Emergency Nursing ● By definition, emergency care is care that must be rendered

(Chapter 71 in Brunner and Suddarth 12th edition) without delay.

Emergency Nursing ● In an emergency department, several patients with diverse
● Is one of the most challenging specialties in nursing. It health problems, some life threatening, some not; may
requires nurses to manage ambiguity and rapid changes in present to the ED simultaneously.
pace and intensity of work, and to have knowledge of a
significant number of clinical presentations, disease, and Triage
conditions. ● From the french word trier meaning “to sort”.
● In the daily routine of the emergency department, triage is
Emergency Management used to sort patients into groups based on the severity of
● Emergency management traditionally refers to care given to their health problems and the immediacy with which these
patients with urgent and critical needs. problems must be treated.
● However, because many people lack access to health care, ● The term triage may have originated during the Napoleonic
the emergency department (ED) is increasingly used for non- wars from the work of Dominique Jean Larrey.
urgent problems, therefore, the philosophy of emergency ● The term was used further during World War 1 by French
management has broadened to include the concept that an doctors treating the battlefield wounded at the aid stations
emergency is whatever the patient or the family considers it behind the front.
to be. ● Those responsible for the removal of the wounded from the
● Care that must be rendered without delay. battlefield or their care afterwards would divide the victims
● The strengths and roles of nursing and medicine are into 3 categories:
complementary in an emergency situation. ○ Those who are likely to live regardless of what care
○ Appropriate nursing and medical interventions are they receive.
anticipated based on assessment data. ○ Those who are unlikely to live regardless of what
● Members of the emergency health care staff work as a team care they receive.
in performing the highly technical, hands-on skills required ○ Those for whom immediate care might make a
to care for patients in emergency situations (Emergency positive difference in outcomes.
Nurses Association, 2013).
Triage Objectives
Emergency Nurse ● Ensure early recognition, assessment of patient’s condition,
● Expert in assessing and identifying patients’ health care and prioritization of treatment according to severity of the
problems in crisis situations. conditions.
● Has had specialized education, training, experience, and ● Reduce unnecessary delay of treatment.
expertise in assessing and identifying patients’ health care ● Give brief first aid advice.
problems in crisis situations. ● Initiate immediate diagnostic tests, intervention, and nursing
● In addition, the emergency nurse establishes priorities, treatment.
monitors and continuously assesses patients who are acutely ● Allow effective utilization of staff and resources by allocating
ill and injured. patients to appropriate treatment areas according to their
● They also support and attend to families, supervise allied conditions.
health personnel, and educate patients and families within a ● Relieve congestion and confusion by controlling and
time limited, high pressure care environment. improving patient flow.
● Nursing interventions are accomplished interdependently, in ● Improve patient staff relationships and departmental image
consultation with or under the direction of a physician or through greeting and communication during the process of
advanced practitioner, such as a nurse practitioner or triage.
physician assistant. ● Promote public relationship by immediate interview with
patient.
Seek emergency care for: ● Enable direct communication with pre-hospital care
Large numbers of people seek emergency care for serious, life providers.
threatening conditions such as: ● Provide documentation: patient’s condition, time of triage,
● Cardiac dysrhythmias and preliminary treatment given in triage.
● Acute coronary syndrome ● To provide staff training and decision making.
● Acute heart failure
● Pulmonary edema Basic Triage System (Berner, 2005)
● Stroke A basic and widely used triage system that has been in use for many
years, has 3 categories:
Issues in Emergency Nursing Care ● Emergent
● Documentation of consent and privacy. ● Urgent
● Limiting exposure to health risks. ● Non-urgent
● Violence in the emergency department.
● Providing holistic care. 1. Emergent
● Highest priority.
Emergency nursing is demanding because of the diversity of ● Life threatening conditions.
conditions and situations that present unique challenges. These ● Must be seen immediately.
challenges may include: 2. Urgent
● Legal issues ● Serious health problems but not immediately life-
● Occupational health and safety risks threatening.
● Must be seen within 1 hour.
ED staff have the challenge of providing holistic care in the
context of fast paced, technology driven environments in which 3. Non-urgent
serious illness and death are encountered on a daily basis. ● Episodic illnesses that can be addressed within 24 hours
without increased morbidity.
Nursing in Disasters
● Another filed in emergency nursing. Comprehensive Triage System: 5 Level System
● With the increasing use of weapons and terror, and mass A more refined, comprehensive triage system which
destruction, both internationally and at home, the recognizes that EDs are used for both emergency and routine health
emergency nurse must recognize and treat patients exposed care. This system has 5 levels:
to biologicl and other weapons, anticipating nursing care in 1. Resuscitation
the event of a mass casualty incident, from natural causes or 1. Emergent
terrorist event. 2. Urgent
3. Nonurgent
Principles of Emergency Care 4. Minor
● Triage
● Assess and intervene
 ● The increased number of triage levels assist the triage nurse
to more precisely determine the needs of the patient and
the urgency for treatment.
● This 5 level triage system is currently used throughout the
world (US, Aus, UK, Canada).
1. Resuscitation
● Need treatment immediately to prevent death.
2. Emergent
● Patients may deteriorate rapidly and develop a major, life
threatening situation.
● Require time sensitive treatment.
3. Urgent
● Patients have non-life threatening conditions but require
two or more resources to provide their care.
● If these patient’s vital signs deviate significantly from their
baseline, they may require up triaging to the emergent
category.
4. Nonurgent
● Patients have non-life threatening conditions and likely need
only one resource to provide for their needs.
5. Minor
● Have no life threatening conditions and likely require no
resources to provide for their evaluation and management.
Resources
● Include imaging studies, IV/IM medications, invasive
procedures.
● Insertion of an indwelling catheter is an example of a one
resource procedure.
● Use of moderate sedation is a two resource procedure
because it requires frequent monitoring and IV medications.
Triage
● An advanced skill where emergency nurses are spending
many hours learning to classify different illnesses and
injuries to ensure that patients most in need of care do not
needlessly wait.
● Protocols may be followed to initiate laboratory or x-ray
studies.
● While the patient is in the triage area, collaborative
protocols are developed and used by the triage nurse based
on his or her level of experience.
Emergency department vs Disaster triage
● Routine Triage: directs all available resources to the patients
who are most critically ill regardless of potential outcome.
● Field Triage: scarce resources must be used to benefit the
most people possible.
Assess and Intervene
● Second principle of emergency care.
● Priorities of emergency care includes Priorities of Emergency
Care: stabilization, provision of critical treatments, and
prompt Transfer to the appropriate setting to the ward,
private room, ICU, or OR.
Simple Triage and Rapid Treatment (START)
● For start triage: expectant who are beyond help, injured who
can be helped by immediate transportation, the injured
who’s transport can be delayed, and those with minor
injuries who need help less urgently.
● Can be performed by lightly trained lay and emergency
personnel in emergencies but not intended to supersede or
instruct medical personnel or techniques.
Algorithm for START Triage
1. Quick assessment: essential for patient’s survival.
2. Treat victim: may call bystanders to assist you in giving initial
care.
3. When you have the color, tag patient, and move on.
1. Green (priority #3) : The patient is having injuries which are minor
and treatment can be delayed hours to days.
● Extremity fractures, minor burns, sprains, smaller serrations
without significant bleeding, behavioral or psychological
disorders.
2. Black or deceased: injuries are extensive and chances of survival are
unlikely even with definitive care.
● The victim is unresponsive with penetrating head wounds,
high spinal cord injury, wounds involving multiple
anatomical sites and organs, 2nd or 3rd degree burns in
excess of 60% of total body surface area, seizures and
vomiting within 24 hours after radiation exposure, profound
shock, fix dilated pupils.
2. Red or immediate: a patient having injury which are life-threatening
but survivable with minimal intervention
4. Sucking chest wound, airway obstruction secondary to
mechanical use, shock, hemothorax, asphyxia, unstable
chest and abdominal wounds, incomplete amputation, open
fractures of long bones, 2nd or 3rd degree burns of 15-40%
total body surface area.
4. Yellow or delayed (priority #2): victims may have injuries which are
significant and require medical care but can wait hours without threat
to life or limb.
● Stable wounds without evidence of significant hemorrhage,
soft tissue injury, fracture requiring orif debridement, most
eye minor injuries.
Military Triage
1. Naval combat situation
● Triage officer must weigh the tactical situation with supplies
on hand and the realistic capacity of the medical personnel,
● Ever-changing. dependent upon the situation.
● Must attempt to do the maximum good for maximum
number of casualties.
2. United States Military Triage
● Class I: Patients who require minor treatment and can return
to duty in a short period of time.
● Class II: Patients whose injuries require immediate life
sustaining measures.
● Class III: Patients for whom definitive treatment can be
delayed without loss of life or limb.
● Class IV: Patients requiring such extensive care beyond
medical personnel capability and time.
In-Hospital Triage
1. Black/Expectant
● Patients who are severely injured that will die of their
injuries possibly in hours or days.
● Include: large area burns, severe trauma, lethal radiation
dose, or in a life-threatening medical crisis.
● Unlikely to survive given the care available such as cardiac
arrest, septic shock, severe head or chest wounds.
2. Red/Immediate
● Require immediate surgery or other life-saving intervention.
● Have first priority for surgical teams or transport to
advanced facilities.
● Cannot wait but are likely to survive with immediate
treatment.
3. Yellow/Observation
● Condition that is stable for the moment but requires
watching by trained persons and frequent re-triage.
● Need hospital care and would receive immediate priority
care under normal circumstances.
4. Green/Wait (walking wounded)
● Require a doctor’s care in several hours or days.
● May wait for a number of hours or be told to go home and
come back the next day.
● May include: broken bones without compound fractures,
many soft tissue injuries.
5. White/Dismiss (walking wounded)
● Have minor injuries.
● First aid and home care are sufficient and doctor’s care is not
required.
● Injuries are along cuts, scrapes, or minor burns.
Psychological Considerations
Approach to Family
○ Understand & accept the basic anxieties of the acutely ill or
traumatized patients.
 ○ Understand and support the patient’s feelings concerning
loss of control.
○ Treat the unconscious patient as if conscious (explain what
you are doing before administering intervention).
○ Be prepared to handle all aspects of acute illness and
trauma.
○ Allow the family to relive the events, actions, and feelings in
proceeding admission to the emergency department.
○ Deal with reality as gently as quickly as possible.
○ Assist family to cope with sudden and unexpected death.
○ Encourage emergency department staff to discuss amongst
themselves their reaction to the event to share intense
feelings for review and support.
Environmental Emergencies: Other Emergencies
A. Poison
★ Poison is any substance that when ingested, inhaled,
absorbed, applied to the skin, or produced within the body in
relatively small amounts injures the body by its chemical
action.
● Poisoning from inhalation and ingestion of toxic materials,
both intentional and unintentional, constitutes a major
health hazard and an emergency situation.
● Toxicology - study of harmful effects of various substances
on the body so even drugs when taking excess it can cause
non therapeutic result.
● Even drugs when taken in excess, can cause non-therapeutic
results.
Types of Ingested Poisons:
1. Ingested Poison: Food Poisoning
★ A sudden illness due to the ingestion of contaminated food
or drink.
★ Food poisoning, such as botulism or fish poisoning, may
result in respiratory paralysis and death
● Botulism, a serious form of food poisoning, requires
continual surveillance.
● The key to treatment is determining the source and type of
food poisoning. If possible, the suspected food be brought to
the medical facility and a history obtained from the patient
and family.
2. Ingested Poison: Corrosive Poisons
★ Corrosive poisons include ALKALINE and ACID that cause
tissue destruction after coming into contact with mucous
membranes.
● Swallowed poisons may be corrosive-may produce
immediate or delayed effects; can be accidental or
intentional.
● Alkaline examples- lye, potassium carbonate, drain cleaners,
toilet bowl cleaners, bleach, non-phosphate detergents, and
button batteries.
● Acid examples- toilet bowl cleaners, pool cleaners, rust
remover, and battery acid.
Treatment Goals for Poisoning
a. Remove or inactivate the poison before it is absorbed.
b. Provide supportive care in maintaining vital organ systems.
c. Administer specific antidotes to neutralize specific poison.
d. Implement treatment to hasten the elimination of the
poison.
Assessment for Poisoning
1. Use ABCs (Airway, Breathing, Circulation)
● Control of airway and ventilations are essential.
● If it’s cerebral or renal damage, the patient’s prognosis
depends on its management of ABC.
2. Monitor VS (vital signs), LOC (level of consciousness), ECG
(electrocardiogram), and urine output.
○ For the measures to stabilize the cardiovascular
functions, shock may result from cardiodepressant
action of the substance from venous pulling or
reduce circulating volume from increased capillary
permeability; Thus, you monitor the urine output.
You can insert a foley bag catheter (FBC).
3. Assess laboratory specimens
4. Determine what, when, and how much substance was ingested.
● Determine the concentration of the poison, details of the
event, identify the poison.
5. Assess signs and symptoms of poisoning and tissue damage.
● Pain and burning sensation
● redness or burns in the mouth or throat
● dysphagia, vomiting, and drooling
6. Assess health history and Determine age and weight.
7. Measures to remove the toxin or decrease its absorption.
● Patient is given water or milk to drink for dilution (not
indicated if with acute airway edema or obstruction, or
evidence of esophageal, gastric, or intestinal burns or
perforation.
● Use of emetics: Syrup of Ipecac - to induce vomiting if
patient is alert, but never with corrosive poisons.
● Gastric lavage - for obtunded patients, gastric aspirate is safe
and sent for toxicology.
● Activated charcoal - if poison is absorbed by charcoal on the
surface of its particles, and allowed to pass with stool.
● Cathartic when appropriate - an antagonist to reverse the
effects of toxin.
● Administration of specific antidotes.
● Other measures may include diuresis, dialysis, or
hemoperfusion - hemoperfusion is similar to dialysis but the
cartridge contains charcoal (monitor vital signs, fluid-
electrolyte balance, high potential and cardiac dysrhythmias,
seizures are possible).
Nursing Alert for Poisoning
1. The Local Poison Center
★ Should be called if an unknown toxic agent has been taken
or if it is necessary to identify an antidote for a known toxic
agent.
● Cagayan de Oro: Northern Mindanao Medical Center
(NMMC) is our local poison center. Other medical facilities
are probably still in the process of having their own poison
centers (same with the animal bite center) because its
establishment is part of the requirements of the Department
of Health.
2. Vomiting is NEVER induced after ingestion of caustic substances
(acid or alkaline) or petroleum distillates.
Inhaled Poison: Carbon Monoxide Poisoning
● Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin, which does not transport oxygen.
● Manifestations: CNS symptoms predominate
○ Headache, muscular weakness, palpitation,
dizziness, confusion.
○ The symptoms can progress to coma.
● Result of industrial or household incidents or attempted
suicide.
● Implicated in more deaths than any other toxin except
alcohol.
● Incomplete hydrocarbon combustion.
● The cerebral blood flow need of oxygen- cerebral hypoxia.
Oxygen saturation is not valid because hemoglobin is well
saturated with carbon monoxide, not oxygen.
● A pale skin color is not a reliable sign.
Management of Carbon Monoxide Poisoning
1. Get to fresh air immediately - open all doors and windows;
loosen all tight clothing.
2. Perform CPR as necessary or if required.
3. Administer oxygen: 100% or oxygen under hyperbaric
pressure - this is to reverse the carboxyhemoglobin; reverse
hypoxia and eliminate the carbon monoxide; watch out for
permanent brain damage.
4. Monitor patient continuously - to prevent chilling, wrap
patients with blankets; keep the patient quiet as possible
and do not give alcohol or permit patients to smoke.
5. Psychiatric consult if due to suicide attempt.
Skin Contamination Poison: Chemical Burns
● Skin contamination poisoning- injuries from exposure to
chemicals.
● Severity of the injury depends upon the mechanism of action
of the substance, the penetrating strength and
concentration, and the amount of skin exposed to the agent.
 ● May be challenging because of the large possible variations
of offending agents with diverse actions and metabolic
effects.
Management of Chemical Burns
1. Determine the Substance
● if lye or white phosphorus, it must be brushed off the skin
dry to prevent explosion or deepening of the burn.
2. Immediately flush the skin with running water
● Flush from a shower hose or faucet
● Clothing is removed
● Prolonged lavage may be done
3.Protect health care personnel from substance
● Especially if burn if extensive or if the agent is toxic and still
present
4. Standard burn treatment (antimicrobial agent, debridement,
tetanus prophylaxis)
● Those appropriate for the chemical burn size and location
must be considered
5. May require plastic surgery
● This is for further wound management
6. Follow-up care includes reexamination of the area at 24 hours, 72
hours, and 7 days
● Reexamining is necessary due to the risk of underestimating
the extent and depth of injury
Nursing Alert for Chemical Burns
1. H2O should NOT be applied to burns from lye or white phosphorus
● Application may cause EXPLOSION or Deepening of burn.
2. All evidence of these chemicals should be brushed off the patient
before flushing occurs.
● Skin is drenched immediately with running water
B. Wound
● Injury to the Soft Tissues may involve skin and underlying
subcutaneous tissues and muscles.
● Primary Goal: to restore the physical integrity and function
of the injured tissue, with minimal scarring and without
infection. (+ to control severe bleeding).
● Proper Documentation - documentation of the
characteristics of the wound is essential and may be needed
for future forensic evidence.
○ Precise descriptions
○ Correct terminology
○ Photographs (if possible) - provide accurate visible
depiction of wound important for exigent wounds
(wounds that would eventually heal).
● Wounds involving injury to soft tissues can vary from minor
tears to severe crushing injuries.
● May be classified as:
○ Closed - without break in the skin; examples are
ecchymosis, hematoma
○ Open - break in the skin happens
Types of Wound
The difference between the two (puncture and penetration) is the
severity or the depth of penetration.
1. Stab
● incision of the skin with well-defined edges, usually caused
by a sharp instrument; a stab wound is typically deeper than
long.
2. Cut
● incision of the skin with well-defined edges, usually longer
than deep.
3. Punctured
● Pointed object can be penetrating only or with perforating.
● Generally do not cause serious external bleeding but there
may be significant internal bleeding and damage to vital
organs for stab.
4. Amputation
● Traumatic cutting or tearing of a finger, toe, arm, or leg.
Assessment of Wound
● When and How the wound occurred -essential because a
treatment delay exceeding 3 hours increases infection risk.
● Extent of damage to underlying structures -using aseptic
technique, the clinician inspects the wound for foreign body.
● Sensory, Motor, and Vascular function changes - might
indicate complications.
● Primary assessment - if bleeding is significant, assess for
shock; inverted triangle; restlessness; skin pale, cold, and
diaphoretic.
● Assessing for arterial or venous bleeding.
1. Arterial Bleeding
○ Spurting blood
○ Pulsating flow
○ Bright red color
2. Venous Bleeding
○ Steady, slow flow
○ Dark red color
3. Capillary Bleeding
○ Slow, even flow
Wound Cleansing
1. Hair around the wound - clipped or shaved
● It is anticipated that hair will interfere with wound closure.
● Head, eyebrows are never shaved.
2. Clean area around the wound with NSS or Polymer agent (Shur-
Clens)
● 50 mL or cc per inch
● If grossly contaminated, wound may need to be cleaned with
surgical scrub (may anesthetize first).
3. Antibacterial agents: Povidone- Iodine or Hydrogen Peroxide
● Not allowed to get deep into wound without thorough
rinsing.
● Use only for initial cleansing because it may injure exposed
and healthy tissue resulting in further injury.
4. Assist with cleaning and debriding the wound
5. Hemostasis: clamped or cauterized
● Anesthetics may be used if indicated.
+ Additional Information:
● Gently irrigate copiously with isotonic solution to remove
dirt.
● Devitalized tissue and foreign matters are removed because
they impede healing and encourage infection.
● The dressing may serve as a splint and also as a reminder to
the patient that the area is injured.
Primary Closure
● Wound is sutured or stapled by the physician and would
depend on:
○ Nature of the wound
○ Time since the injury was sustained
○ Degree of contamination
○ Vascularity of tissues
● Repair without delay yields the fastest healing.
● Wound closure begins when subcutaneous fat is brought
together loosely with a few sutures to close off the dead
space, then subcuticular layer, then epidermis.
● Sutures are placed near the wound edge with the skin edges
level to promote optimal healing and easy removal.
● Then sterile strips of reinforced microporous tape or a
bonding agent may be used to close clean superficial
wounds.
Delayed Primary Closure
● Indicated if tissue has been lost or there is a high potential
for infection.
● Granulate on its own without surgical closure (this is the
secondary intent).
● Steps:
 ○ Thin layer of gauze covered by an occlusive
dressing - to ensure drainage and prevent pulling
of exudate.
○ Split-thickness cadaver or porcine xenografts - to
stimulate the function of epithelium.
○ The wound is splinted in a functional position - to
prevent motion and decrease the possibility of
contractures.
● Wound may be sutured if there are no signs of suppuration.
● Antibiotics - to prevent infection
● The site is immobilized and elevated - to limit the
accumulation of fluid to the interstitial spaces of the wound
(posterior mold).
● Tetanus prophylaxis - given if the last tetanus toxoid is more
than 5 years ago or immunization is unknown.
● Health teaching about signs and symptoms of infection:
○ Sudden persistent pain
○ Fever or chills
○ Bleeding
○ Rapid swelling
○ Foul odor
○ Drainage
○ Redness surrounding the wound
○ Discuss how pain subsides within 24 hrs
Management
1. Direct Pressure
● Controls external bleeding.
● Cover with sterile dressing & apply direct pressure.
● If dressing is soaked, reinforce px to not to remove.
● Pressure bandage may be applied then assess for pulse distal
to dressing.
2. Elevation
● Controls bleeding
● Do not raise limb if function is suspected
● Elevate after treatment for the first 48 hrs
a. Always remember that we have to consider our
own safety.
D. Alcohol Intoxication
● A multisystem toxin and CNS depressant causes drowsiness,
impaired coordination, slurring of speech, sudden mood
changes, aggression, belligerence, grandiosity, uninhibited
behavior and even death.
● Alcohol is a psychotropic drug that affects mood, judgment,
behavior, concentration, and level of consciousness.
● Many drinkers are young adults.
● Prevalence is high, returning frequently to the emergency
department and frustrates the teen.
● Management requires patience and thoughtful accurate long
term treatment.
Treatment Goal:
● Maintain airway and observe for CNS depression and
hypotension.
○ Breathing pattern, rest, keep warm with blanket.
● Rule out other potential causes of behaviors.
○ Assess for hypoglycemia, hypovolemia, or other
neurologic problems.
● Use a nonjudgmental, calm manner.
○ Firm, consistent, accepting, and reasonable
attitude.
○ Alcohol interferes with the thought process.
● Patient may need sedation if noisy or belligerent.
○ Monitor for signs of hypotension and decreasing
LOC.
● Examine for withdrawal delirium, injuries, and evidence of
other disorders.
○ May cause trauma to non-alcoholic people.
○ Pulmonary infection is also common.
● Hospitalized to a detoxification center, recovery and
rehabilitation.

