Nursing Leadership & Management

Peter Eustaquio Capistrano, PT, RN, Theo
Peter Eustaquio Capistrano 1

Introducing Nursing Management
‡ Today all nurses are managers
(but not all can be leaders)

‡ Nurses must learn how to work effectively & efficiently with:  staff  other nurses  UAP
Peter Eustaquio Capistrano 2

‡ Nurses must understand the health care system and how the organization functions. ‡ You need to know what external forces affect your work. ‡ Be able to collaborate with others as a leader, as a follower, a team member
Peter Eustaquio Capistrano 3

Peter Eustaquio Capistrano 4 . & ‡ How you can help create an environment that inspire and sustain the individuals who work with you.‡ You need to know what motivates people.

Forces Changing Health Care + Proliferation of managed care + greater emphasis on the business of health care (financial & marketing aspects) + shift from acute care to community & outpatient settings + shift to costumer-focus + technology advancement Peter Eustaquio Capistrano 5 .

biological warfare.Forces Changing Health Care + emerging new threats such as terrorism. global pandemics + addressing the ever-increasing international nursing shortage + high turnover rates of staff + new legislations of minimum staffing ratios Peter Eustaquio Capistrano 6 .

HCW.Forces Changing Health Care Concerns (for employers. public & policy makers): ‡ Costly live-saving medicines ‡ Robotics ‡ Remote care ‡ Innovations in imaging technologies ‡ Non-invasive treatments & surgical procedures Peter Eustaquio Capistrano 7 .

and.Health Care Networks ‡ Integrated Care Networks Due to the struggle to find ways in today·s cost-conscious health society ‡ Common characteristics: Deliver a whole continuum of care Provide coverage for the buyers of health care services. Peter Eustaquio Capistrano 8 .

Variety of arrangements and affiliations have occurred Peter Eustaquio Capistrano 9 .Health Care Networks ‡ Accept the risk inherited in taking a fixed payment in return for providing health care for all persons.

primary care rather than hospital goal of care: -.keep patients healthy by treating them in the setting that incurs the lowest cost & thereby reducing expensive hospital txs. Peter Eustaquio Capistrano 10 .The focal point for care: -.

‡ It is now the GOAL of the health care industry to keep patients out of the hospitals!!! Peter Eustaquio Capistrano 11 .

Demands to reduce errors Peter Eustaquio Capistrano 12 .

000 death occurred each year from preventable medical mistakes in hospitals . patient·s costs & mortality Peter Eustaquio Capistrano 13 .Medical injuries found to length of stay.Demand to 4 Systems Used to Errors medical errors I.US reported in 1999 ² 98. Control of Medical errors: .

or  adverse reactions B.Computerization system for pharmacy that will alert staff for possible:  drug interactions. Patient ID band w/ bar codes Peter Eustaquio Capistrano 14 .Demand to Errors A. Computerized medication administration records C.

CDC-US. approx: 2m people suffer from nosocomial infections w/c costs $27.Demand to Errors D. Beginning fiscal year 2008.5b (CDC. 2007) Peter Eustaquio Capistrano 15 . CMS-US would no longer reimburse hospitals for the cost related to hospital-acquired infections or medical errors.

A consortium of public & private purchasers .Rewards health care organizations that demonstrate quality outcome measures Peter Eustaquio Capistrano 16 . Leapfrog Group .Provides benefits to more than 37m Americans in all 50 states. .Demand to Errors II.

Using evidence-based hospital referrals 3. Errors ‡ 3 quality indicators: computer-physician order entry system 2. Using ICU physician intensivists staff Peter Eustaquio Capistrano 17 .Demand to 1.

000 medical errors could be avoided Peter Eustaquio Capistrano 18 .000 lives could be saved ‡ • $41b could be saved ‡ • 900.Demand to Errors Most significant impact on preventing medical errors: ‡ • 65.

Demand to Errors III. Quality management Preventive approach to address problems before they become crises Began in post-WW II Japan Peter Eustaquio Capistrano 19 .

