complexity)
Prioritize alternatives and communicate conclusions. This includes thorough analysis,
Step 3: developing the guidelines used for prioritizing factors, and defending the solution option
chosen. (high cognitive complexity)

Integrate, monitor, and refine strategies for re-addressing the problem. This includes
Step 4: acknowledging limitations of chosen solution and developing an ongoing process for
generating and using new information. (highest cognitive complexity)

Models of critical thinking

Benjamin Bloom's Model of Critical Thinking

Perhaps most familiar to educators is "BLOOM'S taxonomy." Benjamin Bloom describes the major
areas in the cognitive domain. The taxonomy begins by defining
 Knowledge as the remembering of previously learned material. Knowledge, according to
Benjamin Bloom, represents the lowest level of learning outcomes in the cognitive domain.
 Comprehension, the ability to grasp the meaning of material and goes just beyond the
knowledge level. Comprehension is the lowest level of understanding.
  Application is the next area in the hierarchy and refers to the ability to use learned material in
new and concrete principles and theories. Application requires a higher level of understanding
than comprehension.
 Analysis, the next area of the taxonomy, the learning outcomes require an understanding of both
the content and the structural form of material.
 Synthesis, which refers to the ability to put parts together to form a new whole. Learning
outcomes at this level stress creative behaviors with a major emphasis on the formulation of new
patterns or structures.
 Evaluation. Evaluation is concerned with the ability to judge the value of material for a given
purpose. The judgments are to be based on definite criteria. Learning outcomes in this area are the
highest in the cognitive hierarchy because they incorporate or contain elements of knowledge,
comprehension, application, analysis, and synthesis. In addition, they contain conscious value
judgments based on clearly defined criteria. The activity of inventing encourages the four highest
levels of learning--application, analysis, synthesis, and evaluation--in addition to knowledge and
comprehension.

EVALUATION

SYNTHESIS

ANALYSIS

APPLICATION

COMPREHENSION

KNOWLEDGE

Structural model Jeffrey Ellis

A simple structural model proposed by Jeffrey Ellis illustrates the structural relationships between major
components of critical thinking. It is based on defining critical thinking as a set of four sets:
CT = {{S}, {H}, {V}, {R}}
where {S} is a set of cognitive skills, {H} is a set of characteristic habits or attitudes, {V} is a set of
values/commitments, and {R} is a set of relationships among the various elements in {S}, {H}, and
{V}.
 Thesetofcognitiveskills{S}includefundamentalreasoningabilitiessuch as , , , , , and so on.

The characteristic habits/attitudes {H} are the acquired behavior patterns that distinguish a critical
thinker from a non-critical thinker. These are approximately equivalent to what Richard Paul has
called the valuable intellectual traits of a critical thinker: intellectual humility, intellectual courage,
intellectual empathy, intellectual integrity, intellectual perseverance, faith in reason, and fair-
mindedness .
The set of values/commitments, for a critical thinker, has but one element: a commitment to the
truth, or in cases where the truth is unknowable, a commitment to the most defensible opinion.
The relationships {R} between the elements in this model are shown graphically (see figure to
right). Values/commitments provide the foundation for critical thinking. It is the commitment to
searching for the truth that motivates the need for intellectual humility, empathy, and the various
other critical thinking traits, and these traits in turn regulate the way in which cognitive skills are
applied to form opinions, make decisions, and solve problems.

Techniques of critical thinking

Here are 16 basic techniques of critical thinking.

1. Clarify.
State one point at a time. Elaborate. Give examples. Ask others to clarify or give examples. If you‘re not
sure what you‘re talking about, you can‘t address it.

2. Be accurate.
Check your facts.

3. Be precise.
Be precise, so you are able to check accuracy. Avoid generalizations, euphemisms, and other ambiguity.

4. Be relevant.
Stick to the main point. Pay attention to how each idea is connected to the main idea.
5. Know your purpose.
What are you trying to accomplish? What‘s the most important thing here? Distinguish your purpose
from related purposes.

6. Identify assumptions.
All thinking is based on assumptions, however basic.

7. Check your emotions.

Emotions only confuse critical thinking. Notice how your emotions may be pushing your thinking in a
certain direction.

8. Empathize.
Try to see things from your opponent‘s perspective. Imagine how they feel. Imagine how you sound to
them. Sympathize with the logic, emotion, and experience of their perspective.

9. Know your own ignorance.

Each person knows less than 0.0001% of the available knowledge in the world. Even if you know more
about relevant issues than your opponent, you still might be wrong. Educate yourself as much as possible,
but still: be humble.

10. Be independent.
Think critically about important issues for yourself. Don‘t believe everything you read. Don‘t conform to
the priorities, values, and perspectives of others.

11. Think through implications.

Consider the consequences of your viewpoint.

12. Know your own biases.

Your biases muddle your thinking. Notice how they might be pushing your thought toward a particular
end, regardless of the logical steps it took to get there.

13. Suspend judgment.

Critical thinking should produce judgments, not the other way around. Don‘t make a decision and then
use critical thinking to back it up. If anything, use the method of science: take a guess about how things
are and then try to disprove it.

14. Consider the opposition.

Listen to other viewpoints in their own words. Seriously consider their most persuasive arguments. Don‘t
dismiss them.

15. Recognize cultural assumptions.

People from different times and cultures thought much differently than you do. In fact, your ideas might
have arrived only in the last 50 years of human history! Why is your perspective better than that of
everyone else in the world today and throughout history?