3. Pressure points
● Used when direct pressure and elevation can’t control E. Violence, Abuse, and Neglect
bleeding. ● Domestic violence is the leading cause of death in young,
● Used if the wound is due to a protruding bone or embedded african american women.
object. ● Young women are likely to suffer non-lethal violent acts that
result in a visit to emergency departments.
4. Expose the wound ● Men and people with disabilities are also victims of domestic
● Remove clothing if necessary violence and abuse.
● Do not remove any impaled objects ● Older abuse take many forms of physical and psychological
abuse, neglect, violation of rights, and financial abuse.
5. Assess for concomitant injuries ● Emergency Departments are often the first place where
6. Assess for vascular status victims of family violence, abuse or neglect go to seek help.
7. Perform Neurological Assessment ● 25% of all women will be in domestic violence sometimes
during their life.
Management: Drug Overdose ● 1-2 million elders are abused and neglected annually.
● Clinical manifestations vary with substance
● Treatment goals: Clinical Manifestations
○ Support respiratory and cardiovascular function. ● They may present with physical injuries.
○ Enhance clearance of the agent. ● Health problems: anxiety, insomnia and GIT symptoms
○ Provide safety of patients and staff. related to stress.
● IV drug users at high risk for: HIV infection, Hep B and C, ● They usually do not identify their abuser.
tetanus. ● A multiple injuries that are in various stages of healing and
an the explained explanation does not fit the picture.
C. Substance Abuse ● Neglect should be investigated whenever a dependent
● Misuse of specific substances to alter mood or behavior e.g. person with adequate resources and the designated care
drugs and alcohol. provider shows evidence of inattention to hygiene, nutrition,
● Drug abuse if it is used other than legitimate medical or to known medical needs.
purposes. ○ Malnutrition
● People who abuse IV drugs are at increased risk. ○ dehydration
● Manifestations vary with substance use but the underlying
principles are essentially the same. Assessment
Ideal position to provide early detection and intervention for victims
Rave Parties requires awareness of the signs and symptoms. The nurse must be
● Large scale parties attended by teenagers involved in drug skilled in interviewing techniques to elicit information.
use. ● I noticed that you have a number of bruises. Can you tell me
● Multidrug or ecstasy produces harmless high, may be even how they happened? Has anyone hurt you?
combined with viagra. ● You seem frightened. Has anyone ever hurt you?
○ Sildenafil (Viagra) - inc. risk for blood borne ● Sometimes patients tell me that they have been hurt by
disease. someone at home or at work. Could this be happening to
you?
Treatment Goal: ● Are you afraid of anyone at home or work, or of anyone with
A. Support respiratory and CV functions. whom you come in contact?
B. Enhance clearance of agent. ● Has anyone failed to help you to take care of yourself when
C. Provide for safety of the patient and staff. you needed help?
 ● Has anyone prevented you from seeing friends or other
people whom you wish to see?
● Have you signed papers that you did not understand or did
not wish to sign?
● Has anyone forced you to sign papers against your will?
● Has anyone forced you to engage in sexual activities within
the past year?
● Has anyone prevented you from using an assistive device
within the past year?
● Has anyone you depend on refused to help you take your
medicine, bathe, groom, or eat within the past year?
Management
● Primary concern: Safety and Welfare of the patient.
● May require a multidisciplinary approach.
○ Treatment focuses on consequences of the crisis
and prevention of further injury.
○ Work collaboratively to develop and implement a
plan for meeting the px needs.
● Patients should be separated from abusing or neglecting
people whenever possible.
○ If px is in immediate danger.
● Referral to a shelter.
○ Most appropriate but many shelters are
inaccessible most especially here in our country.
● Mandatory reporting laws require health care workers to
report suspected child or elder abuse to an official agency.
F. Sexual Assault
● Rape is forced sexual acts, especially if these acts involve
vaginal or anal penetration.
● Perpetrators or victims may either be male or female
● How the patient is received and treated in the Emergency
Department is important to his or her psychological well
being.
● Patient should be seen immediately; most hospitals have a
written protocol that addresses the patient’s physical and
emotional needs as well as collection of forensic evidence.
● Crisis intervention begins as soon as the patient enters the
facility; the patient should be seen immediately.
Management Goals:
● Provide support
● Reduce emotional trauma
● Gather available evidence for possible legal proceedings
● Nurses may be SANE certified
● Physical exam
● Specimen collection
● Treating consequences: STIs, pregnancy
● Encourage follow-up care
Sexual Assault Nurse Examiner
● Complements the ED staff and can spend more time with
both patient and police officers investigating the incident.
● In our city, we have an ER nurse who has the opportunity to
become a trained SANE.
● Training in forensic evidence collection, history taking and
documentation, ways to approach patients and family.
● Learning photographic methods and use of colposcopy.
○ A test to take a closer look at your cervix.
● Evidence collected through photography, video, and analysis
of specimens enables us to identify motile and non motile
sperm and infectious organisms.
G. Rape Trauma Syndrome
Patients reaction to rape; acute stress reaction to a life-threatening
situation.
Phases of psychological reaction:
● Acute disorganization phase
○ Express state in which shock, disbelief, fear, guilt,
humiliation, anger, bad emotions are controlled
and feelings are masked as victims appear
composed.
● Denial phase
○ Unwillingness to talk.
● Heightened anxiety phase
○ Fear, flashbacks, sleep disturbances, hyper
alertness, psychosomatic reactions that is
consistent with PTSD.
● Reorganization
○ Incident is put into perspective.
○ Some victims may never fully recover and go on to
develop chronic stress disorders and phobias.
Management
● Goals are to provide support, reduce emotional trauma, and
gather evidence for possible legal proceedings.
○ Give sympathetic support and aim at encouraging
the px to gain a sense of control over her life.
● Privacy and sensitivity must be respected.
● Reassurance about anxiety and asked whether a support
person may be called.
● Community resources.
● The patient should never be left alone.
○ Throughout stay in ED, hysteria, stoicism or
feelings of overwhelm - support and caring are
crucial.
● Consent.
○ Consent must also be taken for examination.
○ Taking of photographs and release of findings to
police.
● History taking and documentation.
○ History is obtained only if the px have not already
talked yet to a police officer or a social worker; can
be verbatim.
● Collection of forensic evidence.
● Head to Toe assessment: pelvic and rectal exam.
● Specimen Collection.
● Treating potential consequences of rape.
A. Associated injuries
B. Prophylaxis against STD
C. Postcoital contraceptive medication
D. Antiemetic
E. Cleansing douche, mouthwash, fresh clothing.
F. Ask if client has taken a bath, douched, brushed
teeth, changed clothes, urinated, or defecated
since the attack as this may alter the
interpretation.
G. Client is helped to undress and clothing is placed in
a separate paper bag, not plastic bags because
they retain moisture promoting molds which
destroy evidence.
H. Injuries in head or neck , breast, thighs, back, and
buttocks.
I. Dried semen, stains, or broken fingernails, oral
exam, and culture are being observed.
ENVIRONMENTAL EMERGENCY
1. Heat Stroke
2. Hypothermia; Frostbite
3. Near Drowning
4. Decompression Sickness
5. Anaphylactic Reaction
6. Latex Allergy
7. Injected Poison (Stinging Insects)
8. Snake Bites
1. Heat Stroke
Acute Medical Emergency
● Cause: Failure of the heat-regulating mechanisms of the
body.
● Extended heat waves with high humidity.
● Symptoms:
○ Red skin
○ Increased heartbeat/heart rate
○ Vomiting
○ Weakness
○ Tremor
○ Headache
● Failure of heat-regulating mechanisms: CAN CAUSE DEATH!
Types:
● Nonexertional: Prolonged exposure to an environmental
temperature >39.2 C (102.5 F).
● Exertional: Caused by strenous activity that occurs in hot
environments.
● Other people can tolerate this because it is up to the body’s
way of adapting to the environment.
Who are AT RISK?
 ● People not acclimated to heat; older or very young people;
ill or debilitated people; and persons taking some
medications are at high risk.
○ Elderly
○ Very young people
○ Unable to care for themselves
○ Chronic diseases
○ Those taking certain medications
○ Healthy individuals - due to how our bodies adapt
to the heat. Some may tolerate it, some may not.
● The trauma from exposure to freezing temperatures and
actual freezing of the tissue fluids in the cell and intercellular
spaces.
● It may happen to your feet, hands, nose, and ears.
● First degree: redness and erythema
● Fourth degree: full depth tissue destruction which goes
deeper to subcutaneous tissue.
Primary Assessment and Interventions:

Emphasis on manifestations of:

● Central nervous system dysfunctions
● Elevated temperature of around 39 C or higher
● Hot, dry skin
● Anhidrosis
1. Airway, Breathing, and Circulation of the client (ABCs)
● Tachypnea
● If there are any noted unusualities, we have to
● Hypotension
report it immediately for immediate action.
● Tachycardia
2. Deficits coexisting: hypothermia or underlying condition.
HEAT EXHAUSTION vs HEAT STROKE
● This is very opposite with your heat stroke
● The patient suffering from frostbite may
experience hypothermia or underlying conditions.
First Aid
● Call emergency service
3. Protect frostbitten tissue while performing other
● Take immediate action to cool the person.
interventions.
Subsequent Assessment:
Management

● Move to a cooler place

● Drink water if able
● Take a cold shower
● Use cold compresses
○ Armpits, wrists, ankles, and groin
● Remove clothing 1. Frostnip:
● Spraying/sprinkle with cool water ● History of gradual onset
● Use a fan ● Skin appears white
● Monitor patient’s status carefully ● Numb, pain-free
● Administer oxygen (as needed and per doctor’s order)
● Intravenous infusion therapy
● Urine output (monitor)
● Supportive care
● Medications (with doctor’s order): anticonvulsant,
potassium, sodium bicarbonate, benzodiazepines.
○ Patients suffering from heat stroke may also
experience fluid-electrolyte imbalances.
2. Superficial Frostbite:
● Damage limited to the skin and subcutaneous tissue.
Environmental Emergency: Frostbite
● Skin appears white and waxy
● Palpation: skin feels stiff but underlying tissue is pliable, soft,
● A trauma due to exposure to freezing causing actual freezing
and normal “bounce”.
of tissue fluids in the cell and the cellular spaces = cellular
● Absent sensation.
damage.
● Areas: earlobes, cheeks, nose, hands, and feet.
● May be classified as: frostnip (initial response), superficial
frostbite, deep frostbite.
● Common manifestations:
○ Hard, cold, and insensitive to touch - may appear
white or mottled or may turn red and painful as
rewarmed.
● The extent of injury is not always initially known. 3. Deep Frostbite:
● Skin appears white, yellow-white, or mottled blue-white.
Management: ● Palpation: surface feels frozen and underlying tissue feels
● Controlled but rapid rewarming around 37-40 C circulating frozen and hard.
bath for 30-40 minute intervals. ● Affected part: completely insensitive to touch.
● Analgesics for pain if a patient experiences pain. Do not
massage or handle.
● If feet are involved, do not walk.

General Interventions:

● From the image you can see the normal skin to a severe case
of frostbite.

1. Frostnip may be treated by placing a warm hand over the chilled
area.
2. Leave the frostbitten area alone until definitive rewarming is
undertaken. Pad the extremity to prevent damage from trauma.
3. Gently handle the affected part.
4. Remove all constricting clothing and jewelries.
5. Rewarming:
● Fairly large Tepid water bath immersing the affected part
without touching the side or bottom.
● If clothing, socks, or gloves are frozen to the extremity, leave
them and remove after rewarming.
● Slow rewarming is less effective
● Dry heat NOT recommended
● Rewarming is complete when the area is warm to touch and
pink or flushed.
● DON’T rub or massage = ice crystals will lacerate the tissue.
○ Let the frozen area melt.
6. Pharmacologic interventions:
● Narcotic (pain control)
7. Protect thawed part from infection; if blisters occur– keep intact.
8. Sterile gauze or cotton between affected fingers/toes to absorb
moisture.
9. Aseptic technique during dressing changes; loosely apply dressing.
10. Elevate to control swelling.
11. Foot cradle.
12. Physical exam - check for concomitant injury, dehydration, alcohol
coma, fat embolism, immobility.
13. Restore balance (check for dehydration and Hypovolemia).
● The doctor will order to give IV fluids.
14. Whirlpool bath - aid in circulation, debride dead tissue, prevent
injury.
15. Escharotomy (incision through the eschar) - prevent further tissue
damage, allow normal circulation, permit joint motion.
16. Fasciotomy (incision in fascia to release pressure on the muscles,
nerves, blood vessels) = treat compartment syndrome.
17. Hourly ROM of the affected digits.
● To better promote circulation on the affected part.
18. Avoid tobacco use.
● May hinder faster recovery of patients.
19. Serial lab (U/A, serum enzymes) to monitor rhabdomyolysis and
renal failure due to frostbite.
● Per doctor’s order.
Environmental Emergency: Hypothermia
● Hypothermia may be seen with frostbite and treatment
takes precedence. So physiologic changes in all organ
systems, then monitor continuously.
● Internal core temperature is s 35°C or less.
● Older adults, infants, persons with concurrent illness,
homeless people, and trauma victims are at risk.
● Alcohol ingestion increases susceptibility to suffer
hypothermia.
May be classified as:
1. Mild
- Shivering and mental confusion
2. Moderate
- Shivering stops and confusion increases
3. Severe
- There may be paradoxical undressing in which a person
removes his or her clothing.
- Increased risk of the heart stopping.
Management of the Patient With Hypothermia
● Use ABCs (Airway, Breathing, Circulation)
● Remove wet clothing, rewarm, supportive care.
● Note: cold blood returning from the extremities has high
levels of lactic acid → can cause potential cardiac
dysrhythmias and electrolyte disturbances.
GENERAL INTERVENTIONS:
Goal: Rewarm without precipitating cardiac dysrhythmias
A. Supportive Measures
- Gentle and careful handling of patient; continue monitoring
of core temperature.
B. Rewarming Techniques
- Depends on the degree of hypothermia.
- Passive External Rewarming (several blankets, removal of
all wet clothing etc.).
- Active External Rewarming (warm water immersion; warm
hot water bottles).
- Active Core Rewarming (i.e. inhalation of warmed,
humidified O2 by mask or ventilator; warmed IVFs; warmed
gastric lavage; warmed peritoneal dialysis etc).
Environmental Emergency: Near Drowning
● Also known as Immersion Syndrome.
● Clients who initially survive suffocation submersion in a
water or fluid medium.
● Immersion Syndrome is the immersion into cold water that
leads to cardiac dysrhythmias.
● Freshwater drowning is more common than saltwater
drowning.
➔ Around 90% of drowning occur in fresh water such
as swimming pools, bathtubs, and rivers.
➔ This partly because of the chemistry of water and
how it relates to osmosis.
➔ How it works: drowning involves suffocating while
in water so you don’t even need to breathe in the
water for this to occur but if you do inhale salt
water, the high salt concentration prevents the
water from crossing into lung tissue.
➔ If you drown in salt water, it’s because you can’t
get oxygen or expel carbon dioxide.
➔ Breathing in all salt water acts as a physical barrier
between the air and your lungs. If the salt water is
removed, you can breathe again.
Factors that increase the risk: Near Drowning
● Alcohol or drug ingestion
● Overestimation of swimming skills
● Hypothermia
● Hyperventilation
● Extreme fatigue
● Sudden acute illness
● Head or spinal cord injury
● Hypoglycemia
Ultimate result of Near Drowning: Pulmonary Edema
● Both freshwater and saltwater wash out alveolar surfactant.
● Freshwater changes the surface tension of the surfactant.
● Loss of surfactant leads to alveolar collapse, intrapulmonary
shunting, decreased lung compliance, and hypoxemia.
● Poor perfusion and hypoxemia → acidosis and pulmonary
edema.
X-ray result of a near drowning case
● Near drowning also compromises respiratory system. →
hypoxia, hypercapnia, cardiac arrest, and severe alterations
in fluid and electrolyte balance.
CLINICAL MANIFESTATIONS of Near Drowning
● Unconscious or awake BUT restless and with chest pain or
headache
● Vomiting of fluids
● Hypothermia
● Cardiac: tachycardia, hypotension, dysrhythmias
● Pulmonary: pink frothy sputum caused by pulmonary edema
What to do? How to handle near drowning cases?
1. Call for help.
2. Somebody will try to swim towards the victim then get
him/her out of the water.
3. Do CPR
4. Check for the heart if it goes back.
 5. Report to the nearest hospital for further management.
OUTCOME MANAGEMENT of Near Drowning
● ABCs (Airway, Breathing, Circulation).
● Spinal cord Injury suspected = immobilize the patient.
● Perform CPR if needed.
● History: length of submersion, water tension, associated
injury, type of water.
● Assess LOC, respiratory effort or adventitious breath sounds
(can see possible signs of pulmonary edema).
● Open airway while maintaining spinal immobility.
● Assess for hypoxia (manifestations: confusion, irritability,
lethargy/unconsciousness).
● Remove client’s wet clothing & wrap client in warm blanket;
rewarm slowly (to prevent hypothermia).
● Once vital functions are stabilized, correct acid-base or lyte
abnormalities.
● V/S and check for any additional injuries (spinal injury from
diving, air embolism from scuba diving, seizures).
● For respiratory insufficiency: intubation and ventilate w/
100% O2 and 5 to 10 PEEP to prevent alveolar collapse.
● Surfactant level may remain low for up to 48 to 72 hours
especially after freshwater aspiration.
● If client is breathing, provide support with non-rebreather
mask; maintain O2 sat above 90%.
➔ Allows for the delivery of higher concentration of
oxygen.
➔ The reservoir bag is inflated greater than two-
thirds full of oxygen at a rate of 15 L/min.
➔ Approximately one-third of the air from the
reservoir is depleted as the patient inhales, and it
is then replaced by the flow from the oxygen
supply.
➔ If the bag becomes completely deflated, the
patient will no longer have a source of air to
breath.
Environmental Emergency: Decompression Sickness
● DCS also called “the bends”.
● Occurs in patients who have engaged in diving, high-altitude
flying or flying in commercial aircraft within 24 hours after
diving.
● DCS results from nitrogen bubbles trapped in the body; may
occur in joints and muscle spaces → musculoskeletal pain,
numbness, or hypoesthesia.
➔ Hypesthesia: reduced sense of touch or sensation;
partial loss of sensitivity to sensory stimuli.
● Nitrogen bubbles can become air emboli → stroke, paralysis,
or death may happen.
● Recompression is necessary – may necessitate low-altitude
flight to the nearest hyperbaric chamber.
Assessment and Diagnosis Findings: Decompression Sickness
● History from the patient or diving buddy, evidence of rapid
ascent, loss of air in the tank, recent alcohol intake or lack of
sleep, flight within 24 hours after diving.
● Signs and symptoms: Joint or extremity pain, numbness,
hypesthesia, loss of ROM.
● Neurologic symptoms: stroke, spinal cord injury (indicates
air embolism).
● CP Arrest may occur with severe DCS.
● Because of hypoxia – patients seldom survive.
● Rapid transfer of patients to hyperbaric chambers is
necessary.
Hyperbaric chamber therapy (HbO2)
● When a patient is given 100 oxygen under pressure,
hemoglobin is saturated but the blood can be
hyperoxygenated by dissolving oxygen within the plasma.
● The patient can be administered systemic oxygen via two
basic chambers: Type A: multiplace and Type B: monoplace;
both types can be used for routine wound care.
MANAGEMENT: Decompression Sickness
● Patent airway and ventilation (100% O2)
● Chest X-Ray
● Cardio and Neuro Systems supported.
● Air embolism suspect: Lower HOB, remove wet clothing and
keep patient warm.
● Transfer to nearest hyperbaric chamber.
● If air port is necessary, low-altitude flight is needed (below
1000 feet).
● For patients who are awake and alert = ok to travel by
ground ambulance or by automobile.
● Assess patient; document changes.
● If aspiration is suspected, other treatment may be
prescribed.
Allergic Reactions
● An inappropriate, often harmful response of the immune
system to normally harmless substances.
● Hypersensitive reaction to an allergen initiated by
immunologic mechanisms that is usually mediated by IgE
antibodies.
● Allergen is the substance that causes the allergic response.
● Atopy refers to IgE mediated diseases; such as allergic
rhinitis that have a genetic component.
● Manifestation of tissue injury resulting from interaction
between an antigen and an antibody.
● Body encounters allergens that are types of antigens
● Body’s defenses recognize antigens as foreign.
● Series of events occurs in an attempt to render the invader
harmless, destroy them, and remove them from the body.
Immunoglobulins and Allergic Response
● Antibodies (IgE. IgD, IgG, IgM, and IgA) formed by
lymphocytes and plasma cells.
● IgE antibodies are involved in the allergic disorders.
● IgE molecules bind to an allergen and trigger mast cells or
basophils. These cells then release chemical mediators such
as histamine, serotonin, kinins, SRSA, and neutrophil factor.
○ These substances cause the reaction seen in
allergic response.
Role of B cells and T Cells in Allergic Response
● B cells; also known as B lymphocyte
○ Programmed to produce one specific antibody.
○ Stimulates production of plasma cells; antibody
production.
○ Results in outpouring of antibodies.
● T cells; also known as T lymphocyte
○ Assist B cells.
○ Secrete substances that destroy target cells and
stimulate macrophages.
○ Digest antigens and remove debris.
Allergic Reaction
● Allergen triggers the B cell to make IgEantibody, which
attaches to the mast cell. When that allergen reappears, it
binds to the IgEand triggers the mast cell to release its
chemicals.
Type I: Anaphylactic Reaction
● Characterized by vasodilation, increased capillary
permeability, smooth muscle contraction, and eosinophilia.
● Systemic reactions may involve laryngeal stridor,
angioedema, hypotension, and bronchial GI or uterine
spasm.
● Local reactions are characterized by hives.
● Examples of type 1 reactions:
○ Extrinsic asthma
○ Allergic rhinitis
○ Systemic anaphylaxis
○ Reactions to insect stings
Type II Cytotoxic Reactions
● Involves binding either the IgG or the IgM antibody to a cell
bound antigen.
● May lead to eventual cell and tissue damage.
● The reactions is the result of mistaken identity.
● When the system identifies a normal constituent of the body
as a foreign and activates the complement cascade.
● Example:
○ Myasthenia Gravis
○ Good pasture syndrome
○ Pernicious anemia
○ Hemolytic disease of the newborn
○ Transfusion reaction
○ Thrombocytopenia
Type III: Immune Complex Reaction
● Marked by acute inflammation resulting from formation and
deposition of immune complexes.
 ● Joints and kidneys are particularly susceptible to this kind of ● Implicated in rhinitis, conjunctivitis, contact dermatitis,
reaction which is associated with systemic lupus urticarial, asthma, anaphylaxis.
erythematosus, serum sickness, nephritis, and rheumatoid ● Prevalence has been decreasing due to the use of nonlatex
arthritis. gloves.
● Some s/sx: ● 8% to 17% of healthcare workers are affected.
○ Urticaria ● Healthcare providers have died from anaphylaxis related to
○ Join pain latex allergy as per report; latex-free gloves are provided for
○ Fever nurses who have latex allergy.
○ rash ● Significant observation of allergy to latex: itching, redness,
○ Adenopathy or swollen glands rash; severe anaphylaxis can occur.
● Treatment must be rapid, latex product MUST be removed
Type IV: Delayed or Cellular Reaction promptly.
● Occurs 1-3 days after exposure to an antigen.
● Reaction results in tissue damage involves activity by Injected Poison: Insect Stings
lymphocytes, macrophages, and lysozymes. ● Insect stings or bites are injected poisons that can produce
● Erythema and itching are common. either local or systemic reactions.
● Examples: ● Local reactions: pain, erythema, edema.
○ Contact dermatitis ● Systemic reactions usually begin within minutes and
○ Graft vs host disease produce mild to severe and life-threatening reaction.
○ Hashimoto’s thyroiditis
○ Sarcoidosis Clinical Manifestations
● Generalized Urticaria
Assessment of Patients With Allergic Reactions ● Itching
● History and manifestations; comprehensive allergy history. ● Malaise
● Diagnostic tests ● Anxiety
○ CBC: eosinophil count ● Severe Bronchospasm
○ Total serum IgE ● Shock
○ Skin tests: prick, scratch, and intradermal ● Death

Intradermal Testing Management

● Performing a small bleb. ● Stinger removal
● Wound care
● No scratching please!
Interpretation of Reactions ● Ice application
● Oral antihistamine and analgesic
● Epinephrine
● Health education

1. Ice packs
2. Elevate extremity
3. .Oral anti – Histamine
4. Clean wound – soap & water or antiseptic solution
● Negative wheal: as you form a bleb, if the wheal does not go
5. Tetanus Prophylaxis
out from the form.
6. Patient education: epinephrine, emergency bracelets;
● The bigger the wheal, the bigger chances that the patient is
instructions when sting occurs; avoiding exposures.
having a reaction.