Demand to Errors ‡ To improve the quality of manufactured products ‡ Consumers· needs should be the focus of management ‡ Employees should be empowered to evaluate and improve quality Peter Eustaquio Capistrano 20 .

Demand to Errors ‡ TQM build tools for continuous improvement of product & services thru constant evaluation of how well the consumers· needs are met devise plans to perfect the process Done thru patient satisfaction surveys Peter Eustaquio Capistrano 21 .

Benchmarking ‡ Compares an organization w/ similar organizations (in contrast w/ TQM) ‡ Outcome indicators are identified to be used to compare performances across disciplines Peter Eustaquio Capistrano 22 .Demand to Errors IV.

weaknesses can be addressed & enhance areas of strength Peter Eustaquio Capistrano 23 .Benchmarking ‡ Used for standard development & performance improvement ‡ Once the results are known.

Benchmarking Questions to be asked in benchmarking: + ´How did they do it?µ + ´What tools did they use/µ + ´What were their lessons learned?µ Peter Eustaquio Capistrano 24 .

‡ Populations & Cultural Diversity ‡ Generational Diversity ‡ Aging Patients & Aging Nurses Peter Eustaquio Capistrano 25 .

Immigrant Populations & Cultural Diversity ‡ US Census Bureau minority population = 100m in 2007 ‡ Hispanics ² 44m (largest group) ‡ African origin ² 40 m fastest growing minority ‡ Asians ² 14m 2nd fastest growing minority Peter Eustaquio Capistrano 26 .

or socioeconomic status. ethnic origin.Immigrant Populations & Cultural Diversity ‡ The challenge for health care policy makers & the public: to find ways to provide universal access to care regardless of care. Peter Eustaquio Capistrano 27 .

lifestyle of the diverse cultures Peter Eustaquio Capistrano 28 .Immigrant Populations & Cultural Diversity ‡ Current trend: assume trans-cultural focus They consider: .values .beliefs .

only 5.4 nurses are male (2000 survey) Peter Eustaquio Capistrano 29 .from minority population .2% .18.Immigrant Populations & Cultural Diversity ‡ Trans-cultural diversity affects nursing: .81.8% of US nurses caucasians (2004 survey) .

Generational Diversity ‡ Seeing four generations working together side by side in today·s workplace is common:  traditionals  Baby boomers  Generation X  millenials have different values & expectations in the workplace 30 Peter Eustaquio Capistrano .

Generational Diversity ‡ Baby boomers: + value professional & personal growth + expect that their work will make a difference Peter Eustaquio Capistrano 31 .

Generational Diversity ‡ Traditionals: + value loyalty + respect authority + follows bureaucracy policies Peter Eustaquio Capistrano 32 .

Generational Diversity
‡ Generation X ² desire a (+) work

‡ ‡ ‡ ‡

environment Want their work to have worth Want independence, fun Value independence Tend to focus on outcomes rather than processes
Peter Eustaquio Capistrano 33

Generational Diversity
‡ To have balance between work & other important areas of their lives: - personal relationships - child rearing - pleasurable pursuits

Peter Eustaquio Capistrano


Generational Diversity
‡ Millenials
(a.k.a. Generation Y)

‡ ‡ ‡ ‡ ‡

Technically savvy Responsible Competent Expert in connecting online Prepares to participate in collaborative structures
Peter Eustaquio Capistrano 35

leverage differences to enhance teamwork Peter Eustaquio Capistrano 36 .encourage mutual respect for differences .Generational Diversity ‡ Challenge for managers: .avoid stereotyping within the generations .value unique contribution of each generation .

changes in the workplace also add to conflicts due to the generations· different expectations Peter Eustaquio Capistrano 37 .Generational Diversity ‡ Challenge for managers: .

Aging Nurses ‡ Older generation 65 y/o & 37m in 2006 (12% in US population) approximately 1 in every 10 Americans by 2030 ² more than 71m older adults Peter Eustaquio Capistrano 38 .Aging Patients.

advancement in technology are enabling people to survive previously fatal diseases & conditions .people are living longer .Aging Patients.older x often require on-going care for chronic / acute illnesses Peter Eustaquio Capistrano 39 . Aging Nurses ‡ Reasons for continuation of demand for health care for aging patients: .

healthy eating.Aging Patients. screenings) These people will require episodic & chronic care Peter Eustaquio Capistrano 40 . Aging Nurses older people are due to: ‡ Increase in life expectancy ‡ older workers retiring later ‡ good health practices (exercise.