16. Be fair, not selfish.

Each person‘s most basic bias is for themselves.
 Benefits of critical thinking
 We have too much information. Critical thinking helps you focus on what matters.
 We have too many options. Critical thinking helps you do what matters.
 Millions of scam artists want to steal your time and money. You can use critical thinking to
defeat them.
 Critical thinking helps you avoid false beliefs. Do you believe something because you read it
somewhere? Because your family or government or culture told you so? Because it makes you
feel good? Because you ―just believe‖ it?
 If so, you probably have many false beliefs. Critical thinking can help you avoid those. Who
knows? It might even help you form some true beliefs.
 But we probably already agree that critical thinking is good. How do we do it?

Use of critical thinking skills in nursing:

 Nurses use knowledge from other subjects and fields.

 Nurses deal with change in stressful environments.
 Nurses make important decisions.
 Nurses provide care according to nursing process

DECISION MAKING

Choose always the way that seems the best, however rough it may be. Custom will soon render it easy
and agreeable. -Pythagoras

Definition:

Decision making can be regarded as the mental processes (cognitive process) resulting in the selection of
a course of action among several alternatives. –Wikipedia

Decision making is the process of selecting one course of action from alternatives.

Stages of Decision making:

Developed by B. Aubrey Fisher, there are four stages that should be involved in all group decision
making. These stages, or sometimes called phases, are important for the decision- making process to
begin

 Orientation stage- This phase is where members meet for the first time and start to get to know
each other.
  Conflict stage- Once group members become familiar with each other, disputes, little fights and
arguments occur. Group members eventually work it out.
 Emergence stage- The group begins to clear up ambiguity in opinions is talked about.
 Reinforcement stage- Members finally make a decision, while justifying themselves that it was
the right decision.

Principles of decision making:

1. Purpose-Driven. People need a reason to participate in the process.

2. Inclusive, Not Exclusive. All parties with a significant interest in the issues should be involved
in the collaborative process.

3. Educational. The process relies on mutual education of all participants.

4. Voluntary. The parties who are affected or interested participate voluntarily.

5. Self-Designed. All parties have an equal opportunity to participate in designing the collaborative
process. The process must be explainable and designed to meet the circumstances and needs of
the situation.

6. Flexible. Flexibility should be designed into the process to accommodate changing issues, data
needs, political environment, and programmatic constraints such as prime and meeting
arrangements.

7. Egalitarian. All parties have equal access to relevant information and the opportunity to
participate effectively throughout the process.

8. Respectful. Acceptance of the diverse values, interests, and knowledge of the parties involved in
the collaborative process is essential.

9. Accountable. The participants are accountable both to their constituencies and to the process that
they have agreed to establish.

10. Time Limited. Realistic deadlines are necessary throughout the process.

11. Achievable. Commitments made to achieve the agreement(s) and effective monitoring are
essential.
STEPS IN DECISION MAKING:

The decision making task can be divided into 7 steps which are stated in order of sequence are as

1. Establishing goal and objectives

2. Making the diagnosis
3. Analyzing the problem
4. Searching alternative solution
5. Selecting the best possible solution
6. Putting the decision into effect
7. Following up the decision
1. Establishing goal and objectives: goal and objectives can be set prior to beginning the general
process. They will answer the question, what do we want the outcome or results of this
decision to be? When new products or services are the outcome, goals and objectives are
established first and problems or decision are then forecast.
2. Making the diagnosis: the first step is to determine what the real problem is. If the problem is
not ascertained correctly at the beginning, money and effort spent on the decision making will
be a waste. The original situation will not come under control. But new problem will start
from this incorrect appraisal of the situation. The diagnosis should not be merely based on
one or more visible symptoms but it should be diagnosed after the whole situation.
3. Analyzing the problem: The problem should be analyzed to find out adequate background
information and data relating to the situation. This analysis may provide the manager with
some revealing circumstances that will help him to gain an insight into the problem. A
thorough information search include knowledge of organizational policy, prior personal
experience or training or the experience of others. From the information gathered, the facts
should be identified and separated so as to provide the solid foundation for making sound
decision.
4. Searching alternative solution: after analyzing the problem, attempts are made to find
alternative solutions to the problems comparing the potential solutions to the desired outcome
to available resources. Establishing goals with measurable objectives helps to focus the
search the alternatives. This search for alternatives forces the manager to see things from
many view points and to study cases from their proper perspectives. When comparing
potential alternatives, one should certainly consider the cost, time required and available, and
the capabilities of those who will be involved in implementation a decision.
 5. Selecting best possible solution: the selection of one best course of action, out of several
alternatives developed, requires an ability to draw distinction between tangible and intangible
factors as well as facts and guesses. Four criteria suggested by Drucker for choosing the best
possible solution are as
 Proportion of risk to the expected gain
 Relevance between the economy of effort and the possibility of results
 The time consideration that meet the needs of the situation
 The limitation of resources
6. Putting the decision into effect: even the best decision may become inoperative due to the
opposition of employees. The decision can only be made effective through the action of the
people. To overcome the resistance or opposition in the employees, managers must make
necessary preparations for putting the decision into effect. Three important things related to
preparation of this are
 Communication of decision
 Securing employees acceptance
 Timing of decision
7. Follow up the decision for evaluation: in spite of all efforts, the decision taken may not be
accurate mainly because of two reasons:
 Some amount of guesswork becomes inevitable in almost every decision.
Because of the cost and time involved in analyzing the problem.
 Wrong decision also arise from the limited capacity of the manager itself

The 9 step decision making model is proposed by David Welsh in his book 'Decisions, Decisions'.
The 9 step decision making model
Step 1 - Identify your objective

What is it you wish to achieve?