Management of Allergic Disorders

Snake Bites
Two types of reactions: Atopic and Nonatopic
● Daylight hours into early evening during summer months.
● Atopic
● Pit vipers: rattlesnake, copperheads, coral snakes.
○ Asthma, allergic rhinitis, atopic dermatitis
● Upper extremity
○ Familial
● Envenomation
● Nonatopic
○ Process by which venom is injected into some
○ Lack genetic component
animal by the bite or sting of a venomous animal.
○ Latex
● Bites by these snakes may result in envenomation, an
injected poisoning.
Medications to Treat Allergic Reactions
● Oxygen, if respiratory assistance is needed
● Epinephrine used for anaphylactic reactions
● Histamines
● Corticosteroids

Prevention and Management of Anaphylaxis

● Screen and prevent
● Treat respiratory problems, oxygen, intubation, and Primary Assess and Interventions:
cardiopulmonary resuscitation as needed 1. ABCs
● Epinephrine 1:1000 subcutaneously 2. Severe envenomation = neurotoxicity (respiratory paralysis,
● Auto injection system: EpiPen shock, coma, and death)
● May follow with IV epinephrine
● IV fluids

Anaphylactic Reaction
● Acute systemic hypersensitivity reaction that occurs within
seconds or minutes after exposure to certain foreign
substances.
● Medications
● Insect stings
● Foods

Latex Allergy
● Allergic reaction to natural rubber proteins.

Psychiatric Emergencies
- Part of emergency nursing is caring for clients with
Psychiatric Emergencies.
Psychiatric Emergencies
● Psychiatric emergencies often arise in non-psychiatric
settings and give rise to stress for all persons involved. They
may be life threatening and must therefore be treated and
managed.
● Psychiatric emergencies are often but not always caused by
mental illness. They require action without delay to save the
patient and other persons from mortal danger or other
serious consequences.
● Immediate treatment directed against the acute
manifestation is needed both to improve the patient’s
objective symptoms and to prevent behavior.
● An urgent, serious disturbance of behavior, affect, or
thought that makes the patient unable to cope with life
situations and interpersonal relationships.
● Patient may present at the ED:
○ Overactive or violent
○ Underactive or depressed, or
○ Have suicidal behaviors
PATIENTS WHO ARE OVERACTIVE
● Disturbed, uncooperative, and paranoid behavior and those
who feel anxious and panicky may be prone to assaultive
and destructive impulses and abnormal social behavior.
● Intense nervousness, depression, and crying.
● Disturbed and noisy behavior may be exacerbated or
compounded by alcohol or drug intoxication.
Interventions for Overactive Patients
- The immediate goal is to gain control of the situation. If the
patient is potentially violent, security should be nearby.
Restraints are used as a last resort and only as prescribed.
- Approaching the patient with a composed, confident, and
firm manner is therapeutic and has a calming effect.
- Interventions are the following:
1. Introduce yourself by name.
2. Tell the patient, “I am here to help you.”
3. Repeat the patient’s name from time to time.
4. Speak in one-thought sentences and be consistent.
5. Give the patient space and time to slow down.
6. Show interest in, listen to, and encourage the patient to talk
about personal thoughts and feelings.
7. Offer appropriate and honest explanations.
Post-Traumatic Stress Disorder
● The development of characteristic symptoms after a
psychologically stressful event.
● E.g., rape, combat, motor vehicle crash, natural catastrophe,
terrorist attack.
PTSD Symptoms
● Intrusive thoughts and dreams
● Phobic avoidance reaction (avoidance of activities that
arouse recollection of the traumatic event)
● Heightened vigilance
● Exaggerated startle reaction
● Generalized anxiety
● Societal withdrawal
PATIENTS WHO ARE UNDERACTIVE OR DEPRESSED
Patients who are Suicidal
● Attempted suicide is an act that stems from depression.
● E.g., loss of a loved one, loss of body integrity or status, poor
self-image
● Males are at greater risk
● Others at risk are:
○ Older adults
○ Young adults
○ People who are enduring unusual loss or stress
○ Those who are unemployed, divorced, widowed, or
living alone.
○ Those showing signs of significant depression (e.g.,
weight loss, sleep disturbances, somatic complaints,
suicidal preoccupation).
○ Those with a history of a previous suicide attempt,
suicide in the family, or psychiatric illness.
Signs and Symptoms of Potential Suicide
● Communication of suicidal intent
● History of a previous suicide attempt, with risk being much
greater in these cases.
● Famiy history of suicide
● Loss of a parent at an early stage
● Specific plan for suicide
● A means to carry out the plan
Emergency Management
Focuses:
● Treating the consequences of the suicide attempt (e.g.,
gunshot wound, drug overdose)
● Preventing further self injury
Terrorism, Mass Casualties, and Disaster Nursing
Terrorism
The Global Terrorism Database (2017) describes three criteria:
● Criterion I: The act must be aimed at attaining a political,
economic, religious, or social goal.
● Criterion II: There must be evidence of an intention to
coerce, intimidate, or convey some other message to a
larger audience (or audiences) than the immediate victims.
● Criterion III: The action must be outside the context of
legitimate warfare activities.
Chemical Terrorism
● The use of toxic nature of selected substances to cause
death or injury.
● Chemical Warfare (CW) agents may cause injury via the
respiratory route, through the skin, or by ingestion.
○ Nerve agents (e.g., sarin)
○ Blood agents (e.g., cyanide)
○ Lung irritants (e.g., chlorine gas)
Biological Terrorism
● Deliberate use of pathogens to infect persons through
respiratory and ingestion routes causing death or injury.
● e.g. Anthrax and smallpox.
Radioactive Terrorism
● The use of radiological weapons to cause damage or injury.
● e.g. Nuclear weapons
Disaster Nursing
● Refers to a situation in which a health professional, usually a
registered nurse or nurse practitioner, responds to a crisis
situation
Incident Command System (ICS)
● Is a command structure that implements perimeters and
areas to optimize responder safety and patient flow, as well
as the preservation of evidence and environment
Mass Casualty Incident
● An incident in which emergency medical services resources
are overwhelmed by the number and severity of casualties.
● In all types of MCIs, the nurse will be expected to exercise
the following:
1. Assessment and triage of patient’s condition for priority care
2. Provision of care, treatment, and health protection
3. Appropriate utilization of nursing service personnel
4. Detection of changes in the event environment to organize
activities to modify or eliminate health hazards
5. Dealing with mass casualties if necessary
Hospital Incident Command System (HICS)
● Is an incident management framework that can be used to
organize a disaster plan and response
● Reflects the same basic principles of command and control,
chain of command, predefined positions, established
reporting and communication relationships, use of common
 nomenclature, expandability and contractility of the scale of
the operation, and span of control as does the national ICS
Hospital Emergency Preparedness Plans
● Is a comprehensive emergency operations plan that covers
all phases of the disaster and competent staff who know
their roles in executing the plan
● The cornerstone of emergency management is to first
protect life, then property, then the environment.
Phases of Emergency Planning
1. Mitigation Measures
● Have structural mitigation and non-structural mitigation
● Structural Mitigation
○ efforts include those that the hospital performed
through the construction or alteration of the
physical environment through engineered
solutions
○ Example 1: employing disaster resistant
construction or structural modifications such as
hardening
○ Example 2: Detection system, the radiation
monitors at the hospital portals
● Non-structural Mitigation Measures
○ Are those that the hospital undertakes by
modifying human behaviors or processes
○ These may include regulatory measures, staff
awareness, and educational programs
2. Preparedness Efforts
● To effectively manage the full spectrum of emergency
incidents that a hospital may face, hospital emergency
managers—in collaboration with the institution’s emergency
management committee comprising members of every
clinical, operational, and financial department—must
develop and maintain a comprehensive, effective emergency
management plan.
● This will help hospitals to prepare disaster and emergency
situations
3. The Response Phase
● Often, the most visible and well supported by outside
resources of the emergency management plans’ activities
are those that fall under the response phase
● Efforts include those measures taken when an emergency
incident occurs and may involve care for patients, staff, and
visitors: to limit injuries, loss of life, and damage to the
physical environment.
4. Recovery Function
● The primary goal of recovery efforts is to restore core
services and normal operations.
● From a hospital planning perspective, the institution’s
recovery actions and implementation activities for its core
financial, human resources, and support services should also
be addressed.
Emergency Operations Plan
Essential components of the plan
a. An activation response (Activation Measures)
○ This activation response of the facility means
where, how, and when the response is initiated
b. An internal and external communication plan
○ Important for coordination purposes
c. A plan for coordinated patient care
○ Important for the possible transfer of the patient
to other facilities
d. Security plans
○ This is a key to answer chaotic situations
e. Identification of external resources
○ Important to identify resources such as local and
national, to properly utilize these resources
f. A plan for people management and traffic flow
○ Includes strategies to manage the patient, the
public, the media, and the personnel
○ A designated person is delegated to manage these
groups
g. Data management strategy
○ A data management plan, for every aspect of the
disaster, will save time
○ A backup system for documenting, tracking, and
staffing is developed if the facility utilizes
electronic health record
h. Demobilization response
○ Resources should not be unnecessarily exhausted.
The person who decides when the facility resumes
daily activities is clearly identified.
i. After-action report or corrective plan
○ Facilities often see increased volume of patients
after an incident. So incident response critique and
a debriefing for all parties involved, immediately
and again at a later date
j. A plan for practice drills
○ Practice drills that include community participation
allowfor troubleshooting any issues before a real-
life incident occur
k. Anticipated resources
○ Food and water must be available for staff,
families, and all others who may be in the facility
for an extended period
l. Mass casualty incident (MCI) planning
○ includes such issues as planning for mass fatalities
and morgue readiness.
m. An education for all of the above
○ A strong education plan for all personnel regarding
each step of the plan allows for improved
readiness and additional input for fine-tuning of
the EOP.
Personal Protective Equipment
● Is the clothing and respiratory gear designed specifically to
protect the healthcare provider while he or she is caring for
a contaminated patient
Sequence in wearing PPE:
1. Gown
a. Full cover torso from neck to knees, arms to end of
wrists, and wrap around the back
2. Mask or respirator
a. Secure ties or elastic bands at middle of head and
neck
b. Fit flexible band to nose bridge
c. Fit snug to face and below chin
d. Fit-check respirator
3. Goggles or face shield
a. Place over face and eyes and adjust to fit
4. Gloves
a. Extend to cover wrist of isolation band
● Sequence in Removing PPE:
○ Gloves
○ Goggles / Faceshield
○ Gown
○ Mask / Respirator
● Perform hand washing immediately after removing PPE
Hazardous Materials
● Is any substance with the potential to harm people, property
or the environment. This includes not only chemicals but
also biological, radiological, nuclear, and explosive
substances.
Classification of Hazardous Materials
Class 1: Explosives
● The explosives category includes any items or materials that
can rapidly detonate or conflagrate as the result of a
chemical reaction.
Class 2: Gasses
● Substances with a vapor pressure and those that are
completely gaseous.
Class 3: Flammable Liquids
● They are defined as liquids, liquids containing solids in
solution, or mixtures of liquids.
Class 4: Flammable Solids
● Self-reactive substances that may undergo strong
exothermic reactions or solid desensitized explosions are
also included in this category.
Class 5: Oxidizing Substances, Organic Peroxides
 ● Oxidizers are substances that may contribute to or cause
combustion by yielding oxygen as the result of a chemical
reaction.
Class 6: Toxic Substances and Infectious Substances
● Infectious substances are materials that are known to or
likely to contain pathogens such as viruses, bacteria,
parasites, fungi, and other microorganisms that can cause
disease in humans and animals.
Class 7: Radioactive Material
● This class includes materials that contain radionuclides.
Class 8: Corrosives
● Include substances that disintegrate or degrade other
materials on contact by way of chemical action.
Class 9: Miscellaneous Hazardous Materials
● Some hazardous materials do not fall into any of the first
eight categories.
Decontamination
● Is the process of removing or neutralizing a hazard from the
environment, property or life form.
● Its goal is to reduce or remove the hazardous agent while
maintaining safety and to prevent further contamination to
people and the environment.
Decontamination Methods
1. Physical Removal
● Remove clothing: clothing removal is decontamination –
encourage victims to remove clothing at least to their
undergarments.
● Flush with water or aqueous solutions.
● Absorb contaminating agent with absorbent materials (e.g.
rub with flour followed by wet tissues or use a military M291
resin kit for spot decontamination of skin only).
● Scrape bulk agent with a wooden stick (e.g. tongue
depressor or popsicle stick).
● Note: Follow all of these with full decontamination at a
medical treatment facility.
2. Chemical Deactivation
● Water or soap wash: chemical warfare agents have a
generally low solubility and slow rate of diffusion in both
freshwater and seawater. Therefore, the major effect of
water and water combined with soap (especially alkaline
soaps) is via a slow breakdown of the compound (e.g.
hydrolysis) or through dilution of the agent and mechanical
force of the wash. When other chemical deactivation means
are not available, washing with water or soap and water is a
good alternative.
● Chemical solutions: in the event of an emergency, you may
be directed to perform decontamination with other chemical
deactivation agents. These vary depending on the chemical
warfare agent and may include alkaline solutions of
hypochlorite.
3. Hydrolyzing Agent
● Alkaline hypochlorite is effective for hydrolyzing VX and G
agents.
BIOLOGICAL WARFARE
Common Biologic Weapons
1. ANTHRAX
● Incubation 1-6 days
● Skin contact, GI ingestion, inhalation
● Skin lesions, fever, nausea and vomiting, abdominal pain,
diarrhea
● Respiratory symptoms that mimics influenza
● Treatment= Penicillin V, Erythrocin
2. SMALLPOX
● Virus, Incubation 12 days
● Extremely contagious; spread by direct contact, by contact
with clothing or linens, or by droplets person-to-person
● Manifestations: High fever, malaise, headache, backache,
and prostration; after 1 to 2 days a maculopapular rash
appears on the face, mouth, pharynx, and forearms
● Treatment is supportive care with antibiotics for any
additional infection
BLAST INJURIES
Phases of Blast Injury
1. Primary
● Results from pressure wave
● Common Injuries:
➢ Pulmonary barotraumas, including pulmonary
contusions
➢ Head injuries, including concussion, other severe
brain injuries
➢ Tympanic membrane rupture, middle ear injury
➢ Abdominal hollow organ perforation, hemorrhage
2. Secondary
● Results from debris from the scene or shrapnel from the
bomb
● Common Injuries:
➢ Penetrating trunk, skin, and soft tissue injuries
➢ Fractures, traumatic amputations
3. Tertiary
● Results from pressure wave that causes the victim to be
thrown
● Common Injuries:
➢ Head injuries
➢ Fractures, including skull
4. Quaternary
● Results from pre-existing conditions exacerbated by the
force of the blast or by post blast injury complications
● Common Injuries:
➢ Severe injuries with complex injury patterns-
burns, crush injuries, head injuries
➢ Common pre-existing conditions that become
exacerbated- COPD, asthma, cardiac conditions,
diabetes, and hypertension
Natural Disasters
● Are catastrophic events with atmospheric, geological, and
hydrological origins that can cause fatalities, property
damage, and social environment disruption.
Common natural disasters:
● Earthquake
● Flood
● Droughts
● Hurricane/Tornados
Stress Reactions
Post- traumatic Stress Disorder
● The development of characteristic symptoms after a
psychologically stressful event (e.g., rape, combat, motor
vehicle crash, natural catastrophe, terrorist attack),
Symptoms
● intrusive thoughts and dreams,
● phobic avoidance reaction
● heightened vigilance,
● exaggerated startle reaction,
● generalized anxiety
● societal withdrawal
Critical Incident Stress Management
Critical Incident Stress Debriefing (CISD)
● is a formalized, structured method whereby a group of
rescue and response workers reviews the stressful
experience of a disaster
● was developed to assist first responders, it was not meant
for the survivors of a disaster or their relatives
● was never intended as a substitute for therapy
● designed to be delivered in a group format and meant to be
incorporated into a larger, multicomponent crisis
intervention system
Debriefing
● is a formal version of providing emotional and psychological
support immediately following a traumatic event
● its goal is to prevent the development of post-traumatic
stress disorder and other negative sequelae.
● mostly involve a single session which might last between
one and three hours, in the days immediately following a
traumatic event is often provided in groups.
Nurses’ Role in Disaster and Emergency
● Assess the needs of the whole community, including
potentially at-risk populations, as the event unfolds based on
the information available.
 ● Conduct surveillance activities within the health department
as well as in cooperation with in-hospital infection control
practitioners to control the spread of communicable disease.
● Assure the health and safety of themselves as well as their
fellow responders.
● Maintain communication with local, state, or federal
agencies, assuring the accurate dissemination of information
to colleagues and the public-at-large.
● Operate points of distribution (POD), mass countermeasures
centers as
● Provide on-site triage of victims as needed.
119 LEC WEEK 3 & 4
Decision Making, Problem Solving, Critical Thinking, and Clinical
Reasoning: Requisites for Successful Leadership and Management
Nurses constantly face numerous decisions to make problems to solve;
these are part of the usual nursing care activities and are not easy
tasks
● Provides mock experiences tremendous value in applying
leadership and management theory
● The text includes numerous opportunities for readers to
experience the real world of leadership and management
● Some of these learning situations called learning exercises:
○ case studies
○ writing exercises
○ Specific management or leadership problems
○ Staffing and budgeting calculations
○ Group discussion or problem-solving situations
○ Assessment of personal attitudes and values
● Some exercises include:
○ Opinions
○ Speculations
○ Value judgements
● All of the learning exercises require some degree of critical
thinking, problem solving, decision making, or clinical
reasoning

Developing critical thinking, problem solving, and decision-making

skills enables nurses to see all sides of an issue, look for creative
alternatives and approaches to solve problems and make well thought Marquis-Huston Critical Thinking Teaching Model
out decisions. The effect is a stronger organization and more
competent leader and manager.