3 in 1996 ‡ % of nurses over 54 y/o increased to 25. Peter Eustaquio Capistrano 41 .2% in 2004. age : 46.8 (US.Aging Patients. 2007) compared to 44. Aging Nurses ‡ Nurses are growing older ‡ Ave.

Aging Nurses .‡ Means that the current need for nurses will continue and grow as more & more aging nurses will retire from work ‡ US Dept of Labor predicts (2014) that RN will be the second largest occupation second to retail salesperson) Peter Eustaquio Capistrano 42 Aging Patients.

‡ Changes for future nurses Peter Eustaquio Capistrano 43 .

condition & situation to make clinical decisions Peter Eustaquio Capistrano 44 .More Change on the Way ‡ Evidence-based practice applying the best scientific evidence to a px·s unique diagnosis.

identify the clinical question .apply the evidence .Evidence-based practice ‡ The process of EBP: .evaluate the outcome Peter Eustaquio Capistrano 45 .evaluate the evidence .find the evidence to answer the question .

EBP will be successful when nurses & health care decision makers have access to a synthesis of the latest research. and the values & preference of the individuals. families & communities who are served. nursing expertise. a consensus of expert opinion and then exercise their judgment as they plan & provide care that takes into account cultural & personal values & preferences. (2004) Peter Eustaquio Capistrano 46 .Evidence-based practice ‡ International (honor society for nurse) EBP: The integration of best evidence available.

promote spirit of risk-taking + dispel myths & traditions not supported by evidence + Collaborate with others nurses locally & globally + interact with other disciplines to bring nursing evidence to the table Peter Eustaquio Capistrano 47 .Strategies for new Nurses to promote EBP: + keep abreast: subscribe to journals & read widely + encourage use of multiple sources of evidence + find established sources in your specialty + question & challenge nursing traditions.

Electronic Health Records ‡ Integrates health info from all sources and cane be accessed from multiple locations from authorized providers. Peter Eustaquio Capistrano 48 .

improve efficiency .medical errors .lower health care costs Peter Eustaquio Capistrano 49 .Electronic Health Records ‡ Electronic records: .redundancies .

online system allowing patients to track medications. record medical interventions.Electronic Health Records ‡ Patient·s personal health record: . Peter Eustaquio Capistrano 50 . update their own medical information as needed.

Robotics & Remote Care ‡ Use of robots to transfer supplies and to deliver remote care ‡ Systems & supplies can be ordered now electronically & filled by laser-guided robots ‡ Robots deliver the requested supplies to nursing units Peter Eustaquio Capistrano 51 .

Robotics & Remote Care ‡ Physicians in remote locations can access pxs using wireless video connections in robots at the bedside ‡ Some robots offer electronic stethoscopes & other diagnostic devices ‡ Can follow-up lab results between cases instead of after the day·s procedures Peter Eustaquio Capistrano 52 .

epidemic are examples Peter Eustaquio Capistrano 53 . attack of terrorism.Terrorism & Disaster Preparedness ‡ Extensive staff training is required ‡ Assess nurses· concerns & provide accessible info. support & opportunities for debriefing Natural disaster.

teacher & facilitator because they are responsible for others· work Peter Eustaquio Capistrano 54 .Challenges Facing Nurses Nurse mangers are challenged to:  manage with decrease resources  To supervise teams of professionals & non-professionals from a variety of cultures  Must a coach.

& of the organization Peter Eustaquio Capistrano 55 .‡ Must be a leader to motivate & inspire ‡ Must address the interests of both admin & employees ‡ Works thru others to meet the goals of individuals. the unit.

‡ Organizations And organizational theories Peter Eustaquio Capistrano 56 .

Peter Eustaquio Capistrano 57 . human and material resources.Organizational Theories ‡ Organization ² a collection of people working together under a defined structure to achieve pre-determined outcomes using financial.