Step 2 - Do a preliminary survey of your options

Besides the most obvious choices available to you, what other kinds of options can you think of?
Step 3 - Identify the implicated values
What values are at stake here? If it's an easy or unimportant decision you may not necessarily do this
step. But if the decision has a major impact on your wealth, your health or self-respect, then it's useful to
be aware of it.
Step 4 - Assess the importance of the decision
The importance of the decision will determine how much you invest in it in terms of time, energy and
money. The importance is determined by examining the implicated values. You may also
have to consider the context here as well, a different situation or environment can mean that a decision
that is often not very important can become very significant.

Step 5 - Budget your time and energy

Having identified the main alternatives and the values, now decide on which time and energy to spend
making the decision itself. More important decisions are given more time and energy. He suggests that
busy people and nervous wrecks made worse decisions than other people.

Step 6 - Choose a decision making strategy

This step of the 9 step decision making model involves making another decision. The time and energy
you plan to devote will affect the strategy you choose.

And because the strategy you choose may profoundly affect your decision it's important to choose an
appropriate one.

Step 7 - Identify your options

When you examine your options in more detail you may discover other options with different implicated
values. He points out that occasionally you may have to go back to step three to five and make revisions.

Step 8 - Evaluate your options

This is where you compare the options available to you. Again he suggests that seeking advice from an
expert is often easier than making the decision on your own.

Step 9 - Make your choice - on time, on budget

When you're finished doing the evaluation (only as much as it requires!), you make your choice. He notes
that people may still have difficulty at this stage because they fear the consequences of making a bad
decision.
Techniques and Tools of Decision Making

A. Judgmental technique
B. Operational research technique
C. Delphi technique
D. decision tree

A. Judgmental technique:

This is the oldest technique of decision making and is subjective in nature. As it is based on past
experiences or intuition about future, it is frequently used for making routine decisions. It is cheap and
can be quickly done. But it is hazardous as there is chance of taking a wrong decision. So this technique is
rarely used in large capital commitments.

C. Operational research technique:

It is the analysis of decision problem using scientific method to provide manager the need quantitative
information in making decision.
Steps of operational research are
 Construction of a mathematical model that pin points the important factors in the situation.
 Definition of criteria to be used for comparing the relative merits of various possible courses of
action
 Procuring empirical estimates of the numerical parameters in the model that specify the
particular situation to which it is applied.
 Carrying out through the mathematical process of finding and series of action which will give
optimum solution
c. Delphi technique: The Delphi method is a systematic, interactive forecasting method which relies on a
panel of experts. The experts answer questionnaires in two or more rounds. After each round, a facilitator
provides an anonymous summary of the experts’ forecasts from the previous round as well as the reasons they
provided for their judgments. Thus, experts are encouraged to revise their earlier answers in light of the
replies of other members of their panel. It is believed that during this process the range of the answers will
decrease and the group will converge towards the "correct" answer. Finally, the process is stopped after a
pre-defined stop criterion.

Advantage is that it is free from another’s influence and does not require physical presence which
makes it appropriate for scattered group and limitation is that it is time consuming.
D. Decision trees: A decision tree is a graphic method that can help the supervisor in visualizing the
alternative available, outcomes, risks and information for a specific needs for a specific problem over a
period of time. It helps her to see the possible directions that action may take from each decision point
and to evaluate the consequences of a series of decisions. The process begins with a primary decision
having at least two alternatives. Then the predicted outcome for each decision is considered, and the
need for further decisions is contemplated.

Types of Decision Making

Main types
There are many types of decision making and these can be easily categorized into the following
4 groups:

 Rational
 Intuitive
 Recognition primed decision making
 The ultimate decision making model

Rational

Rational decision making is the commonest of the types of decision making that is taught and learned
when people consider that they want to improve their decision making. These are logical, sequential
models where the emphasis is on listing many potential options and then working out which is the best.
Often the pros and cons of each option are also listed and scored in order of importance.
Intuitive

The second of the types of decision making are the intuitive models. The idea here is that there may be
absolutely no reason or logic to the decision making process. Instead, there is an inner knowing, or
intuition, or some kind of sense of what the right
Thing to do is.

Recognition primed...
Gather information from our environment in relation to the decision we want to make. Pick an option that
work. We rehearse it mentally and if we still think it will work, we go ahead. If it does not work mentally,
choose another option .If that seems to work, go with that one. Also points out that as get more
experience, recognize more patterns, and make better choices more quickly.

The ultimate...

Firstly, before you even make a decision, you establish how and who you want to be. You obviously
want to be in a good state so that you can make good decisions. But you also want to be true to yourself,
and that means knowing who 'yourself' is.

(ACCORDING TO Ken Shah & Prof. PARAM J. Shah)

Irreversible
This are those type of decisions, which, if made once cannot be unmade. Whatever is decided would then
have its repercussions for a long time to come. It commits one irrevocably when there is no other
satisfactory option to the chosen course. A manager should never use it as an all-or-nothing instant escape
from general indecision.

Reversible
This are the decisions that can be changed completely, either before, during or after the agreed action
begins. Such types of decisions allows one to acknowledge a mistake early in the process rather than
perpetuate it. It can be effectively used for changing circumstances where reversal is necessary.

Experimental
This types of decisions are not final until the first results appear and prove themselves to be satisfactory.
It requires positive feedback before one can decide on a course of action. It is useful and effective when
correct move is unclear but there is a clarity regarding general direction of action.