Decision Making
● A complex, cognitive process of choosing a particular course
of action
● the thought process of selecting a logical choice from
available options
● This implies that doubt exist in several courses of action and
a choice is made to eliminate uncertainty
● This model assists in achieving desired learner outcomes
Problem Solving
Basically, the model comprises four overlapping spheres,
● A part of decision making; a systematic process focusing on
each being an essential component for teaching
analyzing a difficult situation involving higher order
leadership and management.
reasoning and evaluation
1. Didactic Theory Component
● Many educators use problem solving and decision making
a. such as the material that is presented in each
synonymously but there is a small difference between the
chapter
two: although decision making is the last step in the problem
2. A formalized approach to problem solving and decision
solving process; it is possible for decision making to occur
making must be used.
without the full analysis required in problem solving
3. Use of group process
○ problem solving attempts to identify the root
a. which can be accomplished through large and
problem in situations
small groups and classroom discussion
○ Much time and energy are spent on identifying the
4. The material must be made real for the learner so that the
real problem
learning is internalized.
a. This can be accomplished through writing
Critical Thinking
exercises, personal exploration, and values
● “Reflective thinking”
clarification, along with risk taking, as case studies
● Related to evaluation and has a broader scope than decision
are examined
making and problem solving
● Disciplined thinking that is clear, rational, open-minded, and
Characteristics of a Critical Thinker
informed by evidence
● Insight
● Involves reflecting on the meaning of statements, examining
● Intuition
the offered evidence and reasoning, and forming
● Empathy
judgements about facts
● Willingness to take action
Clinical Reasoning
Whatever definition of critical thinking is used, most agree that it is
● Integrating and applying different types of knowledge to
more complex than problem solving or decision making
weight, critically think about arguments, and reflect on the
● it involves higher reasoning and evaluation
process used to arrive at diagnosis
● has both cognitive and affective components
● Nurses today must have higher order thinking skills to
identify patient problems and to direct clinical judgements
Insight, intuition, empathy, willingness to take action are additional
and actions that result in positive patient outcomes
components of critical thinking. These same skills are necessary to
● When nurses integrate and apply different types of
some degree in decision making and problem solving
knowledge to weigh evidence, critically think about
arguments, and reflect on the process used to arrive at a
Qualities of Successful Decision Makers
diagnosis → CLINICAL REASONING
● Self-aware
○ Clinical reasoning uses both knowledge and
○ Improving self-awareness will help increase
experience to make decisions at the point of care
emotional intelligence and understand the internal
● The process by which nurses and other clinicians collect
factors that drive one’s decision making process
cues, process information, come to an understanding of a
○ how we make decisions, how we make choices,
patient problem or situation, plan and implement
why we make these choices we do, and what
interventions, evaluate outcomes, and reflect on and learn
we’re driven in certain contexts are all pieces of
from the process
the larger puzzle that make up who we are
● Courageous
Experiential Learning
○ Courage requires the ability to face our fears and
● Provides mock life experiences to learn from
take action despite them
● Allows learners to apply leadership and management theory
○ Fear is a natural and a necessary feeling that is
● Promotes whole brain thinking and improved problem-
often useful in decision making to give us a natural
solving skills
necessary caution
 ● Sensitive
○ May be the most noticeable to us personally
○ We process sensory information more carefully
because we use areas of our brain that are
associated with more complex processing
○ Our awareness of subtleties is useful in an infinite
number of ways: from simple pleasure in life to
strategizing our response based on our awareness
of other non-verbal cues, that they may no idea
they are giving off about their mood or
trustworthiness
● Energetic
○ Psychological effects of decision fatigue can vary
potentially leading to difficulty making right
decisions, impulse buying, or other avoidance
behavior
○ If our brain is worn down, it may cause us to
become more reckless with our decision making or
not think things through
● Creative
○ If a decision maker is going to produce novel
alternatives when solving a problem, then he or
she is going to need a little creativity to help the
process along
○ It allows the decision maker to more fully appraise
and understand the problem sometimes in ways
others can see it
Types of Decision Making
● Recurrent and routine problem solving
○ Routine decisions are of repetitive nature and
hence require relatively little consideration. It may
be seen that basic decisions generally relate to
strategic aspects
○ Routine decisions are related to tactical aspects of
an organization
● Satisficing
○ A decision making strategy that aims for a
satisfactory or adequate results rather than
optimal solution
○ instead of maximum exertion towards attaining
the ideal outcome, it focuses on pragmatic effort
when confronted with task
● Maximizing or optimal mode
○ Is a style of decision making characterized by
seeking the best option through an exhaustive
search through alternatives
○ Contrasted with satisficing in which individuals
evaluate options until they find one that is good
enough
○ An optimal decision is a decision that leads to at
least as good, unknown, or expected outcome as
all other available decision options. It is an
important concept in decision theory
○ In order to compare the different decision
outcomes, one commonly assigns a utility value to
each of them
Princess (11:52) - 24:58
Frequent Errors Made in Decision Making
No clear objective or goal for decision #1
● No clear objective or goal for decision
○ If you don't know where you're going, how will you
get the objective?
○ Objectives are important because they convert
visions into clear-cut measurable targets.
○ Clear goals and objectives allow employees to
monitor their own progress all year round and
correct their efforts as necessary.
○ A decision that is made without a clear objective in
mind or a decision that is inconsistent with one's
philosophy is likely to be a poor quality decision.
○ Sometimes the problem has been identified but
the own objectives are set.
Frequent Errors Made in Decision Making #2
● Faulty data gathering
○ Gather data carefully because decisions are based
on knowledge and information available to the
problem solver at the time the decision must be
made one must learn how to process and obtain
accurate information.
○ The accusation of information begins with
identifying the problem or the occasion or the
decision and continues throughout the problem-
solving process.
○ Often the information is unsolicited but most
information is soothed actively.
○ In addition human values tremendously influence
our perceptions therefore as problem solvers
gather information they must be vigilant that their
own preferences and those of others are not
mistaken for facts.
Questions That Should Be Asked in Data Gathering #1
Acquiring information always involves people and a new tool or
mechanism is invaluable to human error. Questions that should be
asked in data gathering are:
● What is the setting?
● What is the problem?
● Where is it a problem?
● When is it a problem?
● Who is affected by the problem?
Questions That Should Be Asked in Data Gathering #2
● What is happening?
● What are the consequences of the problem? Which of these
are most serious?
● Why is it happening? What are the causes of the problem?
Can I prioritize the causes?
● What are the basic underlying issues? Areas of conflict?
Identify a poor decision you made recently because of faulty data
gathering
● Was this poor decision made because necessary information
was intentionally or unintentionally withheld from you?
Frequent Errors Made in Decision Making #3
● Failure to use science, logic, and empirical evidence in
making decisions
○ Use an evidence-based approach to gain
knowledge and insight into managerial and
leadership decision making.
○ Individuals must reach outside their current sphere
of knowledge in solving the problems presented in
this chapter.
○ Some data gathering sources include textbooks,
periodicals, experts in the field, colleagues and
current research.
○ Indeed most experts agree that the best practices
in nursing care and decision making are also
evidence based practice that's according to
Prevost and ??, 2020.
○ Evidence-based decision making and evidence-
based practice should be viewed as imperative for
all nurses today as well as for the profession in
general.
Frequent Errors Made in Decision Making #4
● Not considering enough alternatives
○ So generate numerous alternatives. The definition
of decision making implies that there are at least
two choices in every decision.
○ Unfortunately many problem solvers limit their
choices to two when many more options usually
are available.
○ Remember that one alternative in each decision
should be the choice not to do anything.
○ When examining decisions to be made by using a
formal process, it is often found that the status
quo is the right alternative.
○ The greater the number of alternatives that can be
generated, the greater the chance that the final
decision will be sound.
Frequent Errors Made in Decision Making #5
● Faulty logic or “crooked thinking”
○ Think logically. During the problem solving process,
one must draw inferences from information.
○ An inference is a part of deductive reasoning.
People must carefully think through the
information and the alternatives.
○ Faulty logic at this point may lead to poor quality
decisions.
 ○ Primarily, people think illogically in three ways:
over generalizing, affirming the consequences, and
arguing from analogy.
Frequent Errors Made in Decision Making #6
● Not assessing or ignoring the quality of the decision making
that is required
○ Choose and act decisively. It is not enough to
gather adequate information.
○ Think logically and select from among many
alternatives and be aware of the influence of one's
values.
○ In the final analysis, one must act. Many
individuals delay acting because they do not want
to face the consequences of their choices such as if
managers granted all employees requests for days
off then they would have to accept the
consequences of dealing with short staffing.
○ Many individuals choose to delay acting because
they lack the courage to face the consequences of
their choices.
Frequent Errors Made in Decision Making #7
● Lack of self-awareness
○ Self-awareness is the ability to recognize one's
own feelings as it happens to accurately perform
self-assessments and have self-confidence. It is the
keystone of emotional intelligence
○ Goldman (Goleman?) 1998 argued that all
individuals have a rational thinking mind and an
emotional feeling mind and both influence action.
The goal then in e.i, is emotional literacy being.
○ Self-awareness about one's emotions and
recognizing how the influence influences
subsequent action.
Frequent Errors Made in Decision Making #8
● Too much time spent identifying the problem
○ Mismanagement of time severely compromises an
organization's productivity and results in negative
effects across the board from the manager to the
rank and file.
○ When time is mismanaged, work is rushed and
becomes substandard. Deadlines are missed but
choices are made. Employees suffer from fatigue
and even the nurses personal lives and
relationships are adversely affected.
Frequent Errors Made in Decision Making #9
● Refusal to act
○ It may help the reluctant decision maker to
remember that even though decisions often have
long-term consequences and far-reaching effects,
they are not usually cast in stone.
○ Often judgments found to be ineffective or
inappropriate can be changed by later evaluating
decisions, managers can learn more about their
abilities and where the problem solving was faulty.
However decisions must continue to be made.
○ Although some are of poor quality because
through continued decision making people
develop improved decision making skills.
Frequent Errors Made in Decision Making #10
● Using outcome only for evaluation
○ Using outcome only for evaluation or outcome
evaluation is defined as a type of measurement
used to determine the success or failure of a
program or project.
○ Outcome evaluation conclusions are based on the
statistical analysis of quantitative measures.
Frequent Errors Made in Decision Making #11
● It is not enough to gather adequate information, think
logically, select from among many alternatives, and be
aware of the influence of one’s values. In the final analysis,
one must act.
Decision-Making Variables
● If we all use the same decision-making or problem-solving
model and are given the same information, will we all reach
the same decision? Why or why not?
● A decision variable is an unknown in an optimization
problem. It has a domain which is a compact representation
of the set of all possible values for the variable.
● Decision variable types are references to objects whose
exact nature depends on the underlying optimizer of a
model. Before we continue, let us reflect on the questions
posted. If we all use the same decision making or problem-
solving model and are given the same information, will we
all reach the same decision? Why or why not?
Innovation and Creativity: Critical Aspects of Problem Solving and
Decision Making #1
● Creativity and innovation are two related but separate
notions and each is required for workplace success.
● Creativity doesn't lead to company inventions and growth,
innovation does. However, innovation doesn't happen
without creative people on board so generating creativity
means allowing people to think outside the box and go
against the norm sometimes.
● Creativity and innovation are two words that are constantly
thrown around in brainstorming sessions, corporate
meetings, and company mission statements.
Innovation and Creativity: Critical Aspects of Problem Solving and
Decision Making #2
● New research suggests that gender also plays a role in how
individuals make decisions.
● Although some debate continues as to whether these
differences are more gender role based than gender-based.
● Research suggests however that men and women do have
different structures and wiring in the brain and that men and
women may use their brains differently.
● For example, Harvard researchers have found that parts of
the frontal lobe responsible for problem solving and decision
making and the limbic cortex responsible for regulating
emotions are larger in women 's (Edmonds, 2018??)
● Men also have approximately 6.5 times more grey matter in
the brain than women but women have about 10 times
more white matter than men. Researchers believe that men
may think more with their grey matter whereas women
think more with the white matter. This use of white matter
may allow a woman's brain to work faster than a man's
that's according to Hus as cited in Edmonds, 2018.
What Is Your Risk Quotient in Decision Making?
● Ask yourself how much risk you are willing to take.
● Example: Apply for a new job but are getting conflicting
advice regarding whether your qualifications are appropriate
for this particular job. Do you take the emotional and
professional risk of applying and not getting it or do you take
the risk for professional growth regardless of whether you
get the job or not?
● For example, moving out of ICU was a big risk because I was
in my comfort zone in ICU.
Right Brain vs Left Brain Dominance #1
● Brain hemisphere dominance and thinking styles are ways of
evaluating information and alternatives on which we base
our final decision constitutes a thinking skill.
● Individuals think differently, some think systematically and
are often called analytical thinkers whereas others think
more intuitively.
● About 30 years ago, researchers first began arguing that
most people have either right or left brain hemisphere
dominance.
● They suggested that analytical, linear, left-brain thinkers
process information differently from creative, intuitive,
right-brain thinkers.
● Left-brain thinkers were supposed to be better at processing
language, logic, and numbers whereas right-brain thinkers
excelled at non-verbal ideation and creativity.
Right Brain vs Left Brain Dominance #2
● Some people fail to use any type of systematic examination
of the problem or its alternatives for solution.
● Noer (2018) suggests that the existence of left or right brain
dominance is too simplistic; stated that newer studies failed
to find evidence that individuals have stronger left or right
sided brain networks.
● Cherry (2019) agrees suggesting that recent research has
shown that the brain is not nearly as dichotomous as once
 thought. (e.g. abilities in Math are strongest when both
halves of the brain work together)
● Indeed, both sides of the brain collaborate to perform a
broad variety of tasks and the two hemispheres
communicate through the corpus callosum.
● Cherry also notes that it is true that some brain functions
occur in one or the other side of the brain. Language tends
to be on the left and attention more on the right. But people
don’t tend to have a stronger left or right sided brain
network.
Right Brain vs Left Brain Dominance #3
● Instead, they rely on discrete, often unconscious processes
known as heuristics.
● Heuristics refer to using a “trial-and-error” or “rule-of-
thumb” approach to problem solving.
➢ They are practical mental shortcuts and are not
expected to provide perfect or optimal problem
solving.
➢ They provide a more immediate solution to the
decision at hand.
➢ This is particularly true for uncertain or emergent
situations where knowledge, time, and resources
are limited.
● Parish (2018) notes that most people don’t actually stop to
think, they just take their first thought and run with it. That’s
because most individuals rely on discrete, often unconscious
process, known as heuristics to make decisions.
Comparison of Economic & Administrative Man
Rational and administrative decision making
● For many years, it was widely believed that most managerial
decisions were based on a careful, scientific, and objective
thought process and that managers made decisions in a
rational manner.
● In the late 1940s, Herbert A. Simon's work revealed that
most managers made many decisions that did not fit the
objective rationality theory.
● Simon (1965) delineated two types of management decision
makers: the economic man and the administrative man.
● Managers who are successful decision makers often attempt
to make rational decisions, much like the economic man.
● Because they realize that restricted knowledge and limited
alternatives directly affect a decision’s quality, these
managers gather as much information as possible and
generate many alternatives.
Economic Man
● Makes decisions in rational manner
● Has complete knowledge of problem or situation
● Considers all alternatives
● Has systematic ordering of alternatives
● Selects maximizing choice
Administrative Man
● Knowledge is fragmented
● Is impossible to accurately predict future consequences
● Considers multiple alternatives but not all
● Makes decisions that are good enough
● Final choice is satisficing
To Make Better Decisions
● Use a systematic decision-making process whenever
possible.
● Decision making process is a series of steps taken by an
individual to determine the best option or course of action
to meet their needs.
● In a business context, it is a set of steps taken by managers
in an enterprise to determine the planned path for business
initiatives and to set specific actions in motion.
Steps to good decision making:
1. Identify your goal.
- One of the most effective decision making strategies is to
keep an eye on our goal.
2. Gather information for weighing our options
3. Consider the consequences
4. Make your decision
5. Evaluate your decision.
The Traditional Problem-Solving Process
1. Identify the problem.
2. Gather data to identify the causes and consequences of the
problem.
3. Explore alternative solutions.
4. Evaluate each alternative.
5. Select the appropriate solution.
6. Implement the solution.
7. Evaluate the results.
Nursing Process: A Problem-Solving and Decision-Making Model
1. Assess
2. Diagnose
3. Plan
4. Implement
5. Evaluate
● The nursing process, developed by Ida Jean Orlando in the
late 1950s, provides another theoretical system for solving
problems and making decisions.
● Originally a four-step model (assess, plan, implement, and
evaluate) diagnosis was delineated as a separate step, and
most contemporary depictions of this model now include at
least five steps.
Figure 1.2 Feedback mechanism of the nursing process.
● As a decision-making model, the greatest strength of the
nursing process may be its multiple venues for feedback.
● When the decision point has been identified, initial decision
making occurs and continues throughout the process via a
feedback mechanism.
Strategies for the New Nurse to Promote Evidence-Based Best
Practice
● Given that human lives are often at risk, nurses then should
feel compelled to use an evidence-based approach in
gathering data to make decisions regarding their nursing
practice.
1. Keep abreast of the evidence—subscribe to professional
journals and read widely.
2. Use and encourage use of multiple sources of evidence.
3. Use evidence not only to support clinical interventions but
also to support teaching strategies.
4. Find established sources of evidence in your specialty—do
not reinvent the wheel.
5. Implement and evaluate nationally sanctioned clinical
practice guidelines.
6. Question and challenge nursing traditions and promote a
spirit of risk taking.
7. Dispel myths and traditions not supported by evidence.
8. Collaborate with other nurses locally and globally.
9. Interact with other disciplines to bring nursing evidence to
the table.
Decision-Making Tools
➢ There is always some uncertainty in making decisions.
➢ However, management analysts have developed tools that
provide some order and direction in obtaining and using
information or that are helpful in selecting who should be
involved in making the decision.
● Decision grids
- Allows one to visually examine the alternatives and compare
each against the same criteria
● Payoff tables
- Have a cost-profit-volume relationship and are very helpful
when some quantitative information is available, such as an
item’s cost or predicted use.
● Decision trees
- Decisions are often tied to the outcome of their events,
management analysts have developed decision trees.
- Figure 1.4 compares the cost of hiring regular staff with the
cost of hiring temporary employees.