Organizational Theories ‡ Types: + classical Theory + Humanistic Theory + Systems Theory + Contingency Theory + Chaos Theory + Complexity Theort\y Peter Eustaquio Capistrano 58 .

it tends to stabilize & develop more formal standards.Organization ‡ The lifecycle of the org is dependent on its adaptability & response to changes in its environment ‡ When org tends to grow. Peter Eustaquio Capistrano 59 .

Peter Eustaquio Capistrano 60 .Organization ‡ When the org becomes large. it tends to lose its adaptability & its responsiveness to its environment.

Classical Theory Focuses solely on the structure of the formal organization main premise: efficiency thru design people are operating within a rational & well-defined task Peter Eustaquio Capistrano 61 .

4 elements of Classical Theory ‡ Division & Specialization of Labor ‡ Chain of Command ‡ Organizational Structure ‡ Span of Control Peter Eustaquio Capistrano 62 .

Division & Specialization of Labor ‡ Division of work reduces the tasks that each employee must carry out efficiency proficiency & specialization ‡ Managers can standardize the work to be done Peter Eustaquio Capistrano 63 .

Chain of Command hierarchy of authority & responsibility w/n the organization Authority ² as the right or power to direct activity Responsibility ² as obligation to attain objectives or perform certain functions Peter Eustaquio Capistrano 64 .

Chain of Command
‡ The line of authority ² higher levels of management delegate work to those below them in the organization. ‡ Line of authority ² linear hierarchy ‡ Staff authority ² advisory relationship; recommends & advices
Peter Eustaquio Capistrano 65

Chain of Command
Chief Nurse executive

Acute Care Nurse Practitioner

Nurse Manager

Nurse Manager

Staff Nurse

Staff Nurse

Staff Nurse

Staff Nurse

Peter Eustaquio Capistrano

Organizational Structure
‡ describes the arrangement

of the interrelated work group

‡ The design of the organization is intended to foster the organization·s survival & success
Peter Eustaquio Capistrano 67

Span of Control ‡ Addresses the pragmatic concern of how many employees a manager can handle effectively Peter Eustaquio Capistrano 68 .

k.Span of Control ‡ Complex organizations ² have numerous departments that are highly specialized & differentiated ‡ Authority is centralized ‡ a.a tall organizational structure Peter Eustaquio Capistrano 69 .

Span of Control ‡ Less Complex organizations ² flat structure ‡ Authority is decentralized ‡ With several managers supervising large work groups Peter Eustaquio Capistrano 70 .

‡ Organizational theories Peter Eustaquio Capistrano 71 .

& search for personal fulfilment. respond to group pressures. ‡ Major assumption: People desire social relationships.Humanistic Theory ‡ Criticism of the Classical Theory led to the development of the Humanistic Theory in the 1930s. Peter Eustaquio Capistrano 72 .

Humanistic Theory ‡ Hawthorne effect ² if special attention is given to workers they will work better resulting to increased productivity. Peter Eustaquio Capistrano 73 .

technology & environment Peter Eustaquio Capistrano 74 . people.Systems Theory ‡ Defined as a set of interrelated parts arranged in a unified whole. ‡ Productivity is the result of interplay among structure.

Types of Systems ‡ Closed System ² self-contained & usually can be found in the physical sciences ‡ Open System ² interacts both internally & & with its environment (a living organism) Peter Eustaquio Capistrano 75 .

open system ‡ Framework are interrelated by part of the system and their functions can be studied ‡ Health care org·zn requires human. social.‡ Organizations are complex. financial & material resources Peter Eustaquio Capistrano 76 .


Environment people.Contingency Theory Contingency Theory believe organizational performance can be enhance by matching an organization·s structure to its environment. ideas that influence the org. objects. Peter Eustaquio Capistrano 78 .

Contingency Theory ‡ Environment of a health care org·n:  patients Potential patients  third-party payers  competitors  regulators  suppliers Pharmaceuticals Peter Eustaquio Capistrano 79 .

