Nursing

Leadership and
Management
Ma. Almira P. Nebres, RN, MAN, PhD
Critical Thinking in
Nursing
Why do we need to think
critically?
 Need to make accurate and appropriate
clinical decisions
 Need to solve problems and find solutions
 Need to plan care for each unique client
and client problem
 Need to seek knowledge and use it to
make clinical decisions and problem solve
 Need to be able to think creatively when
planning care for clients
 What IS Critical Thinking?

 Critical thinking can be defined several

ways. One definition is “an active,
organized, cognitive process”.
 Another definition is “a process for
identifying underlying assumptions and
variables in order to draw conclusions
and make decisions”.
 You could even use the definition “a
process used to explore alternatives
to determine what is important”.
 Decision making- is a complex,
cognitive process often defined as
choosing a particular course of
action.
 Problem solving – is a part of
decision making. A systematic
process that focuses on analyzing a
difficult situation.
 Critical thinking – reflective thinking,
is related to evaluation and has a
broader scope than decision
making and problem solving .
 Tools for Critical Thinking
 Ask questions! Sometimes people
hesitate to ask questions because they
fear that asking a question may be
interpreted as a lack of knowledge on
their part. However, the question is a
key element of critical thinking.
 Questions serve many purposes, and
only serve to broaden your knowledge
base, and expand your options.
 Why Question?

 Questioning begins the

information-seeking process.
 All questioning is about seeking
information, re-formulating
information to new situations, and
solving nursing practice dilemmas.
 Can you think of some other
examples of information seeking
that you do?
Characteristics of a Critical Thinker
 Open to new ideas
 Intuitive
 Energetic
 Analytical
 Persistent
 Assertive
 Communicative
 Flexible
 Emphathetic
 Caring
 Observant
 Risk taker
 Resourceful
 “Outside-the-box” thinker
 Creative
 Insighful
 Willing to take action Outcome directed
 Willing to change
 knowledgeable
 It’s no accident...

 It’s no accident that the nursing

process mirrors a lot of the
critical thinking process. They
are both processes developed to
gather information, look ahead,
plan, and evaluate processes.
 Looking at the two, side-by-side
really illustrates that example.
 Side-by-Side
NURSING CRITICAL
PROCESS THINKING
Assessment Exploring
Diagnosis Analyzing
Planning Prioritizing/decision
making
Implementation Prioritizing and
deciding
Evaluation Evaluating
A fishbone diagram, also called a cause and
effect diagram or Ishikawa diagram, is a
visualization tool for categorizing the potential
causes of a problem in order to identify its
root causes. Typically used for root cause
analysis, a fishbone diagram combines the
practice of brainstorming with a type of mind
map template.
 5 Whys
Getting to the Root of a Problem Quickly
The Nurse’s Roles
 Critical thinker – to analyze situations, identify
problems, set priorities, develop multiple possible
approaches to a specific situation, & consider the
consequences of a strategy before thinking
action.
 Caregiver- ensure client care needs are meet.
 Client advocate- mutuality, facilitation, protection
 Change agent –collaborates w/ pts & team
members to identify when & what changes
needed for better health & PPE
 Counselor/Teacher –emotional
support/education to pts.
 Coordinator -
 What Is Leadership &
Management?
 Leadership
 The ability to influence a
group toward the
achievement of goals
 Management
 Use of authority inherent in
designated formal rank to
obtain compliance from
organizational members
 Both are necessary for
organizational success
© 2009 Prentice-Hall Inc. All 12-16
rights reserved.
 Leadership Defined
Leadership combines:
 intrinsic personality traits,
 learned leadership skills,
 characteristics of the
situation.
Leader -
 guides people and groups
to accomplish common
goals,
 influences the beliefs,
opinions, or behaviors of a
person, group, or groups
of people.
 Types of Leaders:

 Formal-persons who hold a position of

power.