Trial and Error

In this type of decisions, knowledge is derived out of past mistakes. A certain course of action is selected
and is tried out, if the results are positive, the action is carried further, if the Results appear negative,
another course is adopted and so on and so forth a trial is made and an error is occurred. Till the night
combination this continues. It allows the manager to adopt and adjust plans continuously before the full
and final commitment. It uses both, the positive and negative feedback before selecting one particular
course of action.

Mainstages
Here the decisions are made in steps until the whole action is completed. It allows close monitoring of
risks as one accumulates the evidence of out- comes and obstacles at every stage. It permits feedback and
further discussion before the next stage of the decision is made.

Cautious
It allows time for contingencies and problems that may crop up later at the time of implementation. The
decision-makers hedge their best of efforts to adopt the night course. It helps to limit the risks that are
inherent to decision- making. Although this may also limit the final gains. It allows one to scale down
those projects which look too risky in the first instance.

Conditional
Such types of decisions can be altered if certain foreseen circumstances arise. It is an
either or ‘kind of decision with all options kept open. It prepares one to react if the competition makes a
new move or if the game plan changes radically. It enables one to react quickly to the ever changing
circumstances of competitive markets.

Delayed
Such decisions are put on hold till the decision–makers feel that the time is right. A go- ahead is given
only when required elements are in place. It prevents one from making a decision at the wrong time or
before all the facts are known. It may, at times result into forgoing of opportunities in the market that
needs fast action.

THEORIES OF DECISION MAKING

1. Marginal theory

This theory stress on profit maximization .this theory focused on increases profit from the
decision. It related to health care cost and patient outcome

2. Psychological theory

The trust of this theory is on the maximization of customer satisfaction (patient). The manager
acts as an administrative man rather than economic man

3. Mathematic theory
This theory is based on the use of models. This is also known as operational research theory. The
techniques generally used include linear programming. Theory of probability stimulation models etc.

4. Classical decision theory

 Views the decision maker as acting world of complete certain

 Classical decision making faces a clearly defined problem. Knows all possible action alternative
and their consequences
 Choose the optimum alternative

5. Behavioral decision theory

 Accepts a world with bounded rationality and views the decision maker as acting only in
terms of what he/she perceive about a given situation
 The behavior decision maker faces a problem that is not clearly defined. has limited
knowledge of possible action alternatives and their consequences
 6. Statistical decision theory

Several statistical tools and methods are available to organize evidence, evaluate risks, and aid in
decision making. The risks of Type I and type II errors can be quantified (estimated probability, cost,
expected value, etc.) and rational decision making is improved

MODELS OF DECISION MAKING

 Roan and yelton‟s normative model

The Vroom-Yetton- model is a decision making tree that enables a leader to examine a situation and
determine which style or level of involvement to engage. This model identifies five styles along a
continuum ranging from autocratic to consultative to group-based. Two are autocratic (A1 and A2), two
are consultative (C1 and C2) and one is Group based (G2).
A1: Leader takes known information and then decides alone.
A2: Leader gets information from followers, and then decides alone.
C1: Leader shares problem with followers individually, listens to ideas and then decides alone. C2:
Leader shares problems with followers as a group, listens to ideas and then decides alone.
G2: Leader shares problems with followers as a group and then seeks and accepts consensus agreement.
 Bounded rationality model: is the notion that in decision making, rationality of individuals is
limited by the information they have, the cognitive limitations of their

Minds, and the finite amount of time they have to make decisions. The process of bounded
rationality involve 3 mechanism they are as

SEQUENTIAL ATTENTION TO ALTERNATIVE: here person examine possible solutions of a

problem systematically i.e. if first solution fails to work it is discarded and next solution is
considered till he gets acceptable solution

HEURISTICS: it is a rule which guides the search for alternative into areas that have a high
probability for yielding solution. Here the decision makers look for obvious solution or previous
solution that worked in similar situation

SATISFYING: Here the decision maker is looked as a satisfier where an alternative is

satisfactory if there exist a set of criteria that describes minimally satisfactory alternative,
alternative in question meets or exceeds all these criteria.

Factors Affecting the Decision-Making Process

Experience and knowledge

Experience and knowledge are two of the major factors affecting decision making. Decision
making within practice disciplines, such as nursing, involves more than the application of theoretical
knowledge. A deep understanding of the situation is required if treatment approaches are to address the
experience of illness as it relates to a particular patient. This understanding evolves from knowledge and
experience. Experience increases the cognitive resources available for interpretation of data, resulting in
more accurate decision making.

Creative thinking
Problem solving involves organization of new and previously learned information to form new responses
to novel situations. The promotion of creative thinking through education calls for teachers to endorse the
creative thinkers' self-worth, listen to them, challenge learners to develop new ideas and to question their
taken-for-granted ideas, demonstrate critical thinking ability, encourage breadth of reading, invite learners
to talk about what they think and feel, and to adopt a conversational approach

Self-Concept

Perceptions of being less intelligent, less educated and less competent result in relinquished
authority to those perceived as being better. Those with an internal locus of control believe in their ability
to influence results, whereas, those possessing an external locus of control believe that events are
contingent upon the actions of others. Locus of control refers to the extent to which a person believes they
can control events and outcomes
Interpersonal Conflict

The stressors involved with interpersonal conflict constitute another barrier to decision making.
Clinical decision making is a social activity involving health care team members and the patient. The
social context in which the clinician functions impacts upon decision making

Inadequate Staffing

That it is stressful to work when staffing levels are inadequate for the tasks required would be
disputed by few. Most nurses have frequently encountered circumstances when experienced staff are
replaced with novices. This situation places stress on staff of all levels and influence the decision

SOME COMMON MISTAKES THAT DECISION MAKERS SHOULD BE AWARE OF INCLUDE:

 Only hearing and seeing what we want. Each individual has their own unique set of preferences
or biases which blinker them to certain information. The best way to deal with this problem is to
identify your preferences and biases whilst attempting to be open to the information around you.
 Placing too great a reliance on the information you receive from others. Often we rely on certain
individuals to provide support and guidance. This may be a suitable course of action in many
cases. However, if the individual is not closely involved in the problem situation they may not
have the necessary information or knowledge to help make the decision.
 Placing too little emphasis on the information you receive from others. This issue can easily
occur in a team situation. In many cases the team members are the people who are most closely
involved in a problem situation and they often have the most pertinent information in relation to
the problem. The best way to deal with this issue is to ensure that team members are involved in
the decision making process.
 Ignoring your intuition. On many occasions we are actually aware at a subconscious level of the
correct course of action. Unfortunately, we often tend to ignore our intuition.
STRESS MANAGEMENT

INTRODUCTION
Right from the time of birth till the last breath drawn, an individual is invariably exposed to
various stressful situations. The modern world which is said to be a world of achievement is also a world
of stress and has been called the ― Age of Anxiety and Stress‖. The word stress was originally used by
Selyle in 1956 to describe the pressure experienced by a person in response to life demands. These
demands are referred to as stressors. Stress can be positive or negative. Perception plays a key role in
interpreting how stressful situations are.
DEFINITION
STRESS
 According to Selye (1956), ―Stress is defined as the pressure experienced by a person in
response to life demands. These demands are referred to as ‗stressors ‘and include a range of life
events, physical factors (e.g.: cold, hunger, hemorrhage, pain), environmental conditions and
personal thoughts.‖
 According to Sale (1976), ―Stress is a process of adjusting to or dealing with
circumstances that disrupt or threaten to disrupt a person‘s physical or psychological functioning.
 Stress is tension, strain, or pressure from a situation that requires us to use, adapt, or develop new
coping skills.
STRESSOR
 Stressor is the stimuli proceeding or precipitating a change. It may be internal (fear, guilt) or
external (trauma, peer pressure, etc.).
TYPES OF STRESS
♪ Distress: Stress due to an excess of adaptive demands placed upon us. The demands are so great
that they lead to bodily and mental damage. e.g.: unexpected death of a loved one.
♪ Eustress: The optimal amount of stress, which helps to promote health and growth. e.g.: praise
from a superior for hard working.
TYPES OF STRESSORS
 Physiological stressors:
a. Chemical agents
b. Physical agents
c. Infectious agent
d. Nutrition imbalances
e. Genetic or immune disorders
 Psychological stressors:
a. Accidents can cause stress for the victim, the person who caused the accident and the families
of both
b. Stressful experiences of family members and friends
c. Fear of aggression or mutilation from others such as murder, rape, terrorist and attacks.
d. Events that we see on T.V. such as war, earthquake, violence
e. Developmental and life events
f. Rapid changes in our world, including economic and political structures and technology
SOURCES OF STRESS
There are many sources of stress, these are broadly classified as:
 Internal stressors: they originate within a person e.g.: cancer, feeling of depression.
 External stressors: it originates outside the individual e.g.: moving to another city, death in a
family.
 Developmental stressors: it occurs at predictable times throughout an individual‘s life. e.g.: child-
beginning of school.
 Situational stressors: they are unpredictable and occur at any time during life. It may be positive
or negative. e.g.: death of family member, marriage/ divorce.
INDICATORS OF STRESS
It may be physiological, psychological and cognitive:
 Physiological indicators: the physiological signs and symptoms of stress result from activation of
sympathetic and neuro- endocrine systems of body.
♥ Pupils dilate to increase visual perception
♥ Sweat production increases
♥ Heart rate and cardiac output increases
♥ Skin is pallid due to peripheral blood vessel constriction
♥ Mouth may be dry
♥ Urine output decreases
 Psychologic indicators: the manifestations: of stress includes anxiety, fear, anger, depression and
unconscious ego defense mechanism.
 ♥
Anxiety: state of mental uneasiness, apprehension, dread or feeling of helpless. It can be
experienced at conscious, subconscious or unconscious level.
♥ Fear: It is an emotion/ feeling of apprehension aroused by impending or seeming
danger, pain or threat.
♥ Depression: It is an extreme feeling of sadness, despair, lack of worth or emptiness.
♥ Unconscious ego defense mechanism: It is a psychologic adaptive mechanism developing
as the personality attempts to defend itself and allay inner tensions.
 Cognitive indicators:
♥ Problem solving: the person assesses the situation or problem analyzes, chose
alternatives, carries out selected alternatives and evaluates.
♥ Structuring: arrangement/ manipulation of a situation so that threatening events does not
occur.
♥ Self-control: assuming a manner and facial expression that conveys a sense of being in
control or in change.
♥ Suppression: willfully putting a thought or feeling out of mind.
♥ Day dreaming: unfulfilled wishes and desires are imagined as fulfilled or a threatening
experience is re worked or re played so that it ends differently from reality.
STRESS CYCLE

An event occurs of neutral value or

meaning

After a period of rest, the individual

The individual appraises whether
is able to prepare for and meet a
the event is a threat or a
new threat or challenge
challenge

Fatigue follows the depletion of Bio-chemicals are released to

bio-chemicals from the exertion enhance the ability of one’s
mind and body to respond

The bio-chemicals are depleted The individual responds to the

through the exertion to meet the threat or challenge through fight
threat or challenge or flight