Contingency Theory ‡ Given the variety of health care services and different types of patients served today. The organizations differ w/ respect to the environment they face Levels of skills & training of their caregivers The emotional & physical needs of patients Peter Eustaquio Capistrano 80 .

Peter Eustaquio Capistrano 81 .Chaos Theory ‡ The nature of relationship we have w/ each other & with the organization does not follow a straight line.

Chaos Theory challenges traditional thinking regarding the design of organizations. organizations are living. selforganizing systems that are complex and ever-changing. Peter Eustaquio Capistrano 82 .

Peter Eustaquio Capistrano 83 .Chaos Theory ‡ Chaos theory suggests that the drive to create a permanent organizational structure is doomed to fail.

Chaos Theory ‡ Organizations. to succeed. & + cultural sensitivity Peter Eustaquio Capistrano 84 . must ensure: + flexibility + fluidity. + speed of adaptability.

Chaos Theory ‡ The role of leadership in Chaos Theory (changing organizations) : + build resilience in the midst of change + to maintain balance between tension & order + promote creativity. & + prevent instability Peter Eustaquio Capistrano 85 .

Chaos Theory ‡ Challenges of Chaos Theory:  to reflect on creative and flexible formats that can be quickly adjusted and changes as organizations shift.  abandon our attachments to any particular model of design Peter Eustaquio Capistrano 86 .

Complexity Theory ‡ Organization is a mixture of all the theories that consider it as a total system. reasons:  random events interfere with expectations  Patient·s condition change in an instant Peter Eustaquio Capistrano 87 .

Complexity Theory necessary staff are not available or is not equipped  failure of equipments to function well  tasks are sometimes contradicting with the values of the pxs. nurses & physicians Peter Eustaquio Capistrano 88 .

Peter Eustaquio Capistrano 89 .Complexity Theory ‡ Health care continues to focus on px care providers rather than the system as a whole. ‡ Using high reliability teams has been effective in preventing serious errors.

‡ Every encounter between a px & a caregiver offers information about possible solutions to problems Peter Eustaquio Capistrano 90 .Complexity Theory ‡ Hierarchy is less important in complexity theory.

Peter Eustaquio Capistrano 91 . leaders & followers. or sideways. bottomup.Complexity Theory ‡ Manager·s task: Encourage the flow of info between and among all team members. whether top-down.

the organizational response to environmental change:  diminishes  decisions are delayed. poor.Traditional Organizational Structures ‡ When structure is not aligned with organizational needs. overlooked  conflicts result  performance deteriorates Peter Eustaquio Capistrano 92 .

Traditional Organizational Structures ‡ Types: + Functional Structure + Service-line Structure + Hybrid Structure + Matrix Structure + Parallel Structure Peter Eustaquio Capistrano 93 .

Functional Structure ‡ Employees are grouped in departments by specialty with similar tasks ‡ Reports to the same manager ‡ Tends to centralize decisionmaking (top organization) Peter Eustaquio Capistrano 94 .

Functional Structure ‡ Weaknesses: + coordination across functions is poor + decision-making responsibilities can pile up at the top + overloaded senior managers Peter Eustaquio Capistrano 95 .

Functional Structure + Coordination across functions are slow + General management training is limited + top managers may be uninformed of day-to-day operations Peter Eustaquio Capistrano 96 .

service-integrated structure ‡ All functions needed to produce a product or service are grouped together in selfcontained units Peter Eustaquio Capistrano 97 . Product-line structure.a.Service-line Structure ‡ a.k.

Service-line Structure CEO Executive secretary Cardiology Oncology Burn Unit Nursing Nursing Nursing Dietary Dietary Dietary Pharmacy Pharmacy Peter Eustaquio Capistrano Pharmacy 98 .

Service-line Structure ‡ Strengths: + have potential for rapid change in an unstable environment + high client satisfaction due to specialization + coordination occurs easily + service is priority because employees sees it as the purpose why the org exists Peter Eustaquio Capistrano 99 .

Service-line Structure ‡ Weaknesses: + possible duplication of resources + lack of in-depth technical training & specialization + services operate independently & often compete + units (w/c is autonomous) have duplicate staff & competes for resources Peter Eustaquio Capistrano 100 .