 Informal- emerge when members of a group

recognize a person has special knowledge,
expertise, communication skills, or other
personality traits they respect &admire
(Donnelly, 2003; Videback, 2008)
Leadership Styles (White, R. & Lippitt, R. 1960)

1. Autocratic – centralized decision making,

leader exercising great control to get the
work done.

2. Democratic – participatory with the

leader & group work together to get things
accomplished.

3. Laissez-faire – passive & permissive,

leader abstains from leading & let
subordinates lead themselves.
 Management Defined
Management -
 coordinates people, time, and
supplies to achieve desired
outcomes,
 involves problem-solving and
decision-making processes.
Managers responsibility:
 maintain control of the day-
to-day operations,
 achieve established goals and
objectives.
 Nurse manager
will have:
an appointed management position
within the organization with
responsibilities to perform
administrative tasks:
 planning staffing requirements,
 performing employee
performance appraisals,
 controlling use of supplies and
time,
 meeting budget and
productivity goals.
 Nurse manager
will have:
an appointed management position
within the organization with
responsibilities to perform
administrative tasks:
 planning staffing requirements,
 performing employee
performance appraisals,
 controlling use of supplies and
time,
 meeting budget and
productivity goals.
 5 Interpersonal Bases of Power

1. Legitimate- bestowed upon a leader by a

given position in the hierarchy of an org.
2. Reward –use of rewards for compliance
of orders/requests.
3. Coercive – the power to punish.
4. Referent – charisma. Influence people
through leader’s personality or behavior.
5. Expert – special abilities/skills unique to a
leader (Expertise).
 Differences between Leaders & Managers
LEADER
May or may not have official
appointment to the position.
Vested with power and authority by the
group.
Influence others toward goal setting.
Interested in risk taking and exploring
new ideas.
Relates to people personally.
Feels rewarded by personal
achievement.
May or may not be as successful as
managers.
MANAGER
Officially appointed.
Vested with power and authority by the
organization.
Implements predetermined goals,
policies, rules and regulations.
Measures the risks to be taken in line
with the expected results, hence, an
orderly, controlled performance must be
carried out.
Relates to people according to their
roles.
Feels rewarded when accomplishing
organizational missions or goals.
Are managers as long as the
appointment holds
PRINCIPLES OF MANAGEMENT(Robbins, 1994)
1. DIVISION OF WORK- specialization makes employees-more efficient-
more/better outputs.

2. AUTHORITY- managers give orders, goes with responsibility.

3. DISCIPLINE - good discipline-clear understanding between management

and workers about organization’s rules, and judicious use of penalties for
infractions of the rules.

4. UNITY OF COMMAND – each employee should receive orders only from

one superior.

5. UNITY OF DIRECTION – for each group of organizational activities having

the same objective, direction comes from one manager using one plan.

6. SUBORDINATION OF INDIVIDUAL INTEREST TO THE GENERAL

INTEREST- employee or group of employees’ interest should not precede
over the interests of the whole organization.

7. RENUMERATION –employee must be paid a fair wage for their services

rendered.
8. CENTRALIZATION – degree subordinates involvement in
decision making. Centralized (Management), or decentralized
(subordinates).

9. SCALAR CHAIN- the line of authority from top management to

the lowest ranks in the organization .

10. ORDER- people and materials are in the right place at the right
time.

11. EQUITY & Justice- fair and just treatment; no favoritism.

12. STABILITY OF TENURE-orderly personnel planning to ensures

that replacements are available to fill vacancies.

13. INITIATIVE – whenever employees are allowed to originate and

carry out plans, they are expected to exert high levels of efforts.

14. ESPRIT DE CORPS- promotion of team spirit builds harmony

and unity within the organization.