● Consequence tables
- Demonstrate how various alternatives create different
consequences.
- Lists the objectives for solving a problem down one side of a
table and rates how each alternative would meet the desired
objective.
● Logic models
- Schematics or pictures of how programs are intended to
operate
- The sychamtic typically includes resources, processes, and
desired outcomes and depicts exactly what the relationships
are between the three components.
● Program Evaluation and Review Technique (PERT)
- A popular tool to determine the timing of decisions
- Developed by the Booz-Allen-Hamilton organization and the
U.S. Navy in connection with the Polaris missile program.
- PERT is a flowchart that predicts when events and activities
must take place if a final event is to occur.
Chapter 2: Classical Views of Leadership and Management
● Various theories and principles of leadership and
management help provide the basis for accomplishing a
goal. They remove the uncertainty in leading and managing.
● The knowledge acquired from learning the theories and
principles of leadership and management contributes to an
empowered nurse leader and manager. One simply has to
activate such knowledge that was learned beforehand to
address work related issues.
● This chapter first artificially differentiates between
management and leadership, focusing on theory
development in each field of study.
● The need to develop nursing leadership skills has never been
greater than it is today. What contemporary factors are
driving this need for nursing leadership skills?
Management Process
● Henry Fields in 1925 first identified the management
functions of planning, organization, command, coordination,
and control.
● Luther Gulick in 1937 expanded on Fields management
functions in his introduction of the 7 activities of
management, which includes:
○ Planning, organizing, staffing, directing,
coordinating, reporting, and budgeting.
○ As denoted by the mnemonic POSDCORB,
although often modified as either by including
staffing as a management function or renaming
elements.
● These functions or activities have changed little over time.
Eventually, theorists began to refer to these functions as the
management process.
Leadership vs. Management
Leaders Managers
- Empower others; maximize - Guide, direct, and motivate
workforce. others.
- Needed to implement the - Intervene when goals are
planned change that is part of threatened.
system improvement.
- Emphasize control.
● But it can be said that every manager should be a leader.
● Fowler, 2015 agrees, suggesting that not only are the
differences between leadership and management difficult to
verbalize, but for the clinical nurse, it is even more difficult
to work out what particular hat you should be wearing when
trying to lead and manage a team through a busy shift.
● Clinicians often act as both leaders and managers in a clinical
setting. Even if not officially recognized as doing so, their
success in these roles is critical to high level unit functioning
and the attainment of patient goals.
● Fowler suggests that clinical leaders must continually find an
intersection between good leadership and management
skills to be successful.
Leadership
● Leadership is the art of getting work done through others
willingly.
● Leaders are in the front, moving forward, taking risks, and
challenging the status quo.
● Leaders are individuals who take risks, attempt to achieve
shared goals, and inspire others to action.
● Those individuals who choose to follow a leader do so by
choice, not because they have to.
● Stoner, 2018 notes that leadership impact depends on the
ability to influence people, not the ability to command,
coerce, or manipulate.
● You can recognize a leader by the response of their
followers.
● A job title alone does not make a person a leader. Only a
person’s behavior determines if he or she occupies a
leadership position.
● The manager is the person who brings things about, the one
who accomplishes, has responsibility, and conducts. A leader
on the other hand, is the person who influences and guides
direction, opinion, and course of action.
Leaders
● Often do not have delegated authority but obtain their
power through other means, such as influence.
● Have a wider variety of roles than managers and may have
different personal goals.
● Are frequently not part of the formal organization.
○ Leaders may or may not be part of the formal
organization.
● Focus on group process, information gathering, feedback,
and empowering others.
● Leaders emphasize interpersonal relationships.
● Leaders direct willing followers.
● Leaders have goals that may or may not reflect those of the
organization.
Managers
● Are always assigned a position within the organization.
● Have a legitimate source of power due to the delegated
authority that accompanies their position.
● Are expected to carry out specific functions.
● Have specific duties and responsibilities they are expected to
carry out.
● Emphasize control, decision making, decision analysis, and
results.
● Manipulate people, the environment, money, time, and
other resources to achieve organizational goals.
● Have greater formal responsibility and accountability for
rationality and control than leaders.
● Direct willing and unwilling subordinates.
Good Leaders and Managers
● Kerr, 2015 suggests that there are 10 important distinctions
between leaders and managers, and these differences must
be understood and recognized so that an organization can
leverage each to the fullest.
 ● One leadership inspires change, while management
manages transformation.
● Leadership requires vision, while management requires
tenacity.
● Leadership requires imagination, while management
requires specifics.
● Leadership requires abstract thinking, while management
requires concrete data.
● Leadership requires the ability to articulate, while
management requires the ability to interpret.
● Leadership requires an aptitude to sell, while management
requires an aptitude to teach.
● Leadership requires an understanding of the external
environment, while management requires an understanding
of how work gets done inside organizations.
● Leadership requires risk taking, while management requires
self discipline.
● Leadership requires confidence in the face of uncertainty,
while management requires blind commitment to
completing the task at hand.
● Leadership is accountable to the entire organization, while
management is accountable to the team.
Good Leaders Good Managers
- Envision the future. - Coordinate resources
- Communicate their - Optimize resource use
visions. - Meet organizational
- Motivate followers goals and objectives.
- Lead the way - Follow rules
- Influence others to - Plan, organize, control
accomplish goals. and direct
- Inspire confidence - Use reward and
- Take risks punishment effectively
- Empower followers to achieve
- Master change organizational goals.
The Management Process
● In many ways, the management process is similar to the
nursing process. Both processes are cyclic and many
different functions may occur simultaneously.
● Suppose that a nurse manager spent part of the day working
on the budget, that is planning.
● Meet with the staff about changing the patient care
management delivery system from primary care to team
nursing, that is organizing.
● Alter the staffing policy to include 12 hour shifts, that is
staffing.
● Held a meeting to resolve a conflict between nurses and
physicians, that is directing.
● Gave an employee a job performance evaluation, that is
controlling.
● Not only would the nurse manager be performing all phases
of the management process, but each function has a
planning, implementing, and controlling phase. Just as nurse
practice requires that all nursing care has a plan and
evaluation, so too does each function of management.
1. Planning
● Encompasses determining philosophy, goals, objectives,
policies, procedures, and rules; carrying out long and short
range projections; determining a fiscal course of action; and
managing planned change.
● While planning is the first function, one must recognize that
it permeates into the other functions that are dependent on
it.
● By forecasting, one can estimate the future; by setting
objectives, the results to be achieved can be determined by
developing and scheduling programs.
● The activities needed within a set time frame can be defined
by preparing the budget, tools, and resources, which can be
allocated while establishing policies and procedures that will
define the course of action and standards.
2. Organizing
● Includes establishing the structure to carry out plans,
determining the most appropriate type of patient care
delivery, and grouping activities to meet unit goals.
● Other functions involve working within the structure of the
organization and understanding and using power and
authority appropriately.
● Organizing establishes formal authority. It sets up the
organizational structure by identifying groupings, roles, and
relationships within the agency. This is depicted in an
organizational chart.
● The job description defines the qualifications and scope of
responsibilities, relationships, and authorities of the
personnel.
3. Staffing
● Consists of recruiting, interviewing, hiring, and orienting
staff. Scheduling, staff development, employee socialization,
and team building are also often included as staffing
functions.
● Staffing includes determining the staff needed, this
developing and maintaining a staffing pattern.
● The process covers recruiting, selecting, orienting, and
developing personnel to accomplish the goals of the
organization.
● The selected personnel are then distributed in the various
areas of the agency, where they are qualified to belong.
● Staffing schedules are made to meet the needs of the
clients, personnel, and agency.
4. Directing
● Directing sometimes includes several staffing functions.
However, these functions usually entail human resource
management responsibilities, such as motivating, managing
conflict, delegating, communicating, and facilitating
collaboration.
● Directing, or leading actuates efforts to the accomplishment
of goals. This includes utilization of various modalities of
nursing care through the nursing process.
● Updating policies and procedures, supervising personnel to
harmonize work through adequate guidance and leadership,
coordinating personnel and services towards a common
goal, communicating via various routes to ensure common
understanding, developing people by providing staff
development programs, and making sound decisions.
5. Controlling
● Includes performance appraisals, fiscal accountability.
Quality control, legal and ethical control, and professional
and collegial control.
● Controlling leads to the assessment and regulation of
performance of workers.
● To ensure the attainment of objectives, certain standards
are utilized to measure performance, monitor and evaluate
nursing care, including the utilization of resources.
● Control promptly reveals deviations from set plans and
standards, necessitating immediate corrective measures,
actions, and or discipline.
Management Theory Development
● The human relations era of management science brought
about a great interest in the study of workers.
● Many sociologists and psychologists took up this challenge,
and their work in management theory contributed to our
understanding about worker motivation.
● By the late 1960’s, there was a growing concern that the
human relations approach to management was not without
its problems. Most people continued to work in a
bureaucratic environment, making it difficult to always apply
a participatory approach to management.
● The human relations approach was time consuming and
often resulted in unmet organizational goals.
● In addition, not every employee liked working in a less
structured environment. This resulted in a greater
recognition of the need to intertwine management and
leadership than ever before.
● Taylor - scientific management
● Weber - bureaucratic functions
● Fayol - management organizations
● Gulick - activities of management
● Follett - participative management
● Mayo - Hawthorne effect
● McGregor - theory X and theory Y
● Argyris - employee participation
Scientific Management (1900 - 1930)
● Frederick W. Taylor, the father of scientific management,
was a mechanical engineer in the Midvale and Bethlehem
Steel Plants in Pennsylvania in the late 1800s.
 ● Frustrated with what he called “systematic soldering”,
where workers achieve minimum standards doing the least
amount of work possible.
● Taylor postulated that if workers could be taught the 1 best
way to accomplish a task, productivity would increase.
○ Taylor called these principles “scientific
management”.
● The 4 overriding principles of scientific management are:
○ Traditional rule of thumb means of organizing
work must be replaced with scientific methods. By
using time and motion studies, and the expertise
of experienced workers, work can be specifically
designed to promote greatest efficiency of time
and energy.
○ A scientific personal system must be established so
that workers can be hired, trained, and promoted
based on their technical competence and abilities.
Taylor thought that each employee’s abilities and
limitations can be identified so that the worker
could be best matched to the appropriate job.
Workers should be able to view how they fit into
the organization, and how they contribute to the
overall organizational productivity. This provides
common goals and a sharing of the organizational
mission.
○ One way Taylor thought that this could be
accomplished was the use of financial incentives as
a reward for work accomplished. Because Taylor
viewed humans as economic animals, motivated
solely by money, workers were reimbursed
according to their level of production rather than
by an hourly wage.
○ The relationship between managers and workers
should be cooperative and interdependent. The
work should be shared equally. The roles however,
were not the same. The role of managers and
functional foremen, is to plan, prepare, and
supervise. The worker was to do the work.
Bureaucracy: Max Weber
● About the same time that Taylor in 1911 was examining
worker tasks, Max Weber, a well/known german sociologist
began to study large-scale organizations to determine what
made some workers more efficient than others -> webber
saw the need for legalized formal authority and consistent
rules and regulations for personnel in different positions ->
then proposed bureaucracy as an organizational design
● Was written in 1922 in response to what he perceived as a
need to provide more rules, regulations, and structure
within organizations to increase efficiency
● Much of weber's work and bureaucratic organizational
design are still evident today in many healthcare institutions
Human Relations Management #1: 1930-1970
● During the 1920s worker unrest developed. The industrial
revolution had resulted in great numbers of relatively
unskilled laborers working in large factories and specialized
tasks. This, management scientists and organizational
theorists began to look at the role of worker satisfaction in
production
● This human relations era developed the concepts of
participatory and humanistic management emphasizing the
people rather than the machines
● Mary Parker Follett 1926: one of the first theorist to suggest
basic principles of what today would be called participative
decision making or participative management
○ In her essay, the giving of orders, Follett’s believed
that managers should have authority with rather
than over employees. This solutions can be found
that satisfy both sides without having one side
dominate the other
The Human Relations Era #2
● Attempted to correct what was perceived as the major
shortcoming of the bureaucratic system, a failure to include
the human element
● Studies done that Hawthorne works of the western electric
company near Chicago between 1927 and 1932 played a
major role in this shifting focus
○ Studies conducted by Elton Mayo and his Harvard
associates began as an attempt to look at the
relationship between the light illumination in the
factory and productivity
The Hawthorne Studies by Elton Mayo
● Mayo and his colleagues discovered that when management
paid special attention to workers productivity was likely to
increase regardless of the environmental working conditions
● This hawthorne effect indicated that people respond to the
fact that they are being studied attempting to increase
whatever behavior they feel will continue to warrant the
attention
● Mayo in 1953 also found that informal work groups, it is the
socially informal work environment that factors in
determining productivity and Mayo recommended more
employee participation in decision making
Theory X and Theory Y by Douglas McGregor
● McGregor in 1960 reinforced these ideas by theorizing that
managerial attitudes about employees and hence how
management treat those employees can be directly
correlated with employee satisfaction - He labeled this
theory X and theory Y
● Theory X managers believe that their employees are
basically lazy, need constant supervision and direction and
are indifferent to organizational needs; Theory Y managers
believe that their workers enjoy their work, are self-
motivated and are willing to work hard to meet personal and
organizational goals
Emerging Theories: 1970 - present
The Evolution of Leadership Theory
● Because strong management skills were historically valued
more than strong leadership skills, the scientific study of
leadership did not begin until the 20th century
● Early works focus on broad conceptualizations of leadership
such as the traits or behaviors of the leader, contemporary
research focuses more on leadership as a process of
influencing others within an organizational culture, and the
inter interactive relationship of the leader and follower
● To better understand newer views about leadership it is
necessary to look at how leadership theory has evolved over
the last century
Great Man Trait Theories
● Were the basis for most leadership research until the mid-
1940s
● The great man theory, from Aristotelian philosophy asserts
that some people are born to lead whereas others are born
be led. It also suggests that great leaders will arise when the
situation demands it
● Trait Theories assume assume that some people have
certain characteristics or personality traits that make them
better leaders than others
● To determine the traits that distinguish great leaders
researchers studied the lives of prominent people
throughout history. The effect of followers and the impact of
the situation were ignored, although trait theories have
obvious shortcomings such as:
○ Neglect the impact of others or the situation on
the leadership role
● Are leaders born or are they made?
○ Contemporary opponents of trade theories argue
however that leadership skills can be developed
not just inherited that is not to say that some
people don't have certain characteristics or
personality traits that make it easier for them to
lead
○ Leadership skills can be learned although some
individuals have certain characteristics or
personality traits that may make it easier for them
to assume leadership roles. For example Houston
2018 notes that some people, even at a very young
age are more fearless. Others are just naturally
more outgoing, they're more curious and take
more risks. But not all leaders need to be
gregarious by nature.
■ There is lots of room for quiet leadership
in fact some of the most effective
leaders are individuals who didn’t seek
out that rule, the simply grew into it
because they stopped for what had to be
done when no one else would
Contingency Leadership Styles #1
● Includes behavioral theories
● 1940-1980: during the human relations era, many behavioral
and social sciences studying management also studied
 leadership. For example, McGregor’s 1960 theories had as
much influence on leadership research as they did on
management science
● As leadership theory developed, researchers moved away
from studying what traits leaders had and placed emphasis
on what he or she did
● A breakthrough occurred when Lewin (1951) and Lippitt and
White (1960) isolated common leadership styles. Later,
these tests came to be called: Authoritarian, Democratic and
Laissez-faire
● Authoritarian Leadership
○ Results in well-defined group actions that are
usually predictable, reducing frustration in the
work group and giving members a feeling of
security.
○ Productivity is usually high but creativity, self-
motivation and autonomy are reduced
○ Frequently found in very large bureaucracies such
as the armed forces
● Democratic leaders
○ Seek input from their followers and include them
in decision making whenever possible
○ Stoker (2018) suggests that when you ask a person
for his or her ideas or to help you solve the
problem, you're sending the message that you
value the person's ideas and experience and you
are also creating a learning opportunity to hear
something you need to know
○ Appropriate for groups work together for
extended periods, promotes autonomy and
growth in individual workers
○ Democratic leadership is particularly effective
when cooperation and coordination between
groups are necessary
○ Studies have shown however that democratic
leadership may be less efficient quantitatively than
authoritative leadership because it is non-directed
leadership
● Laissez-faire, permissive or free rein
○ Can be frustrating. Group apathy and disinterest
can occur however when all group members are
highly motivated and self-directed, this leadership
style can result in much creativity and productivity
lasers
○ Appropriate when problems are poorly defined
and brainstorming is needed to generate
alternative solutions
○ For some time theorists believe that leaders had a
predominant leadership style and used it
consistently. During the late 1940s and early 1950s
however, theorists began to believe that most
leaders did not fit a textbook picture of any one
style but rather fell somewhere on a continuum
between authoritarian and Laissez-faire
● Theorists came to believe that leaders move dynamically
along the continuum in response to each new situation. This
recognition was a forerunner to what is known as situational
or contingency leadership
Contingency Leadership Styles #2
● 1950-1980: the idea that leadership style should vary
according to the situation or individuals involved was first
suggested almost 100 years ago by Mary Parker Follett, one
of earliest management consultants and among the first to
view an organization as a social system of contingencies
○ Her ideas published in a series of books between
1896 and 1933 were so far ahead of their time that
they did not gain appropriate recognition in the
literature until the 1970s
○ Her law of the situation which said that the
situation should determine the directives, given
after allowing everyone to know the problem was
contingency leadership in its humble origins
● Transactional Leader and Transformational Leadership
○ Similarly, Burns (2003), a noted scholar in the area
of leader-follower interactions, was among the
first to suggest that both leaders and followers
have the ability to raise each other to higher levels
of motivation and morality
○ Identifying this concept as Transformational
Leadership, Burns maintained that there are two
primary types of leaders in management:
1. the traditional manager: concerned with
the day to day operations
2. transformational leader: manager who is
committed, has a vision and can
empower others with his or her own
vision
○ Similarly, Bass and Avolio (1994), suggested that
transformational leadership leads followers to
levels of higher morals because such leaders do
the right thing for the right reason, treat people
with care and compassion, encourage followers to
be more creative and innovative, and inspire
others with their vision. This new shared vision
provides the energy required to move towards the
future
○ Similarly, the American Heart Nurses Association
California (2019) suggests that leaders do more
than delegate, dictate, and direct. They help others
achieve their highest potential
Klutzes and Posner’s Five Practices for Exemplary Leadership (2017)
● Furthered the work on transformational leadership in the
past decade
● Suggests that exemplary leaders foster a culture in which
relationships between aspiring leaders and willing followers
can thrive. This requires five practices:
1. Modeling the way: Requires value clarification and
self-awareness so that behavior is congruent with
values
2. Inspiring a shared vision: entails visioning that
inspires followers to want to participate in goal
attainment
3. Challenging the process: identifies opportunities
and taking action
4. Enabling others to act: fosters collaboration, trust
and the sharing of power
5. Encouraging the heart: recognizes, appreciates,
and celebrates followers and achievement of
shared goals
● Suggests that when these five practices are employed
anyone can further their ability to lead others to get
extraordinary things done
BOOK: Marquis, B.L., & Huston, C.J. (2021). Leadership Roles & Management
Functions in Nursing (10th ed.). Wolters Kluwer
★ Points with a star bullet were used in the PPT presentation
Chapter 3: Twenty-First-Century Thinking About Leadership and
Management
Introduction: Managerial Responsibilities
● The new managerial responsibilities placed on organized
nursing services call for nurse administrators who are
knowledgeable, skilled, and competent in all aspects of
management.
● Now more than ever, there is a greater emphasis on the
business of healthcare, with managers being involved in the
financial and marketing aspects of their respective
departments.
● Managers are expected to be skilled communicators,
organizers, and team builders and to be visionary and
proactive in preparing for emerging new threats such as
domestic terrorism, biological warfare, and global
pandemics.
Introduction: 21st Century
● Struck (2018) points out that the 21st century has seen a
breakdown of some of the long-standing barriers that define
leadership.
● For example, individuals holding high positions of power
traditionally tended to be distant from those they serve.
● Today, anyone can find a way to communicate with almost
anyone else through new technologies. Such individuals no
longer have the zones of privacy that separated their
personal and professional life.
● The new trends are part of a transformational change
brought by digital technology.
Introduction: Nursing and Leadership
 ● Throughout history, nursing has been required to respond to strength-based leadership training group found significant
changing technological and social forces. positive changes in the children regarding internal areas of
● In the last decade alone, a growing elderly population, functioning and social skills, anger management skills, and
health-care reform, reductions in federal and state school attitude.
government reimbursement as well as commercial ● Just changing the framework in which the children were
insurance, and new quality imperatives such as value-based approached from “at risk” to “at promise” seem to make a
purchasing and pay for performance have resulted in major difference.
redesigns of most health-care organizations.
B. Level 5 Leadership
● The concept of Level 5 Leadership was developed by Jim
Factors Affecting Health-Care Trends
Collins and published in his classic book, Good to Great: Why
Some Companies Make the Leap . . . and Others Don’t
● Growing elderly population
(Collins, 2001).
● Health-care reform
● Collins (2001) studied 1,435 companies to determine what
● Reductions in reimbursements
separates great companies from good companies. What he
● New quality imperatives
found was that five levels of leadership skill may be present
● Shift in care to community settings
in any organization.
● Technological advances
● Truly great organizations, however, typically have leaders
● Shift to customer-focused care
who possess the qualities found in all five levels.
● Thus, not only do Level 5 leaders have the knowledge to do
● In addition, the locus of care continues to shift from acute the job but they also have team building skills and can help
care hospitals to community and outpatient settings, groups achieve shared goals.
innovation and technological advances are transforming the ● They also though demonstrate humility and seek success for
workplace, and organizational cultures are increasingly the team, rather than for self serving purposes, a core
focusing on externally regulated, safety-driven, customer- component of another 21st-century leadership theory
focused care. known as Servant Leadership.
● All of these changes have brought about a need for leader- ● Level 5 leaders also know when to ask for help, accept
managers to learn new roles and develop new skills. responsibility for the errors they or their team make, and are
incredibly disciplined in their work.
New Thinking About Leadership and Management
● Given the current health-care system and organizational
Jim Collins’s Level 5 Leadership
complexity, most 21st-century nurse leader-managers will
need to improve and add to their leadership skill toolbox to
Level 1: Highly Capable Individual
meet emerging challenges in the coming decade.
● In addition, they will be required to embrace new roles in
● Leader makes high-quality contributions to their work;
new settings.
possesses useful levels of knowledge; and has the talent and
● Some leader-managers, however, will undoubtedly try to
skills needed to do a good job
use a traditional top-down hierarchical approach in leading
and managing others but will likely find that it no longer
Level 2: Contributing Team Member
works well, if at all.
● Instead, they must seek out more participatory,
● Leader uses knowledge and skills to help their team succeed;
transdisciplinary, and collaborative models which are not
works effectively, productively, and successfully with other
easy to develop.
people in their group
● For example, new research on leadership, including full-
range leadership theory, is rediscovering the importance of
Level 3: Competent Manager
organizational context, levels of analysis, and potential
boundary conditions on transformational leadership.
● Leader is able to organize a group effectively to achieve
● Indeed, many recent leadership and management concepts
specific goals and objectives
focus on the complexity of the relationship between the
leader and the follower and much of the leadership research
Level 4: Effective Leader
emerging in the second decade of the 21st century builds on
the interactive leadership theories developed in the latter
● Leader is able to galvanize a department or organization to
part of the 20th century.
meet performance objectives and achieve a vision
● As a result, concepts have emerged as part of the leader-
manager’s repertoire for the 21st century such as:
Level 5: Great Leader
a. Strengths-based leadership
b. Level 5 Leadership
● Leader has all of the abilities needed for the other four levels,
c. Servant leadership
plus a unique blend of humility and will that is required for
d. Principal agent theory
true greatness
e. Human and social capital theory
★ Level 5 Leadership is characterized by knowledge, team
f. Emotional intelligence (EI)
building skills, the ability to help groups achieve goals,
g. Authentic leadership
humility, and the empowerment of others through servant
h. Thought leadership
leadership.
i. Quantum leadership
● Level 5 leaders also possess qualities found in the four other
levels of leadership.
A. Strengths-Based Leadership and the Positive Psychology
● It is not necessary to pass sequentially through each
Movement
individual level before becoming a level 5 leader but the
★ Strengths-based leadership, which grew out of the positive
leader must have the skills and capabilities found in each level
psychology movement (began in the late 1990s), focuses on
of the hierarchy to be a top performing leader.
the development or empowerment of workers’ strengths as
opposed to their weaknesses or areas of needed growth.
● Thus, strengths-based leadership is part of the development C. Servant Leadership
of positive organizational scholarship, which focuses on ● Although Greenleaf (1977) developed the idea of servant
successful performance that exceeds the norm and leadership more than 35 years ago, it continues to greatly
embodies an orientation toward strengths and developing influence leadership thinking in the 21st century.
collective efficacy in organizations ● In more than four decades of working as director of
★ Research suggests that using a strengths-based approach, leadership development at AT&T, Greenleaf noticed that
even at a young age can have a profound impact on the most successful managers lead in a different way from
ability of individuals to self-manage and to regulate their traditional managers.
emotions. ★ These managers, which he termed servant leaders, put
● A study by Dennison, Danielle, Groberg, Kavanaugh, and serving others, including employees, customers, and the
Mayfield (2018) of 5th and 7th graders exposed to a brief community, as the number one priority.
 ● This choice between personal advantage and organizational
advantage speaks to the heart of servant leadership.
★ The win-win is challenging when you win later and others
win sooner. In addition, servant leaders foster a service
inclination in others that promotes collaboration, teamwork,
and collective activism.
● Ken Blanchard, author of Servant Leadership in Action: How
You Can Achieve Great Relationships and Results notes
however that although servant leadership is about leading
from the ground up, it still requires leadership and that
aspect is often forgotten (Cruz, 2018).
● Servant leaders must still create and communicate their
vision, direction, and goals.
● Followers must be clear about what the leader is trying to
accomplish as well as their values and goals.
● Once that is clear, the pyramid can be turned upside down
so that the leader can begin to help.
● Followers live according to the vision of values and goals and
be successful.
★ Remember that followers are an important part of the
leadership equation
D. Principal Agent Theory
● Principal agent theory, which first emerged in the 1960s and
1970s, is another interactive leadership theory being actively
explored in the 21st century.
● Occurs when one person (the agent) can make decisions on
behalf of another person (which is the principal).
● In this situation, there are issues of moral hazard and
conflicts of interest.
★ This occurs because not all followers (agents) are inherently
motivated to act in the best interest of the leader or
employer (the principal).
● This is because followers may have an informational
(expertise or knowledge) advantage over the leader as well
as their own preferences, which may deviate from the
principal’s preferences.
● The risk then is that agents will pursue their own objectives
or interests instead of that of their principal.
E. Human and Social Capital Theory
Human Capital
★ represents the capability of the individual
○ Refers to the collective skills, knowledge, or other
intangible assets of individuals that can be used
to create economic value for the individuals, their
employers, or their community
○ Human capital can refer to a group’s collective
knowledge, skills, and abilities.
Social Capital
★ represents what a group can accomplish together
● The traditional view of employees as costs is not obsolete.
● Instead, employees are now viewed as assets or capital that
can be developed and nurtured.
● Human capital theory suggests that individuals and/or
organizations will invest in education and professional
development if they believe that such an investment will
have a future payoff.
● For example, a health-care organization that provides tuition
reimbursement for nurses to go back to school to earn
higher degrees is likely doing so in anticipation that a more
highly educated nursing staff will result in increased quality
of care and higher retention rates—both of which should
translate into higher productivity and financial return.
F. Emotional Intelligence
Another leadership theory gaining prominence in the 21st century is
the EI or Emotional Quotient.
● Refers to the ability to use emotions effectively and is
required by leaders/managers in order to enhance their
success.
● This refers to the ability to perceive, understand, control
one’s emotions as well as those of others.
● Gabriel (2018) suggests that it is our EIs that give us the
ability to read our instinctive feelings and those of others.
● It also allows us to understand and label emotions as well as
express and regulate them.
● Gabriel (2018) suggests that many people overestimate their
EI because they think that it is the ability or tendency to
nice, it’s not. Instead it is about being empathetic; being able
to look at situations from alternative points of view; being
open-minded; bouncing back from challenges; and pursuing
goals despite challenges.
● Some proponents of EI have suggested that having EI may
even more critical to leadership success than Intellectual
Intelligence or IQ.
● Emotional intelligence is critical for building a cooperative
and effective team.
Five Components of Emotional Intelligence
Goldman (1998) in his best seller, Working with Emotional
Intelligence, built in his work his identification of 5 components of EI:
● Self-awareness: The ability to recognize and understand
one’s moods, emotions, drives, as well as their effects on
others.
● Self-regulation: The ability to control or redirect disruptive
impulses or moods as well as the propensity to suspend
judgment.
● Motivation: A passion to work for reasons that go beyond
money or status. A propensity to pursue goals with energy
and commitment.
● Empathy: The ability to understand and accept the
emotional makeup of other people.
● Social skills: Proficiency in handling relationships and
building networks and ability to find common ground.
G. Authentic Leadership
● Another emerging leadership theory for the contemporary
leader manager’s arsenal is that of authentic leadership, also
known as Congruent Leadership.
● Authentic leadership suggests that in order to lead, leaders
must be true to themselves and their values and act
accordingly.
● Integrity is conformance between what leaders profess and
how they actually act.
Francesca Gino’s Eight Principles of Rebel Leadership
Thought leadership and rebel leadership, relatively new leadership
theory to emerge in the 21st century is that of thought leadership,
which is applied to a person who is recognized among his or her peers
for innovative ideas and who demonstrates the confidence to promote
those ideas. Thus, thought leadership refers to any situation in which
one individual convinces another to consider a new idea, product or
way of looking at things.
Gino’s Eight Principles of Rebel Leadership are:
● Seek out the new.
● Encourage constructive dissent.
● Open conversations—don’t close them.
● Reveal yourself– and reflect.
● Learn everything—then forget everything.
● Find freedom in constraints.
● Lead from the trenches.
● Foster happy accidents (mistakes may unlock a
breakthrough).
Characteristics of Agile Leadership
Another newer leadership theory is Agile Leadership, a term borrowed
from the software world. Agile leaders have the ability and agility to
think in many ways so that they can be:
● Fast, flexibile, and adaptable decision making.
The Center for Agile Leadership (2018) concurs noting that agile
leaders are inclusive, democratic leaders who exhibit a greater:
● Openness to ideas and innovation.
Agile leaders listen deeply and ask powerful questions to gain insights
and make the right decisions to help the organization move forward
through problems. Agile leaders also quickly adapt to situations as
they come along and are flexible and open to change and growth. In
addition, agile leaders demonstrate agility with their employees.
Indeed, agile leadership was proposed to meet the needs of the
millennial workforce, which has different needs, different wants, and
different motivators than any generation before them.
● Inclusive and democratic approach to followers.
H. Thought Leadership
● Thought leadership refers to any situation whereby one
individual convinces another to consider a new idea,
product, or way of looking at things.
 ● In other words, thought leadership is the expression of ideas
that demonstrate that you have expertise in a particular field
area or topic.
● Many executives and business leaders try to become
thought leaders in their respective fields. It takes dedication,