PREPARED BY: ANOOP, CHETAN, DEEPAK, LINGARAJ, SARATH CHANDRAN, MITHUN

THEORIES OF STRESS

 SELYE’S GENERAL THEORY OF STRESS

During 1930‘s and 40‘s Sale performed the first extensive studies on stress responses. His
famous treatise ―the physiology and pathology of stress‖ describes his general theory of stress and
influenced stress research throughout the world. Sale defined stress as a physiological phenomenon.
Stress in biology is the nonspecific response of the body to any demand made upon it. It suffices
to keep in mind that by stress the physician means the common results of exposure to the any stimulus.
The bodily changes established when a person is exposed to nervous tension, physical injury, infection,
cold, heat, x-rays or anything are also called stress.
 HOLMES AND RAHE’S MODEL RELATING LIFE CHANGES TO ILLNESS
They studied on relationship between change and illness. Change is a form of stress requiring
both psychological and physical adaptations. Adapting to change consumes energy beyond that needed to
maintain a steady state of life.
They developed the Social Readjustment Rating Scale, a ranking of major life change units. They
explored the link between the amount of changes in a person‘s life and subsequent illness and discovered
that the higher a person‘s life change score, the greater the likelihood that an illness will subsequently
develop.
 LASARUS’S THEORY OF STRESS AND COPING
This theory emphasizes that cognitive appraisal is central in determining what is stressful and in
coping with stress. He also pointed out that one of the major problems in defining stress is that, emotions
have been treated as a cause of stress response rather than the effect of these responses. In the process of
coping, the individual shapes as well as responds to a demand or stress. Coping may change the stressful
experience and thus may influence what happens next.

STRESS MODELS
The adaptation of the concept of stress by the biological and behavioral sciences resulted in the
formulation of a number of models to describe stress and its effects. They are,
 STIMULUS BASED MODELS:
In this model, stress is defined as a stimulus, a life event or a set of circumstances that arouses
physiologic or psychologic reactions may increase the individual‘s vulnerability to illness. In this
model person is viewed as being constantly exposed to environmental stressors in their daily life, e.g.
the demand of work, family responsibilities, disablement or to more specific stressors such as smell
or poor lighting.
Here stress is a state that can generally be empirically observed, measured and evaluated and
which can potentially be removed or altered to reduce the individual stress.
 PSYCHOSOMATIC MODEL:
Stress is unique in the causation of diseases. It has not biological carrier such as germ or virus.
Rather it is the result of how mind and body function or interact. It is psychosomatic in the true sense
of word-psyche meaning ‗mind‘and soma ‗body‘. It is the disease created by the mind leading to
different illness. Person may suppress the anger and eventually develop the mental dysfunction of
depression. Emotional stress leads to physiological stress and results in psychosomatic illness.

 THE SYSTEM MODEL:

Stress response is here defined as carrying six components.
 Environmental stimuli- Some environmental stimuli activate stress response as a direct
consequence of their physical or biochemical properties. e.g... Caffeine, nicotine, and extreme
cold and heat.
 Cognitive-Affective domain- The individual‘s interpretation of the environment gives rise to
most of the stress reactions.
 Neurological triggering mechanisms- The limbic system and the hypothalamic nuclei are
the anatomical site for the integration of sensory cognitive, affective and visceral activity. It is
the basis for a host of psychiatric and psycho physiological disorders.
 The physiological stress response axis- Stress response occurs sequentially along the
neurological, neuro endocrine and endocrine axes and results in neural and hormonal activity
directed at target organs.
 Coping- In this final phase of stress response, the individual attempts to reduce their level of
arousal by manipulating the environment or making cognitive adjustment.
 Target organ effects- If coping are unsuccessful and arousal is either excessive or
prolonged, the physiological process of stress response is likely to lead to target organ
dysfunction or disease.

 TRANSACTION BASED MODEL:

It is based on the works of Lazarus (1966) who states that stimulus theory and response
theory do not consider individual differences. It encompasses a set of cognitive, affective and
adaptive responses that arises out of person environment transactions. As the person and environment
are inseparable, each affects and is affected by other. There are moderating factors such as one‘s
copying behavior and cognitive appraisal. Effective preventive and health promotion strategies can be
planned based on this model.

 RESPONSE BASED MODEL:

In this model the word stress is used to describe the experience of a person who feels they are in a
threatening or difficult situation. Stress is thus a person‘s response to threat as in the stimulus based
model, is not necessarily inherent in the environment or situation. By using the response based model,
it is possible to make sense of an individual‘s unique stress response and even of responses that might
seem, within the stimulus based model, to be irrational, such as birds, spiders or flying. It consists of
mainly 2 responses,
 1) Local adaptation syndrome: It is a localized response of body to stress and it involves only
specific body part (tissues, organs) instead of the whole body. It may be traumatic or pathologic. e.g.:
inflammatory responses of a body part in response to a trauma or injury. It is a short term adaptive
response which primarily is homeostatic. 2 most common stress responses that influence nursing care
are reflex pain response and the inflammatory response

 Reflex pain response:

It is the response of central nervous system to pain. It is rapid, automatic and serves as a
protective mechanism to prevent injury. e.g.: if you are about to step into a bath tub filled with
dangerous hot water, skin senses the heat and immediately sends a message to the spinal cord. A
message is then sent to motor nerve, which consciously realize that the water is too hot not safe.
 Inflammatory response:
It is a local response to injury or infection. It helps to localize and prevent the spread of
infection and promote wound healing. There are 3 phases:
 First phase: vasoconstriction occurs to control bleeding initially. Histamines are realized
and capillary permeability increases resulting in increased blood flow to the area. Then
the blood flow returns to normal but remain to help resist the infection.
 Second phase: exudates (made up of fluids, cells and inflammatory by products) are
realized from the wound. The amount of exudates depends up on the site, severity of
wound.
 Third phase: damaged cells are repaired by regeneration (replacement with identical
cells) or formation of scar tissue.
2) General adaptation syndrome: It describes body‘s general response to stress. It consists of 3 stages
 The alarm reaction: it is initiated when a person perceives a specific stressor, various
defense mechanisms are activated. The autonomic nervous system initiates the fight or
flight response preparing the body to either fight off the stressor or to run away from it.
 Resistance: the body attempts to adapt to stressor, after perceiving the threat. Vital signs
and hormone levels return to normal. If the stress can be managed or confirmed to small
area the body regains homeostasis.
 Exhaustion: it results when the adaptive mechanism are exhausted. Without defense
against the stressor, the body either rest or mobilize its defense to return to normal or
reach total exhaustion and die.
 STRESS ADAPTATION MODEL:
The model was given by Gail Stuart so it is called Stuart stress adaptation model. It integrates
biological, socio-cultural, psychological, and environmental and legal- ethical aspects of patient care
into a unified frame work for practice.
 The first assumption of Stuart stress adaptation model is the nature is ordered as a society
hierarchy from the simplest unit to the most complex. Each level is a part next higher level,
so nothing exists in isolation. Thus individual is a part of family, group, community, society
and the large biosphere, through which material and information flows across various levels.

BIOSPHERE

SOCIETY

COMMUNITY

GROUP

FAMILY

INDIVIDUAL

BODY SYSTEM

ORGAN

TISSUE

CELL
 Second assumption of the model is that nursing care is provided within a biological,
psychological, socio-cultural, and environmental and legal- ethical context. The nurse must
understand each of them to provide holistic nursing care.

 Third assumption of the model is that health/ illness and adaptation / maladaptation are 2
distinct continuums: The health/illness continuum comes from a medical world view, the
adaptation/ maladaptation continuum comes from a nursing world view. This means that a
person with a medically diagnosed illness may be adapting well to
 It. In contrast a person without a medical illness may have adaptive coping resources.

 Fourth assumption is that the model includes the primary, secondary, and tertiary levels of
prevention by describing four stages of psychiatric treatment: crisis, acute, maintenance and
health promotion. For each stage of treatment, the model suggests a treatment goal, a focus of
nursing assessment, nature of interventions and expected outcomes of nursing care.

 Fifth assumption is based on the use of nursing process and standards of care professional
performance. Each step of the process is important and it is a local response to injury or
infection. It helps to localize and prevent the spread of infection and promote wound healing.

TECHNIQUES OF STRESS MANAGEMENT

Stress management involves controlling and reducing the tension that occurs in stressful
situations by making emotional and physical changes. The degree of stress and the desire to make the
changes will determine how much change takes place. Some of the techniques of stress management are:
Laughter
Adopting a humorous view towards life`s situations can take the edge off everyday stressors. Not
being too serious or in a constant alert mode helps maintain the equanimity of mind and promote clear
thinking. Being able to laugh stress away is the smartest way to ward off its effects.
Benefits of laughter:
 Laughter lowers blood pressure and reduces hypertension.
 It provides good cardiac conditioning especially for those who are unable to perform physical
exercise.
 Reduces stress hormones (studies shows, laughter induces reduction of at least four of
neuroendocrine hormones—pinup shrine, cortisol, dopamine and growth hormone, associated
with stress response).
 Boosts immune function by raising levels of infection-fighting T-cells, disease-fighting proteins
called Gamma-interferon and disease-destroying antibodies called B-cells.
 Laughter triggers the release of endorphins—body`s natural painkillers.
 Produces a general sense of well-being.
 AUTOGENIC TRAINING:
It is a relaxation technique developed by the German psychiatrist Johannes Heinrich Schultz and
first published in 1932. The technique involves the daily practice of sessions that last around 15 minutes,
usually in the morning, at lunch time, and in the evening. During each session, the practitioner will repeat
a set of visualizations that induce a state of relaxation. Each session can be practiced in a position chosen
amongst a set of recommended postures (for e.g.: lying down, sitting meditation). The technique can be
used to alleviate many stress-induced psychosomatic disorders. E.g. of an autogenic training session are:
♣ Sit in the meditative posture and scan the body
♣ "my right arm is heavy"
♣ "my arms and legs are heavy and warm" (repeat 3 or more times)
♣ "my heartbeat is calm and regular" (repeat 3 times)
♣ "my forehead is cool"
♣ "my neck and shoulders are heavy" (repeat 3 times)
♣ "I am at peace" (repeat 3 times)
Effects of autogenic training:
Autogenic Training restores the balance between the activity of the sympathetic (flight or fight)
and the parasympathetic (rest and digest) branches of the autonomic nervous system. This has
important health benefits, as the parasympathetic activity promotes digestion and bowel movements,
lowers the blood pressure, slows the heart rate, and promotes the functions of the immune system.
GETTING A HOBBY:
Hobby is an activity or interest that is undertaken for pleasure or relaxation, typically done during
one's leisure time.eg: collecting, games, outdoor recreation, gardening, performing the arts, reading,
cooking and etc.
MEDITATION:
Meditation is a holistic discipline during which time the practitioner trains his or her mind in
order to realize some benefit. Meditation is generally a subjective, personal experience and most often
done without any external involvement, except perhaps prayer beads to count prayers. Meditation often
involves invoking and cultivating a feeling or internal state, such as compassion, or attending to some
focal point, etc. The term can refer to the process of reaching this state, as well as to the state itself.
DEEP BREATHING:
Diaphragmatic breathing, abdominal breathing, belly breathing, deep breathing or costal
breathing is the act of breathing deep into one's lungs by flexing one's diaphragm rather than breathing
shallowly by flexing one's rib cage. This deep breathing is marked by expansion of the
Abdomen rather than the chest when breathing. It is generally considered a healthier and fuller way to
ingest oxygen and is often used as a therapy for hyperventilation and anxiety disorders.
A common diaphragmatic breathing exercise is as follows:
1. Sit or lie comfortably, with loose garments.
2. Put one hand on your chest and one on your stomach.
3. Slowly inhale through your nose or through pursed lips (to slow down the intake of breath).
4. As you inhale, feel your stomach expand with your hand.
5. Slowly exhale through pursed lips to regulate the release of air.
6. Rest and repeat.
Another diaphragmatic breathing exercise for raising oxygen levels in the blood and energy in the
body is to take several negative breaths, immediately followed by an equal number of positive breaths.
 During negative breaths, one inhales, immediately exhales and then holds one's breathe for a
short time. The emphasis is on keeping one's lungs empty. Negative breaths reduce the amount of
oxygen in one's blood.