Hybrid Structure During growth of organizations. both selfcontained units & functional units converge Peter Eustaquio Capistrano 101 .

Hybrid Structure
‡ Strengths:
+ provides simultaneous coordination w/n product divisions while maintaining the quality of each function + improves the alignment between corporate & service or product goals + fosters better adaptation to the environment while still maintaining efficiency
Peter Eustaquio Capistrano 102

Hybrid Structure
‡ weaknesses:
+ conflict between top admin & managers + managers often recent admin·s intrusions into what they see as their own area of responsibility + over time, organizations tend to accumulate large corporate staff to oversee divisions
Peter Eustaquio Capistrano 103

Hybrid Structure





Peter Eustaquio Capistrano


Matrix Structure ‡ Integrates both product & functional structures into one overlapping structure. Nurse manager for oncology clinic may report to the vp for nursing as well as to the vp for outpatient services) Peter Eustaquio Capistrano 105 .g. ‡ Different managers are responsible for function & product ‡ (e.

Matrix Structure ‡ Weakness: + dual authority + excellent interpersonal skills are needed from managers involved + time consuming due to frequent meetings to resolve conflicts & problems Peter Eustaquio Capistrano 106 .

Matrix Structure ‡ Weakness: + one side of the organization may become dominate over the other Peter Eustaquio Capistrano 107 .

Outpatient Services Oncology Pediatrics Family medicine Vice-President for Nursing Services Nurse Manager Nurse Manager Nurse Manager Peter Eustaquio Capistrano 108 .Matrix Structure Vice-President.

) ‡ two lines of authority: organizational dilemma Peter Eustaquio Capistrano 109 .Parallel Structure ‡ Unique to health care ‡ Complex relationship that exists between he formal authority of the HC org and the authority of its medical staff (separate &a autonomous from its org.

Parallel Structure CEO Chief Nurse executive Hr dIRECTOR chief financial Officer Chief Suport Services MEDICAL dIRECTOR NM NM UAP NM BUDGET HOUSEKEE PING MAINTENA NCE CHIEF OF SERVICES RN LPN BUDGET pERSONNE L INTERNAL mEDICINE SURGERY OB Peter Eustaquio Capistrano 110 .

Leadership And Management Peter Eustaquio Capistrano 111 .

‡ Nurse managers need a body of knowledge and skills distinctly different from those needed for nursing practice!!! ‡ Yet few nurses have the education or training necessary to be managers!!! Peter Eustaquio Capistrano 112 .

‡ Managers depend on experiences with former supervisors. who also learn supervisory techniques on the job!!! ‡ Often a gap exists between what managers know and what they need to know!!! Peter Eustaquio Capistrano 113 .

Leader ‡ Anyone who uses interpersonal skills to influence others to accomplish the specific goals. Peter Eustaquio Capistrano 114 . ‡ Exerts influence by using a flexible repertoire of personal behaviors & strategies.

agere. Peter Eustaquio Capistrano 115 .Manager ‡ Latin: manu. ´to lead from the handµ ‡ An individual employed by an organization responsible & accountable for efficiently accomplishing the goals of the organization.

Manager ‡ Have assigned position w/n the formal organization ‡ Have a legitimate source of power due to delegated authority ‡ Expected to carry out specific functions. duties.Leader ‡ Often do not have delegated authority but obtain power thru influence ‡ Have a variety of roles than do managers ‡ May or may not be a part of a formal org. responsibilities 116 Peter Eustaquio Capistrano .

money. decision analysis & results ‡ Manipulate the environment. time & other resources to achieve organizational goals Peter Eustaquio Capistrano 117 . informal gathering. decision-making. people. empowering people ‡ Emphasize interpersonal relationship Manager ‡ Emphasize control.Leader ‡ Focus on group process.

Leader ‡ Directs willing followers Manager ‡ Have a greater formal responsibilities & accountability for ‡ Goals that may or rationality & control may not reflect than leaders the those of the organization ‡ Direct willing & unwilling subordinates Peter Eustaquio Capistrano 118 .

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