patience, strategy, and education.
● Most thought leaders not only have a command of their
subject area, they are passionate about it and eager to share
their knowledge with others to benefit a company,
organization, or cause.
● Thought leaders attract followers not by any promise of
representation or empowerment but by their risk taking and
vision in terms of being innovative.
● Thought leaders are informed opinion leaders and the go to
people in their fields of expertise. They become the trusted
sources who move and inspire people with innovative ideas;
turn ideas into reality; and know and show how to replicate
their success.
● Over time, they create a dedicated group of friends, fans,
and followers to help them replicate and scale their ideas
into sustainable change, not just in an industry nature across
an entire ecosystem.
I. Quantum Leadership
● This is another relatively new leadership theory that is being
used by leader manager to better understand dynamics of
environments, such as healthcare.
● This theory emerged in the 1990s builds on transformational
leadership.
● Suggests that the environment and context in which people
work is complex and dynamic and that this has a direct
impact on organizational productivity.
● This is especially true during periods of rapid change and
needed transition.
● Because the healthcare industry is characterized by rapid
change, the potential for intraorganizational conflict is high.
● Porter O’Grady and Malus (2015) suggest that because the
unexpected is becoming the normative, the quantum leader
must be able to address and unsettle the space between
present and future and resolve these conflicts appropriately.
● In addition, they suggest that the ability to respond to the
dynamics of crisis and change is not only an inherent
leadership skill but must now also be inculcated within the
very fabric of the organization and its operation.
Comparing Industrial and Relationship Age Leadership
● In considering all these emerging leadership theories, it
becomes apparent that a paradigm shift has taken place
early in the 21st century: a transition from industrial age
leadership to relationship age leadership.
● Scott (2006) condensed that Industrial Age Leadership focus
primarily on traditional hierarchical management structures,
skill association, competition, and control. These are the
same skills traditionally associated with management.
● Relationship Age Leadership focuses primarily on the
relationship between the leader and his or her followers on
discerning common purpose working together cooperatively
and seeking information rather than wealth.
● The table differentiates between the Scientific/Industrial Age
and the Relationship/Information Age.
● Tamara McCleary, a speaker, author, and business expert
suggests that employee engagement is the key to
relationship building in the 21st century.
● To build this engagement, McCleary invests time, energy,
and passion into caring about employees. She also
constantly checks to see whether her plans, decisions, and
actions are building relationships effectively and she refines
those actions if they don’t.
○ McCleary’s 3 step action plan for engaging
employees to build relationships is shown in
display 3.8 in the textbook.
● Leading and managing in the 21st century promises to be
more complex than ever before, and leader-managers will
be expected to have a greater skill set than ever before.
○ Contemporary leader managers then, are
challenged not only to know and be able to apply
classical leadership and management theory but
also to keep abreast of new insights, new
management decision making tools, and new
research in the field.
○ It is more important than ever that leader
managers be able to integrate leadership roles and
management functions and that some balance be
achieved between industrial age leadership and
relationship age leadership skills.
○ The key to organizational success will likely be
having enough highly qualified and visionary
leader managers to steer the course.
STRATEGIC PLANNING
WHAT IS PLANNING
P- process of establishing goals
● SMART (Specific, Measurable, Attainable, Realistic, Time-
bounded)
L- leads to change with known facts
● If you have a plan, it means it will actually lead to change
(change is the only constant thing in this world)
● Without adaptation to change we might be left behind
● When we plan, use evidence-based facts as the basis of our
planning
A- A forecasting of events
● You have this vision in your mind on things that will actually
be expected of what will happen of the organization in the
end because you have a plan prior to that.
N- need to find answers to Wh & H questions
● What, Where, When, Who, Why, How
● You have to make you have the answers to these questions
as the basis for the planning
VARIOUS PLANNING SAMPLE
● Business planning
● Program planning
● Career planning
● Performance planning
● Disaster planning
● Management planning
- Focus for this subject
- Planning is the first step in our management function
PLANNING MODES
R- reactivism
● Occurs after a problem exists.
● From the word REACT: a problem has already existed; it is
done in response to a crisis
● Because there is dissatisfaction with the current situation,
planning efforts are directed at returning the organization to
a previous, more comfortable state.
● Problems are dealt with separately without integration with
the whole organization.
● Because it is done in response to a crisis, this type of
planning can lead to hasty decisions and mistakes.
● Probably commit several mistakes especially when you are
going to react immediately with the occurrence of a
situation
I - inactivism
● Type of conventional planning where the person considers
the status quo as a stable environment
● Formula in identifying the status quo: N/2 + 1 → majority
(e.g. 10 members in a group; 10/2 is 5; 5 + 1 is 6; Status quo
is 6.)
● Inactivists seek the status quo, and they spend their energy
preventing change and maintaining conformity.
● There is a majority decision
● When changes do occur, they occur slowly and
incrementally.
P- pre-activism
● Preactive planners utilize technology to accelerate change
and are future oriented.
● Unsatisfied with the past or present, preactivists do not
value experience and believe that the future is always
preferable to the present.
 ● FOCUS: Future and utilize technology to help make a
decision
I- inter-activism
● Proactive planning.
● Planners who fall into this category consider the past,
present, and future and attempt to plan the future of their
organization rather than react to it.
● Because the organizational setting changes often,
adaptability is a key requirement for proactive planning.
● Proactive: flexible, adaptable, and highly innovative
● Proactive planning occurs, then, in anticipation of changing
needs or to promote growth within an organization and is
required of all leader-managers so that personal as well as
organizational needs and objectives are met.
LEVELS OF PLANNING IN NURSING
S- strategic planning
● Development plan
● Futuristic in nature
● Contingency or the plan for possible disasters or calamities
● Occur 3-5 years or more
● The ones involved are the chief executive officers, chief
operations officers, division/department heads, and chief
nurses
● It exists further in the future; sometimes it will be extended
after 5 or 10 years
I- intermediate planning
● Done in 6 months - 2 years
● Involve department heads in the nursing service such as the
supervisors, head nurses, and clinical specialists
O- operational planning
● Done 1 week to 1 year
● Managers of the nursing unit, head nurses, charge nurse,
primary care nurse, and team leader are involved
● Most common example: Nursing Care Plan (NCP) because it
is a day-to-day basis
STEPS IN STRATEGIC PLANNING
S- set up clearly define purpose
● It is the best time to have your MISSION
● Mission is the reason of your existence
T- think of realistic goals
● Vision, Mission, Goals (VMG)
R- re-align purposes & operations
● There is a need to make sure that there is realignment of the
purposes and operational activities in your organization
because it will be significant that this realignment will adapt
to the current situation of your organization
A- allow communication to flow
● Up and down communication
● Vertical or horizontal
T- the sense of ownership
● Take into consideration that all of the members in your
organization has the ownership of the plan
● The ownership itself can avoid possible blaming in the end
E- elicit strategies to goals
● There are strategies that will be employed to achieve the
goals that we wanted in the organization
● These strategies will be of help in the achievement of the
goals that has been prepared ahead of time
G- give the most effective use
● Ensure that the most effective use is made of the
organization’s resources
● Appropriate resources and it is properly maximized
I- initiate a base of progress
● Progress of the specific planning
● This can be measured using the standard objective
formulation → SMART
C- change has to be mechanized
● Make sure that the people will adapt to change in the
organization
S- solid consensus of direction
● Make sure that all of you are one in the journey together
● Building of consensus as to where the organization is going
● Everyone needs to be involved in the strategic planning
WHO SHOULD BE INVOLVED IN STRATEGIC PLANNING
T- top level managers
O- officers/board of directors
P- personnel in first-level management
● Long-range planning for health-care organizations
historically has been accomplished by top-level managers
and the board of directors, with limited input from middle-
level managers.
● To give the strategic plan meaning and to implement it
successfully, input from subordinates from all organizational
levels may be solicited.
● There is increasing recognition, however, of the importance
of subordinate input from all levels of the organization to
give the strategic plan meaning and to increase the
likelihood of its successful implementation.
● The first-level manager is generally more involved in long-
range planning at the unit level.
● However, because the organization’s strategic plans affect
unit planning, managers at all levels must be informed of
organizational long-range plans so that all planning is
coordinated.
● All organizations should establish annual strategic planning
conferences, involving all departments and levels of the
hierarchy; this action should promote increased
effectiveness of nursing staff, better communication
between all levels of personnel, a cooperative spirit relative
to solving problems, and a pervasive feeling that the
departments are unified, goal directed, and doing their part
to help the organization accomplish its mission.
PURPOSE OF PLANNING
D-Directs the organization
● If there is a proper plan, it directs where the organization is
going
I-Improves management functions
● Management function starts with planning, therefore when
you have a very wonderful plan, there will be an expected
good management functions
R-Resources are maximized
● Effective utilization of the resources available
E-Effective measure for controlling
● It is very important to make sure that there is a “best plan”
because that will be good in the controlling aspect of the
organization
C-Cost effective phase of management
T-Total enhancement of human resource
● Best resource in the organization: human resource or the
personnel
SWOT Analysis
● There are many effective tools that assist organizations in
strategic planning, one of the most commonly used in
healthcare is the utilization of SWOT Analysis. It involves
identification of:
○ S - trengths
○ W - eaknesses
○ O - pportunities
○ T - hreats
● SWOT analysis can also be known as TOWS.
● Developed by Albert Humphrey at the Stanford University in
the 1960s and early 1970s
● The first step in SWOT analysis is to make sure that there is a
desired end state or objective
● The desired end objective is defined
● SWOT are being discovered and listed
● The decision makers must then decide if the objective can be
achieved; If not, a different objective is selected and the
process then repeats.
● Important: there should be an applicable objective prior to
proceeding to another objective
Components of SWOT Analysis
● Strength
○ internal attributes that help an organization to
achieve its objectives
○ What are you considered best of?
○ Characteristics that are actually at par of other
organizations
● Weaknesses
○ Internal attributes that challenge an organization
in achieving its objectives
○ Challenge; probably a limitation. This limitation
can be addressed because the organization will be
 doing its best in order to achieve what is best for
the organization
● Opportunities
○ External conditions that promote achievement of
organizational objectives
○ Diverse opportunities available in the community
or organization for these people to grow
● Threats
○ Threats in the achievement of organizational
objectives
○ It will be important to as much as possible limit the
threats in our organization for it might actually
affect the effectiveness or quality of the output at
the end of the planning
Simple Rules of SWOT analysis (SWOTSS)
S-
● Strengths and weaknesses should be realistic
● It should be realistic as it would be the flow or direction of
your people or subordinates
W-
● What might be possible in the future must be clear
● It is important to make sure that you know the difference
between the possibilities of the future in your organization
(has to be written)
O-
● Observe specific goals needs to be accomplished
● This will be the basis of the achievement of your
organization’s plan
T-
● To apply SWOT with competitors
● SWOT analysis has to be applied against a competitor and
that competitor is going to be the basis where your
organization is as of the moment
S-
● SWOT is short and simple
● No flowery words
S-
● SWOT is subjective
● Based on how you feel, what is existing, and the response of
the people involved in the SWOT analysis
Balanced Scorecard
● Another way of evaluating the planning
● originally developed by Dr. Robert Kaplan of Harvard
University and Dr. David Norton in the early 1990s
● A tool that is highly assistive in strategic planning
● Measures alined individual, departmental, organizational
goals and identify an entirely the new processes for meeting
customers and shareholder’s objectives
● All of the measures are considered to be related and
because the measures are assumed to eventually lead to
outcomes, overemphasis on financial measures is avoided →
the scorecard is then balanced and the outcomes are
imbalanced
● Also allow organizations to align their strategic activities with
the strategic plan
● The best balanced score cards are not static, it has to be
proactive sets of measurements that instead reflect the
dynamic nature of the organizational environment because
the balanced scorecard is able to translate strategy into
action.
● It is an effective tool for translating an organization’s
strategic vision into a clear and realistic objective
● Metrics
○ Performance indicators
○ Collect data
○ Analyze data
● Organizational perspectives
○ Financial
○ Customers
○ Processes
○ Learning and growth
Phases in Planning
This will guide us on what is expected of us in the organization
● D - Determine Objective
● C - Collect Vital Data
● D - Develop Action
● E - Evaluate Plan
Scopes of Planning
Talks about the planning hierarchy
1. Forcast
○ Estimate the future
○ Short or long range projections
○ Important as it will give us an opportunity to take
into consideration the journey of the organization
that we are going to be in or belong
● It becomes broader as you move along the bottom part of
the planning hierarchy
1. Vision/Mission
○ Vision is the description of the future goals or aims
of the organization. It is a description in words that
conjures up a picture for all group members for
what they want to accomplish together.
■ Critical as organization leaders recognize
that the organization will never be
greater than the vision that guides it
■ In the board exam, the most common
question that talks about vision is going
to be your imagined future
○ Mission is the brief statement, typically no more
than 3 or 4 sentences, identifying the reason that
organization exists
■ In the board exam; the question that has
been talking about your mission is the
reason of existing (the purpose why the
organization exists)
■ Identifies the organization’s constituency
and aggresses its position regarding
ethics, principles, and standards of
practice
■ The reason why you are existing as an
organization
2. Philosophy
○ Flows from the purpose or mission statement and
dealinates a set of values and beliefs
○ The most common question in the board
examination of your philosophy is values and
beliefs
○ Guides all actions of the organization
○ Basic foundation that directs all further planning
toward that mission
○ A statement of philosophy can usually be found in
policy manuals at the institution or is available
upon request
○ Different types of Philosophy
■ Organizational Philosophy is providing
you the basis for developing nursing
philosophies at the unit level and for
nursing service as a whole. It talks about
the entire organization
■ Nursing Service Philosophy is addressing
the fundamental beliefs about nursing
and nursing care. It also talks about the
quality, quantity, and scope of nursing
services and how nursing specifically will
meet the organizational goals
■ Unit Philosophy adapted the nursing
service philosophy. This specifies how
nursing care, provided on the unit, will
correspond with nursing service as as
organizational goal
3. Goal
○ Defined as the desired result toward which effort
is directed
○ It is the aim of the philosophy
○ Goals are broad. These are the general objectives.
4. Objectives
 ○ Similar to goals as they motivate people to a
specific end and are explicit
○ These are the specific objectives
○ Follows the SMART method in identifying the
objectives (Specific, Measurable, Attainable,
Realistic, Time-bounded)
5. Policies
○ Plans reduced to statements or instructions that
direct organizations in their decision making
○ These comprehensive statements, derived from
organization’s philosophy, also including the goals
and objectives will help in explaining how goals will
be met and guide the general course and scope of
organizational activities (focusing more on
objectives)
○ Types of Policies
■ Implied Policies are neither written nor
expressed verbally. It is already
considered to be implied. It is developed
over time and follow a precedent
■ Expressed Policies delineated verbally or
in writing . Most organizations have
written policies that are readily available
for people to read, at the same time this
will promote consistency of action. May
include the following: dresscode, policy
for sick leave, disciplinary procedures,
etc
6. Procedures
○ Plans established customary or acceptable ways of
accomplishing a specific task and delineate a
sequence of steps of required action. Established
procedures save staff time or facilitate delegation,
reduce cost, increased productivity, and provide a
means of control
○ Identifies the process or steps needed to
implement a policy and are generally found in the
manuals at the unit level of the organization
○ There will be a specific set of procedures that are
included in the manual and it will be the basis for
the people or subordinates to follow, especially in
the performance of specific procedures that will
usually follow the standards steps in a given
procedure
7. Rules
○ Rules and regulations
○ Plans that define a specific action or nonaction.
○ Generally included as part of policy and procedure
statements, rules describe situations that allow
only one choice of action. (prioritization)
○ Rules are fairly inflexible, so the fewer rules, the
better.
○ Existing rules, however, should be enforced to
keep morale from breaking down and to allow
organizational structure.
Scopes of Planning
2. Set Goals or Objectives
○ Goals - broad
■ Achieve goals through objectives
○ Objectives - specific
■ SMART
■ Behavioral (Bloom’s Taxonomy)
3. Develop and Schedule Strategies, Programs, Activities. Set
time frame
○ Strategy
■ Overall plans of the higher management
system
○ Programs
■ Series of activities that function together
to facilitate attainment of some desired
goals
4. Prepare Budget
○ Allocation of resources or systematic plan of
meeting expenses
○ Purpose is to set operating cost limits
5. Policies
○ Are guides of basic rules that define the general
course and scope of activities
6. Procedures
○ Step by step guide to action
7. Rules
○ Describe the situation that allow only one choice
of action
Types of Standards
These standards will be the basis for evaluation of the plan
S - structure
● Those that focus on the structure or management system
use to deliver care including number and categories of
personnel
● Common in the board examination; when talking about
structure standards: equipment, building, other tangible
things
● Evaluate and have an inventory
P - Process
● Actual procedure itself
● Those activities that engage in to administer care
● Board exam; asked about process: it is the steps, procedure,
or methods
O - Outcome
● The result of the procedure and nursing care
● Usually, you will be asked on what results occurred as a
result of the interventions
● Evaluation aspect of planning
Overcoming Barriers to Planning
B - be able to establish goals
A - allows flexibility of plan
R - remember to include all affected people by a plan
R - realistic, specific, and simple plan
I - initiate when to plan
E - evaluation checkpoints are built-in
R - re-evaluate at the end of the plan
Integrating Leadership Roles and Management Functions in Planning
Leadership
● P - personally prepared
● L - leads sensitivity
● A - appraise accurately
● N - need to take risks
Management
● N - needs theory expertise
● I - Initiate unit assessment
● N - needs to be receptive
● G - gives emphasis to vision, mission, philosophy
Planned Change
Sir Joseph B. Abang
“The nature of leadership is resistance and change.” - Scott Mabry
● If there is leadership, there will be an accompaniment of
resistance due to presence of change.
● Planned change is ‘overt’ meaning the people are aware of
this change.
● Planned change is also ‘covert’ meaning hidden or occurs
without the people’s awareness.
● Planned change may be gradual or sudden.
● If there is unplanned change, there is an alteration imposed
by external factors and it occurs with unexpected
event/force/reaction.
● Major change may bring feelings of achievement, loss or
feelings of stress.
Planned Change
● In contrast to accidental change or change by drift, it results
from a well thought out and deliberate effort to make
something happen.
● It is a deliberate action or application of the knowledge and
skills of a leader to bring change.
● Successful leader manager must be well-rounded in the
presence of the change theories and be able to apply these
theories appropriately in response to the implementation of
change.
1. Change Agents
a. Persons who are skilled in the theory and
implementation of planned change.
b. People who deal appropriately with conflict
regarding conflicted human emotions and to
connect and balance all aspects of the organization
that would be affected by the change.
2. Types of Change
 a. Personal
○ What you want to change in your own
self.
b. Professional
○ Academic preparations or skill expertise
c. Organizational
○ Manager is the change agent
○ Having change in the organization e.g.,
leadership positions, creating new
departments
3. Strategies of Change Agents
a. Power coercive
○ When you comply to the plans and at the
same time direction of the more
powerful
○ E.g., Strikes, sit ins, negotiations,
creations of unions.
b. Empirical rational
○ People are willing to adapt or change if it
is justified and they are shown how they
can benefit from the change.
○ Based from logic data and evidence-
based practice
○ Since it talks about rational, it has to be
logic in nature
c. Normative reeducative
○ Based on the assumption that people act
according to their commitment to
sociocultural norms
○ Focused on the norm
○ E.g., staff training
Kurt Lewin's Phases of Planned Change (Change Theory)
● Unfreezing
○ When a change agent convinces members of the
group to change
○ When guilt, anxiety, and concerns can be elicited
so that people become discontented and aware of
a change to need.
○ NO change is going to occur yet because you are
still introducing change
● Movement/changing
○ Change agent is focused more on planning,
identifying, and implementing appropriate
strategies that ensure driving forces exceed
restraining forces.
○ Trying to identify the best action to be
implemented in order for the change to occur.
● Refreezing
○ Change agent assists in establishing the system so
that it becomes integrated in the status quo.
○ There is already acceptance of the entire majority.
○ If refreezing is incomplete, the change will be
infective and the pre-change behavior will resume.
○ At this stage, you have to make sure that the
majority is adapting to the change that has
happened.
Responsibilities of Change Agent (unfreezing)
● S- sufficient data gathering
○ Data that will prove that there is a need for change
to occur.
○ Without this, people will not believe you and not
trust you.
● T- take time to diagnose
○ Accurate diagnosis of the need for change is
essential.
○ Without that, it means that you will not be able to
succeed.
● O- observe & decide if change is needed
○ Thinking about the possibility that there is a need
for you to decide from the solution or present
alternatives especially if there is a need for change.
● P- promote awareness to others
○ Often involves deliberate tactics to raise the
group’s discontent level in order for you to
proceed to the next stage until the status quo has
been disrupted.
○ Need for change is perceived by others.
○ Introduce vital information to others.
Responsibilities of change agent (movement)
● M-make a plan
○ That plan will be the basis of identifying whether
or not that a particular plan will be feasible in the
implementation of change.
● O-often set goals
● V-verify support/resistance
○ Identify areas of support and resistance because it
will be your basis on whether you should focus on
the support or resistance.
● E- everyone is included
○ Include everyone that will be affected by the
change because it will be the basis of the people
whether to participate, support, or resist.
● M- make target dates
○ Make time tables and decide on the dates that will
give you the best time on when to have this
specific change implemented.
● E- enhance strategies
○ Important in the implementation of change.
● N- now implement change
○ The best time to implement change. Implement
the strategies or techniques that you want to
employ now.
● T- to offer support to others
○ Be available to support others where you are going
to encourage others through the implementation
of change.
● S- strategize to resistance
○ Use strategies in order for you to overcome the
presence of resistance.
● T- take time to evaluate
○ Will be the basis of the thing that you are going to
have in mind especially if you need to have the
change entirely.
● O- opt to modify if needed
○ Modify if there is so much resistance from the
people involved in change.
Responsibilities of Change Agent (unfreezing)
● Support others for change to continue
○ You have to support and empower others so that
they are given the opportunity to grow while
change is being implemented.
Forces in Planned Change
Two forces used by the change agent in the implementation of
change. Kurt Lewin, 1951 theorized that people maintain status quo or
equilibrium or balance by the simultaneous occurrence of these
driving forces. There should be a balance between these forces to
succeed in the planned change.
● Driving - force that push towards change
○ These are the facilitators
○ Advance a system toward change
○ A force that push towards change
● Restraining - force that pulls away change
○ These are the barriers
○ Force that pulls away/impede change
Stages to Change Model (Barrows? and Meads?, 2009)
Stage 1: Precontemplation
● The individual has no intentions to change his or her
behavior in the foreseeable future.
● There is no need for that person to change because there is
no intention at all.
● Part of unfreezing
Stage 2: Contemplation
● Individuals consider making a change but have not yet made
a commitment to take action.
● Where unfreezing will usually occur.
Stage 3 Preparation
● Transition from unfreezing to movement
● Movement stage
● Individual intends to make action in the short term future
Stage 4 Action
● When the individual actively modifies his or her behavior.
● Probably adapting to change already
● Part of movement stage
Stage 5 Maintenance
● Individual work to maintain changes made during the action
stage and prevent relapse.
● Refreezing stage
Behaviors in Response to Change
● Innovators
○ Love change and thrives on it.
○ They first recognize the problem, they already
have a solution that they tried and they are eager
to share how the solution worked.
○ Base their change ideas on creative and critical
thinking and analytical observation
○ Includes insight, scientific literature
○ Play an important role in the diffusion process
○ Managers identify innovators in the unit - more
innovators in the unit, it will lead to a visionary and
progressive environment
○ Think about staff members who frequently come
to you with problems
● Early adopters
○ Staff to approach first with a new idea
○ They quickly see the benefit of the change and go
with it; fine-tuning it to increase viability
○ Have the greatest degree of opinion and can
influence the majority
○ ‘Change champions’
○ Managers can identify these people by doing daily
operations and staff interaction
● Early majority
○ The staff who eventually go along with the flow
sooner than others
● Late majority
○ The staff who eventually go along with the flow
○ May go along together with early majority
● laggards
○ Staff that want no part in change
○ Exhibit the greatest resistance
○ Require great motivation to make them change
such as formal policies, integrating certain
behaviors for the mandatory
○ As a manager, you must focus on these people as
they might actually resist change
● Rejecters
○ People that will not adapt with change because
the focus of this people is that they don't want
change
○ Will not support the planned change
Planned Change as Collaborative Process
P-people meet to discuss
● Let people be involved in the discussion
R-rule to include all affected
● Rule to include everyone especially in the discussion
O-openly develop goals
● Achievement of the things that you want in the organization
C-change interest is defined
● There has to be a definition of the greater interest of all
E-empower early adopter
● This early adopter will usually be of help especially in
convincing other people to follow change. Through this, it
would be easier for you to achieve the change (from the
laggards and may even change the motivation of the
rejecters.
S-share perceptions
● Share to all
S-support open conversation
● Essential because it will be of help in making sure that these
people will actually voice out their feelings
● Discouragement or dissatisfaction can be discussed with
properly
Leader-Manager as Role Model
M-models of change
● You have to be the role model as a leader
● You yourself have to adapt to the presence of that change
O-offer positive views
● Help people adjust with change
● Tell them the positive outcome of the change
D-deal it with confidence
● It is essential that you are not confuse of your decision
● You have to deal with it with confidence so that the people
will also have the interest to adapt to change
E-embrace it as challenge
● In order for you to limit the presence of resistance
L-level up engagement
● People will be of help if they are engaged especially in the
implementation of the planne change
Nonlinear Dynamics
● Complex Adaptive Systems(CAS) Theory
○ The relationship of elements or agents within any
system is nonlinear.
○ These elements are constantly in play to change
the environment or outcomes.
○ Nonlinear means that it has this inverse
relationship. It means that they will not go
together.
○ The relationship of elements is not going together
○ There will be instances that there is a great impact
with driving and restraining forces which are
present in nonlinear dynamics.
● Chaos Theory
○ Finding the underlying order in random data
○ You are going to identify the most relevant data or
the underlying cause why these people are
resistant to change.
Integrating Leadership Roles and Management Functions in Planned
Change
Leadership
P-proactive inventor/creator
● Create something new
L-look for trends and changes
● take into consideration what are the trends/norms in the
community
A-ability to articulate & tenacious
● You have to know how to articulate the purpose of that
change in the organization
N-need to retain a big picture focus
● Go for what is actually the vision
N-need to be confident, flexible
E-environmental factors evaluated
● These factors could actually be a hindrance to planned
change
D-do proactive preparations
● Be responsive with what is actually occuring in the
community
Management
C-cognizant of forces
● Have the knowledge or be aware of the restraining or driving
forces
H-has clear process understanding
● Make sure that you know the process and methods
implemented
A-a mechanic to implement change
● In leadership, you are the inventor or creator but here in
management, you are the mechanic where you will be the
one to implement it
N-needs to be a proactive agent
● Be responsive
G-generally can apply work change
● Apply professional and organizational change in your
organization
E-engage resources for change
● Involve resources for your planned change for your
organization
● Integration of leadership roles and management function in
your planned change
Time Management
Pareto Principle
● 20% focused effort with 80% outcome.
○ This exemplifies work smartly, 20% focus has a
greater percentage of outcomes in the end.
● 80% unfocused effort with 20% outcome.
○ This means that the person focuses on things that
are not that important, which will yield only 20%
of the outcome.
○ Work harder.
Time Management
● T - to have more work in less time.
○ You are accomplishing the most important tasks
on a daily basis, and you are having your work in
the least time possible.
 ● I - increase opportunity for advancement.
○ You will be able to proceed to another work as you
are already done with the previous one.
● M - making optimal use of available time.
○ Time is precious, if you will not do something with
your time, you will not be able to repeat time, and
you are not able to do what is lacking because you
wasted your time.
● E - exert work that is smarter not harder.
4 Steps in Time Management
1. T - time to establish priorities
● It is important for you to make sure that there are priorities
in the things you have to do. This will guide you on what to
do first and last.
● Prioritization is making sure that the most important
activities are performed ahead of time compared to those
that are less important.
2. I - into finishing a task
● As much as possible, you have to do a task first before
proceeding to another.
3. M - move to another task
● If you are done performing a task, then you now have the
opportunity to move to another task.
E - examine and re-prioritize
● When you have already examined that you were able to
perform the task when, this means that you are capable of
re-prioritizing your activities.
Priority Setting
● Take into consideration these 3 levels of prioritization:
○ Don’t do - you avoid doing these things because
they are time consuming and not a priority.
○ Do later - set the activity aside for later. A form of
procrastination.
○ Do now - if you have available time, do the task
immediately. Do not waste time, as time is
precious.
Procrastination
● “Maniana habit”
● You are setting aside or putting off something until future
time.
● Postpone or delay needlessly.
● This is what happens when the value of doing something
else outweighs the value of doing it now.
● Filling your day with low priority tasks. It means that you are
not that aware of the most important things you are
supposed to do.
● People usually procrastinate because these activities are
unpleasant, so they do not want to do those activities.
● People also procrastinate because they do not know where
to start and what to begin.
● The third reason for procrastination is disorganization. A
person is disorganized on the things they have to do.
● We have to make sure to prevent procrastination by:
○ Deciding the task that has to be done - make sure
you have prioritized your tasks.
○ Set a timer - to make sure you are doing tasks
smartly.
○ Work on tasks until the time rings - make sure that
there is an indicator of when you are supposed to
finish the task.
○ Take a short, 5 minute break if you are done with a
task.
○ Take 15-30 minute breaks, especially if you are
planning to take your lunch or take meals.
● As much as possible, procrastination has to be eliminated in
our system because we are wasting our time on things that
are not important.
Productivity
● P - participate in training for self-sufficiency
○ It is important for you to enhance your knowledge
on time management as this will help you develop
and grow more, and fulfill your self-sufficiency
needs.
● R - re-organize work
○ Priority setting
○ You prioritize things that are highly important.
● O - observed designated workspace
○ As much as possible you need to have a workspace
at home. This will help in the management of your
time.
● D - develop my wellness routine
○ Even if the time is very short, you have to make
sure that you focus on your wellness routines such
as brisk walking for 15-30 minutes.
● U - utilized an effective time inventory
○ Time inventory - following a planner that will serve
as your guide in the things you are going to do for
the day.
● C - communicate with family and friends
○ It is vital for productivity to increase conversations
with significant people.
○ It is essential to socialize.
● T - taking my break outside
○ Go outside, breathe fresh air.
● I - initiate eating meals on time
○ For you to be progressive and productive, you
have to be physiologically satisfied.
● V - very open for feedbacking
○ In time management, you are expected to be open
for feedback, especially for the things you have
already done.
● I - initiate limits of time wasters
○ This will prevent you from wasting your time.
● T - tasks are being prioritized well
○ You have to make sure that you have prioritized
your tasks on what are your priorities.
○ Work smart, not hard.
● Y - your support system is of value
○ If you have a support system in your family, this
will be of great help especially in making sure that
you are productive in the utilization of your
available time.
● In order for us to say that we value our time well, there has
to be an increase in productivity.
External Time Wasters
● It is important to limit this as it takes up much of our time.
1. W - workers are incomplete
● Especially if you have trainings or meetings, you will not be
able to start on time because the employees are incomplete.
2. A - all about paper works
3. S - socializing with coworkers
● Chit chat with friends can waste your time.
4. T - telephone interruptions
● Especially if you are near the telephone, there will be
instances that you will be affected by frequent calls.
5. E - existing meetings
● Especially if you are occupying high positions in the
organization, it is expected that you have scheduled
meetings that you are expected to attend. It is required by
the organization.
Internal Time Wasters
1. W - with delegation failure
● It means that you are not familiar with delegating tasks, and
this affects your time management.
2. A - a failure to set objectives
● Make sure that you have an objective, as this will help you in
making sure that you know what to prioritize.
3. S - some with poor planning
● Sometimes for individuals who has poor planning, their time
management will also be affected.
4. T - the inability to say NO
● If you always say yes, your time will be compromised.
5. E - exercising procrastination (ngano exercise, basin exorcise?
HAHA)
Benefits of Time Management
1. Greater productivity and efficiency
● You will be able to prioritize things, you become productive,
effective and efficient in what you are doing.