 During positive breaths, one inhales, holds one's breath, and then exhales. The emphasis is in
keeping one's lungs full of air. Positive breaths increase the oxygen in one's blood. Although not
always taught, continuing to breathe into the chest at the same time can provide an ever more
"fulfilling" exercise. The goal is to have the entire torso move in & out when breathing, as if one
is surrounded by an expanding and contracting inner tube.

YOGA NIDRA
Yoga-indri may be rendered in English as "yoga sleep". It is a sleep-like state that occurs with
some practitioners of meditation, details of which have been handed down by guru-to- disciple
transmission (parampara) within the Indian religions. These aspects may include relaxation and guided
visualization techniques as well as the psychology of dream, sleep and yoga. Yoga-nidra should not be
confused with hypnotic states, known as "yoga tandra". The practice of yoga relaxation has been found to
reduce tension and anxiety. The autonomic symptoms of high anxiety such as headache, giddiness, chest
pain, palpitations, and sweating, abdominal pain respond well.

NOOTROPICS
Nootropics also referred to as smart drugs, memory enhancers, and cognitive enhancers, are
drugs, supplements, nutraceuticals, and functional foods that are purported to improve mental functions
such as cognition, memory, intelligence, motivation, attention, and concentration.
Nootropics are thought to work by altering the availability of the brain's supply of neurochemicals
(neurotransmitters, enzymes, and hormones), by improving the brain's oxygen supply, or by stimulating
nerve growth. However the efficacy of nootropic substances, in most cases, has not been conclusively
determined.
RELAXATION TECHNIQUES:
Relaxation technique (also known as relaxation training) is any method, process, procedure, or
activity that helps a person to relax; to attain a state of increased calmness; or otherwise reduce levels of
anxiety, stress or anger. Relaxation techniques are often employed as one element of a wider stress
management program and can decrease muscle tension, lower the blood pressure and slow heart and
breathe rates, among other health benefits.
FRACTIONAL RELAXATION:
Fractional relaxation is a method of releasing muscular tension in one small part of the body at a
time, such as relaxing one finger, then relaxing another, then adding another... Then the whole hand is
relaxed, followed by the forearm, and then the upper arm... The other arm is relaxed next, starting with a
finger... Then the legs (each starting with a toe)... and so on, including all body parts (including all the
parts of the head) until the entire body is relaxed. The fractional relaxation approach is often used in
preparation for trance induction and hypnosis, but is very useful as a relaxation technique by itself. The
theory behind this tension release method is that it is easier to relax a fraction of the body than it is to
relax the whole body all at once.
„ABC‟ OF STRESS MANAGEMENT

Always take time for yourself at least 30 min/ day.

Be aware of your own stress meter; know when to step back and cool down. Concentrate on
controlling your own situation, without controlling everybody else. Daily exercise will burn
off the stress chemicals.
Eat lots of fresh fruit, veggies, bread and water; give your body the best for it to perform at its
best.
Forgive others, do not hold grudges and be tolerant; not everyone is capable as you.
Gain perspective on things, how important is the issue?
Hugs, kisses and laughter; have fun and don‘t be afraid to share your feelings with others.
Identify stressors and plan to deal with them better next time.
Judge your own performance realistically; don‘t set goals out of your own reach.
Keep a positive attitude, your outlook will influence outcomes and the way others treat you.
Limit alcohol, drugs and other stimulants, they affect your perception and behavior.
Manage money well, seek advice and save at least 10% of what you earn.
No is a word you need to learn to use without feeling guilty.
Outdoor activities by yourself, or with friends and families, can be a great way to relax.
Play your favorite music rather than watching TV.
Quit smoking; it is stressing your body daily, not to mention killing you too.
Relationships; nurture and enjoy them, learn to listen more and talk less.
Sleep well, with firm mattress and supportive pillow; don‘t over heat
yourself and allow plenty of ventilation.
Treat yourself once a week with a massage, dinner out and the movies.
Understand things from the other person point of view.
Verify information from the source before exploding.
Worry less, it really doesn‘t get things completed better or quicker.
Xpress; make a regular retreat to your favorite space, make holidays part
of your yearly plan and budget.
Yearly goal setting; plan what you want to achieve based on your
priorities in your career, relationships etc.
Zest for life; each day is a gift, smile and be thankful that you‘re the part
of the bigger picture.