15. Motivation of personnel – allowed to work in problem

solving/decision making(Tan & Beltran, 2009).
Management Resources (7M’s) use to
accomplish goals

1. Money (budget)
2. Men (human resources-staffing)
3. Machines (faster, easier)
4. Materials (syringe)
5. Methods (techniques-assessing well-
being in health & disease)
6. Moment (Time Management for a task)
7. Manager
Who Needs Nursing Management?
 All types of health-care organizations,
including nursing homes, hospitals, home
health-care agencies, ambulatory care
centers, student infirmaries, and many
others, need nursing management.
 Even the nurse working with one client and
family needs management knowledge and
skills to help people work together to
accomplish a common goal.
 A primary nurse working with several
clients prioritizes their care to assist time to
improve health or, sometimes, peaceful
death.
Nursing Management Functions:
IN nursing, management relates to performing the
four basic functions (Processes): or

 Planning – provides the framework for

performance
 Organizing – in order to establish order
and systematically achieve the goals
 Directing – focuses on leading the staff in the
most effective manner possible
 Controlling – evaluates performance against
established standards
 Universality of Management

Top
Management P O D S C
P O D S C
Middle
Management

P O D S C
First-Line
Management

Amount of Emphasis on Management Function

P - Planning S - Staffing
O - Organizing C - Controlling
D - Directing
Patient Classification System (PCS)

 method of grouping patients according to the

amount and complexity of their nursing care
requirements, of nursing time & skill they
require.
 serves in determining the amount of nursing
care required, generally within 24 hours, as
well as the category of nursing personnel
who should provide that care.
Purposes for classifying patients: For/ to

1. staffing. Perceived patient needs can be

matched with available nursing resources
2. program costing & formulation of the
nursing budget
3. tracking changes in patient care needs
4. determine values for the productivity
equation: output divided by input.
5. determine quality
 Orem’s Self-Care Theory
Self Care
Capabilities Deficit Nursing Systems

Intense Intense
Work
NURSE Work
for for
the the
Nurse Patient
PATIENT

Wholly Partially Educative /

Compensatory Compensatory Supportive

34
Types of Patient Classification Systems:
A. Descriptive – narrative descriptive of
various degrees of care required by a
particular patient
A.1 Checklist – lists down patient
problems according to patient acuity.
A1.1. Self-care
A.1.2 Minimal care
A.1.3 Moderate Care
A.1.4 Extensive care
A.1.5 Intensive
care
 A.2 Time-based – lists patient needs
according to
level of acuity and ascribe the
amount of
nurse-time needed to meet the needs
A.2.1 Minimal
A.2.2 Partial
A.2.3 Acute
A.2.4 Complex
The number of categories in a patient
classification may range from 3 to 4, which is
the most popular, to 5 or 6. These classes
relate to the acuity of illness and care
requirements, such as minimal, moderate, or
intensive care.
 Other factors affecting the
classification system would relate to
the patient’s capability to meet his
physical needs to ambulate, bathe,
feed himself, instructional needs
including emotional support.

 Patient care classifications have

been developed primarily for medical,
surgical, pediatrics, and obstetrical
patients in acute care facilities.
Classification Categories
 Level I – Self Care or Minimal Care
– Patient can bathe, feed and perform ADL.

 Level II – Moderate Care or Intermediate Care

– Patient needs some assistance in ADL,
ambulating up and about for short periods
of time,

 Level III – Total, Complete or Intensive Care

– Patients are completely dependent upon
the nursing personnel.
 Level IV – Highly Specialized Critical
Care -

- Patients maximum nursing care, they need

continuous treatment, observation, many
medications, IV piggy backs, vital signs q
15-
30 mins. hourly output;

- significant changes in doctor’s orders more

than care hours / patient /day may range
from 6-9 or more.
 Levels of Care NCH Needed Ratio of Prof. to
Per Patient/ Day Non-Prof

Level I
Self Care or
Minimal Care 1.5 55:45
Level II
Moderate or
Intermediate Care 3 60:40

Level III
Total or Intensive Care 4.5 65:35

Level IV
Highly Specialized 6 70:30
or Critical Care 7 or higher 80:20
 Percentage of Patients in Various Levels of Care

Types of Hospital Minimal Moderate Intensive Highly

Care Care Care Specialize
Care

Primary Hospital 70 25 5 -

Secondary Hospital 65 30 5 -

Tertiary Hospital 30 45 15 10

Special Tertiary 10 25 45 20
Hospital
NURSING CARE ASSIGNMENT
(sometimes called.. )

Modalities of Nursing Care,

Systems of Nursing Care,
Patterns of Nursing Care
Modalities of Patient Care

1. Primary nursing - total care of an individual is the responsibility

of one nurse.