2. Professional Reputation
● This will build trust, reputation, and credibility as a
professional, especially if you can work smartly and not
hardly.
● Refers to effective and efficient delivery of services while
generating needed revenues for continued organizational
productivity.
● Is the responsibility of every healthcare provider.
● The viability of most healthcare organizations depends on
their ability to use fiscal resources wisely.

3. Experience less stress Being cost effective however, is not the same as being
4. Increased opportunity for advancement inexpensive. Cost effective means producing good results for the
● If you have properly worked and planned your activities, you amount of money spent. In other words, the product is worth the
have more time for self sufficiency trainings. price. In fiscal planning, we focus more on quality, not quantity.

5. Greater opportunity to achieve important activities in life Basics of Budgets

● This is a way of developing yourself as a professional. ● Budgets:
○ Fixed
6. Less missed deadlines ○ Variable
7. Less inefficient workflow ○ Controllable
● There is an efficient flow of work because you have properly ○ Non controllable
planned what to do with your time. ● Because a budget is the best prediction of plan and not a
rule, fiscal planning requires flexibility, ongoing and revision.
8. Good quality of work ● In budgets, expenses are classified as either fixed or variable,
and either controllable or non controllable.
Integrating Leadership Roles and Management Functions in Time
Management Fixed Expenses
Leadership ● These expenses do not vary with volume.
● T - to focus on self value system ● Examples:
○ Make sure that you focus on how to value time ○ Building’s mortgage payments
properly. ○ Manager’s salary
● I - interpersonal communications
○ There has to be building up of communication Variable Expenses
between colleagues and coworkers. ● Varies with volume.
● M - model to followers with time ● The expenses themselves vary because it is focused on the
○ If you are good in time management, your volume.
followers will also follow what you are doing with ● Examples:
your time. ○ Payroll of hourly wage employees - since you
● E - effective self-awareness cannot know in advance how much they are going
○ Time management will give us an opportunity to to be paid.
say that we are aware or oriented on time and ○ Cost of supplies (office supplies).
dates.
Controllable Expenses
Management ● Can be controlled or varied by the manager.
● K - keep time as productivity related ● Ex: the unit manager can control the number of personnel
○ As much as possible, you make sure that you are working on a certain shift or the staffing.
utilizing your time well. ● Controlling the number of people working in the area, or
● E - enhance cooperation on time use individuals you can control.
○ There has to be proper utilization of time and
cooperation from members of the organization. Non Controllable Expenses
● E - elicit time management analysis ● Cannot be controlled by the manager.
○ If you are not satisfied with the way you manage ● The manager cannot control the equipment depreciation
your time, it is best if you re-prioritize things and and the number and types of supplies needed by patients
balance tasks that are important. overtime that occurs in response to emergencies.
● P - prioritize activities ● Caused by contingency activities, how much of the resources
○ Work smartly, not hardly. used is not controlled.
● E - eliminate time wasters
● R - remember the value of time Types of Budget
○ Remember that time is precious and it is the most ● Capital budget
important thing we can offer to our organization. ● Operating budget
● Manpower budget
FISCAL PLANNING
Which of these budgets is the most important budgeting to do in fiscal
Fiscal Planning planning? Answer: Manpower budget
● Is not intuitive, but is a learned skill that improves with ● This is the most important element in fiscal planning.
practice.
● It is expected that a person will learn about it, especially if it How can we say that that is considered a capital budget? Answer:
is developed through training. based on how much the equipment cost. If it is greater than 50,000, it
is considered a capital budget.
Approaches or Systems of Budgeting
● Centralized Capital Budget
● Decentralized ● Examples: land, building, major equipment and supplies.
● If the budget itself is more than 50,000.
Centralized Budgeting
● The upper level makes the budget. Operating Budget
● The top level management is the one making the budget ● Includes day to day expenses such as the cost of supplies,
itself. minor equipment repairs, and overhead expenses.
Manpower Budget
Decentralized Budget ● Focus is on the salaries, wages, and benefits of the
● Middle and lower level managers set the budget and give it employees.
to the upper level management. ● This type is the most important type to take into
● The unit heads or unit managers are the one who do the consideration in fiscal planning.
budgeting.
Budgeting Methods
Cost Containment ● Incremental budgeting
 ● Zero-based budgeting
● Flexible budgeting
● New performance budgeting
● Sunset budgeting
Incremental Budgeting
● Also known as flat percentage budgeting.
● There is a flat percentage increase method.
● Considering the inflation rate (ex: 20%), then you are going
to multiply the current expenses by the inflation rate. Then
there will be an incremental or flat percentage increase.
● Simplest method of budgeting.
● Multiplying the current year expenses by a certain figure.
○ Usually the inflation rate or the consumer price
index.
● Although this method is simple and quick, it requires little
budgeting.
● It is generally inefficient fiscally because there is no
motivation to contain costs and no need to prioritize
programs and services.
● Hospitals have historically used incremental budgeting in
fiscal planning.
Zero-Based Budgeting
● It requires the managers to justify in detail the cost of all
programs both the old and the new in comparison.
● Managers must re-justify their needs every budgeting cycle.
● This method does not automatically assume that because a
program has been funded in the past, it will continue to be
funded.
● Thus the budgeting process is labor intensive for nurse
managers and the use of decision packages to set priorities
is a key feature of zero based budgeting.
Flexible Budgeting
● Budgets that are flexed up or down over the year depending
on the volume.
● This automatically calculates what the expenses should be
and given the volume that is occuring.
● This works well in many healthcare organizations as a result
of changing census, especially if there is an increase in the
number of patients in the hospital and manpower needs that
are difficult to predict despite historical forecasting tools.
● This budgeting is adaptable and is focused on what the
situation demands.
New Performance Budgeting
● Emphasizes outcomes and results instead of activities or
outputs.
● The focus of this budgeting is on the outcomes or evaluation
criteria.
● The manager would budget as needed to achieve specific
outcomes and would evaluate budgetary success
accordingly.
● The focus is all about identifying the outcomes first and then
use it as a basis for budgeting.
Sunset Budgeting
● Designed to self destruct within the prescribed period to
ensure cessation of the funded program.
● If you are done funding the program and if the program
itself is already done, the funding is also done.
Steps in Budgetary Process
1. B - budget Coverage: make sure it covers requirements of
organization
2. U - use cost effective budget: make sure there is utilization
of available resources because it shows effectiveness of
budget
3. D - develop budget in ways: there has to be an application of
different ways and methods of budgeting
4. G - generate monitoring need to make sure there is a
monitoring tool that will be focused on identifying if budget
is effective with the requirement
5. E - enhance periodic review: important to have periodic
budgeting because it will give the organization an overview
on how effective you are in your budgeting
6. T - to be accountable: you are answerable of the result or
outcome of your budgeting, there is no blaming
Cost Containment
● Awareness - you are aware of the budget that you have
prepared; this is one way of making sure that you contain
what are inclusive of the budget
● Fairness - there has to be justice, fairness and equality of
budget
● Monitoring - focuses on how much will be spent, where will
you spend it, when, and why will you spend it
● Management - what can be done to manage the cost
● Incentives - talks about the motivation and rewards
especially for those who are doing well in the organization,
especially staff
● Avoidance - focused on not buying supplies, technologies, or
services not necessarily needed
● Reduction - spending less on goods and services, specially on
cost cutting
● Control - effective use of available resources through careful
planning, forecasting, reporting and monitoring
Personnel Budget Computation
Patterns of work
● 5 days/ week; 8h/day; 2 days off = 40 hr/week
● 4 days/week; 10 h/day; 3 days off
● 3 1/2 days/week; 12h/day; 3 1/2 days off
● This is based on the requirement of the law (RA 5901 or 40
hour week law) wherein employees will work for 40 hours,
specifically for hospitals with 100-bed capacities or more
also for community population of at least 1 million
○ However, a nurse will render 48 hours per week
with only one off duty a week if the hospital is less
than 100-bed capacity, and communities with less
than 1 million population
○ There are benefits enjoyed by the personnel
regardless of the working hours as per Civil Service
Commission Memorandum Circular Number 6,
Series of 1996.
○ Government employees are granted 3 days which
may be spent for birthdays, weddings,
anniversaries, funerals, relocation, enrollment,
graduation, accident leave
Patient Classification
● Important for computation of nursing hours. In fiscal
planning you need to know how to compute for the nursing
care hours of your patient because in that case you will be
able to identify how much nsg care hours is required per
patient per day
NCH/P/D RN:NRN
Level 1: self care or minimal care 1.5 55:45
Level 2: moderate or 3.0 60:40
intermediate
Level 3: total or intensive care 4.5 65:35
Level 4: highly specialized or 6.0 70:30
critical care 7 or higher 80:20
Legend:
● NCH/P/D: nursing care hours per patient per day
● RN/NEN: RN to non-RN
Levels
Level 1
● Patient can take a bath on his own, feed himself and
perform his ADLs, and pt is about to be discharged, those
considered to be non-emergency, and newly-admitted do
not exhibit unusual symptoms and require little treatment or
instruction
Level 2
● Patients who require some level of assistance and extreme
symptoms of their illness must subside or have not yet
appeared or probably in the incubation period
● Pt with emotional needs with vital signs ordered up to three
times per shift, requires also intravenous fluid or blood
transfusion, are semi-conscious or exhibiting psychological
problems, there is need for periodic treatment, observation,
and instructions
Level 3
 ● Pt completely dependent on nursing personnel and they are ● PM: 34-47% of personnel
marked with emotional needs, with vital signs monitoring ● NOC (Night Shift): 15-18%
more than 3x per shit, on continuous oxygenation therapy ● Here in the Philippines:
with chest tubes or abdominal tubes and this requires close ○ AM: 45%
observation of at least 30 minutes for impending
○ PM: 47%
hemorrhage with or without hypotension or hypertension,
○ NOC: 18%
and those with cardiac arrhythmias

Standard Computation Formula

Level 4
Example. 250 patients in a tertiary hospital
● Pt requires maximum nsg care, patient needs continuous
1. Categorize patient per level
treatment and observation with many medications, IV
(1) 250 x 0.30 = 75 Level I
piggybacks, and v/s are 15-30 minutes hourly output
(2) 250 x 0.45 = 112.5 Level II
(3) 250 x 0.15 = 37.5 Level III
Staffing
(4) 250 x 0.1 = 25 Level IV

% of Patient at Various Level of 2. Find the nursing care hours (NCH) per patient per level
scare (1) 75 X 1.5 = 112.5 NCH/day for L-I
Types of Hospital Level Level Level Level (2) 112.5 X 3 = 337.5 NCH/day for L-II
1 2 3 4 (3) 37.5 X 4.5 = 168.75 NCH/day for L-III
Primary 70% 25% 5% - (4) 25 X 6 = 150 NCH/ day for L-IV
▶ Sum total is 786.75 NCH per patient per day
Secondary 65% 30% 5% -
Tertiary 30% 45% 15% 10% 3. Find the total NCH by 250 patients/year
Special 10% 25% 45% 20% 786.75 X 365 days = 280, 593.75 NCH/year for 250 patients
Note: Level 4 requires intensive care unit
4. Find the actual working hours by each Registered Nurse (RN)
Nursing Care Hours/Cases 8 h/day X 213 (40 h/week duty) d/year= 1704 working hours

NCH/ RN:NRN 5. Find the number of personnel. Divide the total # of nursing
P/D care hours per year by total # of working hours of a nurse
General Medicine 3.5 60:40 working in a 40h/week duty
(1) 280, 593.75 / 1704= 165 personnel
Medical 3.4 - (2) 0.15 (from relievers if 40/week) x 165 personnel =
Surgical 3.4 - 25 relievers needed
Obstetrics 3.0 - ▶ 165 + 25 = 190 personnel needed
Pediatrics 4.6 70:30 (RN to Nursing Assistant)
6. Categorize to RN and NA (nursing attendants)
Pathologic Nursery 2.8 - (1) 190 x 0.65 = 124 RN
ER/ICU/special areas 6.0 70:30 (2) 190 x 0.35 = 66 NA
Critical care unit 6.0 80:20 (RN to Nursing Assistant) *since tertiary hospital is 65:35 for RN per
non-RN
7. Distribute by shifts
Personnel Privileges
(1) 124 X 0.45 = 56 RN AM
(2) 66 X 0.45= 30 NA AM
Rights and privileges Working hr/week Working hr/week
given each 48 hours 40 hours
personnel/year
(3) 124 X 0.37 = 46 RN PM
(4) 66 X 0.37= 24 NA PM
Vacation leave 15 15
(5) 124 X 0.18 = 22 RN NOC
Sick Leave 15 15 (6) 66 X 0.18= 12 NA NOC