2. Team nursing – a group of nurses work together to fulfill the full

functions of professional nurse, to be led by one
nurse

3. Case method/total Patient Care – provides one-to-one RN-to-

client ratio & constant care for a specified period of time.

4. Functional Method/Task nursing

– the oldest nursing practice modality
- task oriented method: 1 nurse for giving medicines
- no one is responsible for total care of any patient
- it accomplishes the most work in the shortest amount of
time.

5. Modular Nursing –RN provides direct nursing care with assistance of

aides.
 1. Functional Nursing

– Task oriented

- best system that can be used

when there are many patients and
few professional nurses.
Lines of Authority:
Head / Senior Nurse

R.N. R.N. Nsg. Attendant Housekeeper

Medication Treatment Hygienic Care Linen Attendant

Patients
 Total Care / Care Nursing

– 1 nurse: 1 patient (private duty nursing)

 - the nurse is accountable for her own
actions
- this works best when there are plenty
of nurses and patients are few
- nurses may not be familiar with
patients in other areas
 Head / Senior
Nurse

Staff Nurse

Patient


Total Care / Care Nursing
Team Nursing – decentralized system giving
care through participative effort
 assigning patients and task according to job
description
 leader has the responsibility for coordinating
the total care of a group of patient (Team
Conference – the heart of team nursing)
 if not fully implemented, it can lead to
fragmentation of care
 in this method only team leader has
significant responsibility and authority & care
may resemble functional method if the leader
does not keep members informed
Charge Nurse

Team Leader

Staff Nurse Team Nursing

Clients
 Primary Nursing
– a form assigning patient care responsibilities
is an extension of the principle of
decentralization.

Each RN is responsible for the total care of a

small group of patient from admission to
discharge.

 nurse assumes 24 hours responsibility for

nursing care
 Secondary or associate nurses executes the
nursing care plan during afternoon and night
shifts or day when the primary nurse is off-duty.
 Physician Head Nurse Hospital and Community
Resources

Primary Nurse
Patient/ Client

Secondary/ Ass. Secondary/ Ass. Secondary/ Ass.

Nurse PM Nurse Nite Nurse Relief

Lines of Authority in Primary Nursing

 Modular Method - Modification of
team
and primary nursing
- RN provide direct nursing care
with
assistance of aides

 Case Management – responsible for

assessment of patient and
family
Functions of Communications
 Communication Fundamentals
(Direction)

LATERAL

© 2009 Prentice-Hall Inc. All 11-54

11-54
rights reserved.
Lines of Communication
a. Downward – from superior to the subordinate which
may pass through various levels.
e.g. policies, rules and regulations, memos,
handbooks,
interviews, job descriptions, and performance
appraisal
b. Upward – emanates from subordinates to superior,
usually in the form of feedback and does not flow
as
easily as downward communication.
e.g. discussions between subordinates and
superiors, grievance procedures written
reports, incident reports and statistical
reports.
c. Horizontal – or lateral – flows from between peers,
personnel or departments on the same level.

e.g. endorsements, between shifts, nursing

rounds,
journal meetings and conferences, or
referrals
between departments or services

d. Outward – deals with information that flows from the

care-givers to the patients, his family, relative,
visitors
and the community.

e.g. information about the nature of their illness,

medical and nursing plans of care
 …again and again, the impossible problem is solved
when we see that the problem is only a tough decision
waiting to be made.
-Robert H. Schuller

…in any moment of decision the best thing

you can do is the right thing, the next best
thing is the wrong thing, and the worst thing
you can do is nothing.
-Theodore Roosevelt
LET HIM THAT
WOULD MOVE
THE WORLD,

FIRST MOVE
HIMSESF.

- Socrates