Integrating Leadership Roles and Management Functions in Fiscal

Legal holidays 10 10
Planning
● Leadership
Special holidays 2 2 ○ F - flexible and creative: fiscal planning has to be
flexible will adapt to the requirements of the
Special privileges 3 3 institution
○ I - initiate vision for future needs
Off duties/R.A. 5901 104 52 ○ S - skilled in identifying alternatives: there has to
be choices that you will allow others to follow
○ C - continue acting proactively: you have to
Continuing Education 3 3
Program proactive and responsive to the needs of time
○ A - anticipate budget constraints: possibility of
constraints present if it talks about budget
Total non-working 152 100 ○ L - lead in meeting patient need: specially in
days/year delivering quality care
● Management
Total Working 213 265
○ F - fiscal planning understanding: know theories
days/year
about fiscal planning
Total working 1,704 2,120 ○ I - initiate adequate staffing: important because it
hours/year will give us vital information about how to properly
staff our institution
○ S - sensitive to organizations climate: specially on
Computing the Number of Relievers
requirement of human resource
● Thirty-three (33) days average # of leaves divide it with 213 ○ C - cost effective in meeting goals: make sure to
for 40 hour/week or 265 for 48 hours/week work meet goals with effective use of resources
○ The result is 0.15 (15%) - 40 hours/week ○ A - articulate unit needs
○ The result is 0.12 (12%) - 48 hours/week ○ L - lead a skillful monitoring aspect
Distribution of Shifts
● AM: 45-51% of personnel are required CAREER PLANNING
“Career Plans are about where you are today and, more importantly,
where you’re going tomorrow” -Phil McPeck
● With this note, it tells us that career planning is going to
direct our journey or path to where we should be in the
future
● It is important because career planning is essential as it gives
you the destiny or destined future
Career Planning
According to definition, career is an occupation or profession
● It’s an Occupation because you get a salary; you are being
paid because you’ve done something.
● It’s a Profession because you’ve been through trainings and
competency evaluation for you to prove that indeed you are
a professional.
According to Shirey, there are three stages of career
1. Promise Stage
● for the first 10 years after you finish your course
● in this case, you are trying your best to establish your name,
you create your own brand
● at the same time, it will give you an opportunity on what
field you really want to dwell on for the remaining years of
your career
2. Momentum Stage
● 11-29 years
● Refers to the peak level of your career
● Gives you the utmost achievement in life with regards to
your career
3. Harvest Stage
● 30-40 years
● Going to be with regards to your prime experience
● If you exceed more than 40 years you will be considered as
legacy clinicians because you are already an expert in the
field especially on your specific field of nursing
● There are actually 301 careers in nursing (will not be
discussed, but we will rather talk about how to plan your
career for your future)
Is Nursing a Profession or a Vocation?
When referring to a profession, there’s a mnemonic that you can
remember (EUT 😭):
● E - extensive educational preparation
○ Tells us that we are actually being trained,
mentored in order for us to achieve this level that
we have now
● U - use of skills, knowledge, attitude
● T - teaching, training, mentoring, coaching
○ When you talk about teaching, it is a profession
because you have been taught of a knowledge
○ When you talk about training, it means that you
have been taught of a skill
○ When you talk about mentoring, it means that you
are being evaluated because of your skill
○ When you talk about coaching, you have been
coached and questioned-you have to defend (on
that note, it implies that you have a body of
knowledge)
When referring to a vocation, there’s another mnemonic you can
remember (CDO):
● C - calling to serve
○ Vocation implies that you have been called to
serve; to do this and to do that
● D - desire is strong
● O - occupation
For Mr. Abang, Nursing is both a vocation and a profession because if
you are not being called to serve the sick in the sick room, of course
you will not be able to provide the therapeutic touch that this patient
requires from you-that will actually be of help for their healing
Criteria of a Profession
The following are the criteria to say that a particular thing is a
profession (Mnemonic: ABACADA):
● A- authority
○ Means that is is considered to be a legitimate
power
○ When one is authorized, it means that we are
obliged or authorized to perform
activities/interventions without the permission of
the doctor- because of course we have our
independent nursing interventions
● B- body of knowledge
○ Entails our theories and nursing theories
● A- altruism
○ Means that we are one in a team
● C- code of ethics
○ We have our code of ethics for Filipino nurses that
will actually guide us on the things that are norm
and the things that are expected of us to do that
will not violate the bill of rights, ethical principles
● A- autonomy
○ Means that we are self-determined, independent
from other professions- we will not depend on
them based on their decision making
● D- distinct culture
○ We have our distinct culture
○ Women will be wearing their cap
○ Men will be wearing badges
○ Both will be wearing white uniforms, scrub suits
○ We have our distinct celebration such as our
capping and badging ceremony, pinning ceremony
○ These are going to be distinct in our profession
● A- accountability
○ It is very important to have accountability because
we have to be answerable of the actions that we
do
○ Whatever outcomes our action is going to have,
we are answerable to that
Professional Nursing
When you talk about professional nursing, you talk about the
following (Mnemonic: COST)
● C- compensation
○ We work because we want to be compensated
○ As much as possible there must be compensation
because of work
● O- opportunity/privilege
○ To be a nurse is a privilege, it is not given to all
● S- service orientation
○ In our heart, there has to be heart of service
because we focus more on rendering care to our
patient and at the same time, it will give us the
opportunity to give it all without even counting the
returns to it
● T- task performance
○ It is expected that when you are going to have
your professional nursing, you are going to
perform a task- that task must be evaluated by
your organization
Patricia Benner’s Level of Nursing Expertise
According to Patricia Benner, there are actually 5 levels of nursing
expertise (Mnemonic: NACPE)
★ The most common question in the board exam is about Patricia
Benner’s NACPE
● N - novice (no experience)
★ Common in the board exam, when you talk about
novice, the keyword you are going to look for is
the word virgin, virgin nurse
○ A virgin nurse is a novice nurse because it has no
experience at all
○ A beginner with no experience and is taught
general rules to help perform tasks
○ Rules are context free, independent of specific
cases, and applied universally
○ However, rules cannot express which task are
most relevant in life or when exceptions are
needed
● A - advance beginner (at least 1)
○ Common in the board exam, when you talk about
advance beginner, the keyword you are going to
look for is the word advancing education, enrolled
in master’s degree programs
○ Has at least 1 year of experience
○ Means that the focus is probably engaging into
advanced education (the nurse may have
proceeded to graduate studies or enrolled in a
master’s program)
○ Demonstrates acceptable performance and has
gained prior experience in actual situations to
recognize a recurring, meaningful proponents
○ Principles based on experience begin to be
formulated to guide actions
● C - competent (at least 2-3)
 ★ Common in the board exam, when you talk about
competent, the keyword you are going to look for
is the word complex care
○ Experience is at least 2-3 years
○ Typically a nurse with 2-3 years of experience and
job in the same area or in similar day to day
situations
○ They gain perspective from planning, on actions,
based on conscious, abstract, and analytical
thinking- these help to achieve greater efficiency
and organization
● P - proficient (at least 5)
★ Common in the board exam, when you talk about
proficient, the keyword you are going to look for is
the word holistic care
○ It requires at least 5 years of experience
○ Perceives and understands situations as a whole
○ Focus more on holistic understanding of an
improved decision making
○ Learn from experiences and what to expect in
certain situations and how to modify plans
● E - expert (at least 10)
★ Common in the board exam, when you talk about
expert, the keyword you are going to look for is
the word intuitive; they have a clinical eye
○ They will have at least 10 years of experience
○ Expert nurses no longer rely on principles, rules, or
guidelines to connect situations and determine
actions
○ Much more background of experience and has
intuitive grasp of clinical situations
○ Performance is fluid, flexible, and highly proficient
Justifications for Career Development
Why do we need to have career development? (Mnemonic: JUSTIFY)
● J-justly reduced employee attrition
○ Means that there will be a decrease in
disappointments, discouragements, of the
employees especially at work
○ This will help them plan for their future field of
expertise
● U-usual equality of employment opportunity
○ When you have your career development, that will
give you justice
● S-several opportunities for employees growth
○ If there will be career development, it is essential
for you to have opportunities because it will help
in growing your competencies as a registered
nurse
● T-there is improved quality of work life
○ If you have a good career development, it means
that you will experience quality of life both
personal and professional
● I-improved competitiveness
○ Especially if you’re going to have your career
development, you are going to become
competitive especially for those who are also in
the field
● F-fosters new skills acquisition
○ Career development increases your skills and
expertise
● Y-you promote evidence-based practice
○ Means that you are expected to have career
development
Personal Roles and Responsibilities for Career Development
Mnemonic: PERSONAL
● P-personally setting up goals
○ If you want to have career development, you have
to establish your own goal
● E-evaluate individual plan
○ You have to make sure that your plan is properly
evaluated
● R-re-emphasized actions based on plans
○ You need to make sure that there is emphasis on
the actions based on what is planned
● S-self-assess interests, skills
○ If that interest is strong, that will direct you to the
development of this career development
● O-organizational opportunity assessment
○ There is a need to assess if there is the presence of
career development in the organization because it
is the basis if you are going to participate.
● N-need to develop strategies
○ Identifies whether or not training or the program
will benefit you as a professional
● A-assess outside opportunities
○ Very important because it will identify if this career
development is going to give you an opportunity
outside of the institution
● L-leads to making new plans
○ Career development will usually help you in
making new plans if you are going to move to a
greener pasture or if you are looking for
opportunities that will compensate you better
compared to your current organization
Organizational Roles and Responsibilities for Career Development
These are the responsibilities of the organization, especially for the
career development of their employees: (Mnemonic: ORGANISE)
● O-often disseminate career information
○ As much as possible, create and disseminate
information to all employees in the institution
especially if there is a development or opportunity
that is present
● R-regular posting of all job openings
○ Job postings and hiring must be seen on the
bulletin board
● G-give support and encouragement
○ Support and encourage the employees to (for
example) apply for a managerial position
● A-assess employees career needs
○ Assess needs on what they want for personal
growth
● N-needs provided for employee development
○ Make sure that training will be provided such as
your in-service education
● I-integrates employees and organizational needs
○ Integrate them especially on the needs of the
organization
● S-service related training
○ To increase the employees’ expertise and keep
them abreast of the trends, especially on their
competencies
● E-establish, design, implement career path
○ Ask employees regarding their career path in the
future9
Career Coaching
Why is there a need for us to have career coaching?
● Career coaching
○ involves helping others to identify professional
goals and career options, and then deciding a
career to better achieve those goals
● Long-term career coaching
○ is a plan management action that occurs over the
duration of employment
○ If you are employed in an institution for this
number of years, you are going to have this long-
term career coaching
○ Because this type of coaching occurs or is covered
over a long time, it is frequently neglected and less
managers use a systematic scheduling plan and a
form for documentation
What are the steps in Career Coaching?
1. Gathering Data
● Gather data from the organization, whether there’s a need
for you to have this career coaching.
2. Asking what is possible
● Ask what type of coaching is required or needed by the
people in the organization
3. Conducting the coaching session
● The coaching session is not about teaching them what to do
but you are going to ask them and lead them towards their
career path
Management Development
In management development, we have two things to remember:
1. In-service education
○ These are trainings, programs, activities that are
offered by your institution for free
 ○ Example: St. Joseph Medical City is offering a free
updates on CPR to all employees who belong to
the code blue team
2. Continuing education
○ In general, if you are participating in any program
that will improve your competency, that is
continuing education
○ In-service education can also be a continuing
education (but to differentiate, in-service
education is purely provided to the institution
employing you)
○ For continuing education, this is offered outside
the institution and you will be the one to pay for it
○ You are participating in an activity outside of your
organization and it is not free
Many nurses feel that they lack the knowledge and experience
necessary to become a manager. That’s why it’s very important to
have this management development to help people in an organization
to have a background knowledge with regards to management.
Continued Competency
● Refers to Continuing Professional Development (CPD)
● In our Republic Act No. 913, it is called our Continued
Professional Education or (CPE) but in Republic Act No.
10912, otherwise known as the “Continuing Professional
Development (CPD) Act of 2016,” it is referred to as CPD.
● CPD includes seminars or training that will be attended by
professional nurses as a basic requirement for the renewal
of their license.
● CPD Requirements
According to CPD or RA 10192,
● General Transitory Period: The general transitory period is
the implementation of this law started in 2017, and of
course, if you are going to renew your license in that period,
then you are required to submit at least 30% of the
requirements. In 2018, 60%, then in 2019, 100%.
○ July - December 2017 (30%)
○ 2018 (60%)
○ 2019 onwards (100%)
Because of the pandemic, the CPD has been waived until December
2021. CPD or CPE more properly refers to trainings, which are linear
and formal. Training objectives are usually focused on learning a
particular skill or set of skills to improve professional competence.
CPD refers to both training and knowledge, skills, attitude
development significantly relevant to capability and competency in
one’s profession. PRC uses both terms, CPE and CPD. If you are talking
about your CPE, probably that is talking about your training, such as
masters program. CPD that is gonna be for training. This is all about
the general transitory period of your CPD requirement.
When it comes to the number of units required, this is also common in
the board, PRC Resolution…
● Pursuant to Resolution No. 10 s. 2017 of PRBON
(Professional Regulatory Board of Nursing), the following is
the transitory period for compliance:
○ Jan-Dec 2017: 0 units
○ Jan-Dec 2018: 15 units
○ Jan-Dec 2019: 45 units
Of course you will be able to participate in trainings in different fields,
and of course you will be getting 5 units or 5 credit units for that and it
will be accumulated until you reach 45 units. But of course, as what
was mentioned earlier, for this year for 2021 until December 2021, the
credit units or CPD is actually waived. That is all about the CPD or
continued competency.
Professional Specialty Certifications in PH
We will not talk about professional certifications outside of the
country, but we focus more in the Philippines. There are 10
professional certifications in the Philippines, which was launched by
the Department of Health last September 24, 2013, and this is a
certification program.
1. Cardiovascular - offered in the Philippine Heart Center. You
are going to receive certification for that.
2. Renal - offered in the National Kidney Transplant Institute or
the NKTI.
3. Pulmonary - focus of this is in the Lung Center of the
Philippines.
4. Mental health - offered in the National Center for Mental
Health.
5. Maternal and child - offered at Dr. Jose Fabella Memorial
Hospital.
6. Infectious diseases - offered at San Lazaro Hospital, our
center for infectious diseases.
7. Orthopaedic and rehabilitation - offered at Philippine
Orthopaedic Center.
8. Trauma and emergency - offered in the East Avenue Medical
Center.
9. Operating room - offered in National Kidney and Transplant
Institute and Philippine Heart Center.
10. Anesthesia care - offered in the East Avenue Medical Center,
Philippine Heart Center, Quirino Memorial Center, and Jose
Reyes Memorial Medical Center.
The Department of Health Nurse Certification Program will be offered
to all Filipino Registered Nurses, as well as for nurses with special
temporary permit from the Professional Regulation Commission. These
are the 10 specialty certification program here in the Philippines.
Benefits of Professional Certification
What does the professional certification do to us?
1. C - common sense of accomplishment
● As much as possible, if you are participating in a
professional certification, you are going to have
this self sufficiency and self accomplishment. It is a
form of an achievement on your part.
2. E - experienced increased self-confidence
3. R - revalidated competence
● This professional certification will actually improve
your nursing competencies.
4. T - there is greater autonomy
● That will increase your self determination and
authority.
5. I - increased credibility
● That is expected of you.
6. F - financially/salary incentives
● If you are participating in a certification program,
you might as well experience increase rate.
7. I - increased career opportunities
● Probably if you are in trauma nursing, that will
actually provide you with career opportunities to be
part of the special areas.
8. E - empowered and more positive
● Because of course, you know already what to do. You
are expected to be more empowered.
9. D - delivered improved patient outcomes
Just remember, if you are talking about professional certification, our
goal here is to make sure that we will be able to deliver the best
possible quality of care that the patient needs from us. That is the
most important thing that we need to have especially when we talk
about the benefits of having your professional certification program.
Reflective Practice & Professional Portfolio
As much as possible, you have to have your portfolio with you or your
form 201 or file 201 in your organization.
● Reflective practice - actually gonna be a process or:
○ Assessment of one’s own practice
○ Identify and seek learning opportunities to
○ Promotes continued competence
Inherent in the process is the evaluation and incorporation of this
learning into one’s practice. Self-assessment is gaining popularity as a
way to promote professional practice and maintain competence.
Of course, when you talk about reflective practice, that is one way of
assessing your own practice. At the same time, when you assess that,
you are going to identify and seek learning opportunities with that
reflection, and of course, that will promote continued competence. Of
course, often it is done through the use of:
● Professional portfolio - for competence and assessment. And
of course professional portfolio, which all nurses should
maintain especially in your form 201 can be described as:
○ Collection of materials that document
competencies or skill competencies and also…
○ Illustrate nurse expertise
This professional portfolio will typically contain a number of core
components such as your biographical information; educational
background; certifications achieved; your employment history;
resume; and competence record or checklist; personal and professional
goals; professional development experiences; presentation
consultations; and publications; professional and community activities;
honors and awards; letters of thanks from patients, families, peers,
organizations, and others. That is part of your professional portfolio
which is gonna be derived after you are going to have your reflective
practice.
Career Planning & The New Graduate Nurse
It is very important to have a career plan. As much as possible when
you finish your course, you are need to pass the board examination.
These are the criteria for you in the selection of your employers.
● First employment selection is based on:
○ Strong reputation - look for the credibility
○ Shared governance
○ Positive work cultures - the work culture really
affects the people working in the organization.
○ Reputation of excellence
● Functions of mentors/preceptors
○ High quality role model
○ Evidence-based decision making
○ Sound clinical practice
As much as possible, there have to be these characteristics for your
mentors and preceptors.
There was a question when you talk about the employment in the
board examination: How long wil you stay with your first employment?
At least 2 years. The first year is adjustment, and the second year is
looking for greener pastures.
New Graduate Participation in Professional Associations
When you talk about new graduate participation in professional
associations, there are associations that you need to be a member of.
But the most common question of the board examination is: What are
organization/association should a graduate nurse be a member of
(pinaka first)?
● Alumni association - not a professional association, but it is
an association wherein the professional should have to be a
member of, especially because it will give them the altruism
or solidarity of the graduates of the school.
● Philippine Nurses Association (PNA) - the accredited
professional organization (APO) and all newly registered
nurses are required to be a member of PNA. We have to be a
member of PNA because this is for the welfare of the Filipino
nurses in the Philippines and outside of the country. There
are so many organizations in the Philippines that pertain to
nurses. Of course, they have to be accredited by the PNA.
● Association of Deans of Philippine Colleges of Nursing
(ADPCN) - this is an association of deans of the colleges of
nursing in the Philippines.
● Association of Nursing Service Administrators of the
Philippines (ANSAP) - this is an association for those
occupying a managerial position in the hospital.
● National League of Philippine Government Nurses (NLPGN) -
this will be those working in public institutions.
● Operating Room Nurses Association of the Philippines
(ORNAP)
I will be attaching a link or file that contains a list of other
organizations in the Philippines that are accredited by the PNA (wala
sa PLP section sa E-Learn zzz).
Transition to Practice Programs
There are studies being conducted in which they are comparing
graduates of nursing to those who, after passing the board
examination, will immediately work as registered nurses. If you are
going to compare that with those in the medical field or in medicine,
they will still have their residences, externships, and internships. So
there is a debate that is ongoing right now, especially if the new
graduate nurses will have their residences, externships, and
internships prior to the board. examination. But this is a very long
process and there is ample time for deliberation before
implementation.
● Residences
● Externships
● Internships
Resume Preparation
As of this time, we are done with the preparation of the career
planning. We are now going to focus on how you are going to
formulate your resume.
The Difference between a Resume and a Curriculum Vitae:
1. Curriculum Vitae - this presents a full history of your
academic credentials. The length of your document is
variable.
2. Resume - presents a concise picture of your skills and
qualifications for specific positions. The length tends to be
shorter and dictated by years of experience. According to the
board examination, resume has to be 1-2 pages only.
● R - Representation of oneself
○ You have to make sure that that represents you.
● E - Ensures creating a positive image
○ You are selling yourself when you are creating your
resume. As much as possible you must create the
most positive image of yourself.
● S - Somewhat distinguishes self from the masses of
applicants
○ This resume is also very important because it
distinguishes your edge from the other applicants
who are also applying for this position.
● U - Usually decisions for promotion is made
○ Based on your updated resume, it will also be the
basis of your promotion.
● M - Makes impression to employers why you are special.
○ This will provide the employer with the impression
of why they need to hire YOU.
● E - Ensure current & professionally made
○ You have to make sure that you have an updated
resume with you always because this will give us
the opportunity to say that you are improving
yourself professionally because you have
participated with trainings, programs, and
activities that will increase your self-sufficiency.
Resume Guidelines
● R - Resume is 1-2 pages long
○ As much as possible, it has to be limited to this.
Compared to your curriculum vitae, wherein the
number of pages is varied, for a resume it has to
be 1-2 pages only.
● E - Ensure clear & concise writing
○ As much as possible, there has to be no flowery
words, make it direct to the point.
● S - Specify the desired job
○ What you are applying for (staff nurse, chief
nurse).
● U - Use single font easy to read (font size 12)
○ Ideally font size 12, standard formal Arial or Times
New Roman.
● M - Make use of bullets
○ As much as possible, make sure it is in bullet form,
not paragraphs. Because if it is in paragraphs, that
will actually be very difficult for the employers to
read.
● E - Elaborate qualifications
○ As much as possible, you have to elaborate your
experiences because it is the basis of your
employers to hire you especially on the specific
position.
● G - Generally not requiring personal information
○ You don’t need to put your sex, gender, age,
address, religion, and vital statistics on your
resume. Get rid of that as much as possible.the
most important thing to include is your complete
name and contact details.
● U - Unify strong points
○ As much as possible, focus on your strength
because that will actually let the employer have
the impression that this is the best candidate for
this position.
● I - Introduce accomplishments properly
○ As much as possible, you are going to introduce
you have been awarded or achieved an award
(Dean’s lister, board topnotcher).
● D - Do utilize good grammar
○ There are some applications nowadays which you
can actually use to check the grammar of your
output.
● E - Eliminate confidence inspiring words
○ Because that is already very common (gasgas pas
gasgas).
● L - Look for heavy white paper
○ As much as possible use WHITE paper.
● I - Include splash of colors
○ Employ your creativity and innovativeness in the
creation of your resume.
● N - Need to have a cover letter
○ It is accompanied by this. This will tell us that you
are interested in applying for such a position.
● E - Express professional goal
○ Expressing professional goals such as when you
are going to be accepted, you are going to grow,
or stay in that organization for that period of time.
● S - Sure only to list people whom you know well
 ○ For the references, put in there people you've
known well for the past 2-5 years.
○ Do not include anymore people whom you do not
talk to anymore. Because when the employer calls
this reference person, the person might tell them
na di na kayo nagkikita, then there might be a
problem.
A common question in the board examination here is when you are
going to have your interview, what will you wear? Formal attire or
semi-formal attire.
● Choices are: type a uniform (white uniform), scrub suit. But
when you go to an interview wear formal or semi-formal
always.

Integrating Leadership Roles and Management Functions in Career

Planning & Development
LEADERSHIP
● C - Consider own values to career decisions
○ Very important to make sure we have our own
beliefs and practices that guides our decision-
making.
● A - Allows genuine interest in career development
○ As much as possible, you have to be genuine. You
have to have a strong desire to grow. Especially in
your career.
● R - Rewarded present leader during training
○ As much as possible, there is going to be a reward
if you are to participate in a training program.
● E - Encouraged potential leaders
○ This career planning encourages potential leaders,
especially for them to assume their future roles.
● E - Empower advance in career
○ Have their specialties or certification programs.
● R - Re-develop leadership skills
○ This is one way of making sure that they are going
to possess the best leadership skills required for
the position.

MANAGEMENT
● C - Career information dissemination
○ Very important for everyone to know.
● A - Allot time in posting job opening
○ That will actually further the recruitment process.
● R - Requires developed system
○ For the hiring and staffing needs.
● E - Ensures career development
○ For people in your unit or in your institution.
● E - Encourage long term coaching
○ Involve people in career coaching.
● R - Reconsider transfers
○ It means that if you want to be transferred to a
specialized unit, or specialized department, then
that is going to be part of your management
function especially on the career development
aspect.