NURSING LEADERSHIP AND MANAGEMENT

Topic: Nursing Management Functions (Directing and Controlling)

DIRECTING Intrinsic Motivation vs Extrinsic Motivation

Directing  Intrinsic motivation
۩ Fourth phase of the management process o Comes from within the person, driving him/her
۩ May be refereed to as COORDINATING or ACTIVATING to be productive
۩ “Doing” phase of management, requiring the leadership o Often influenced by family unit or cultural values
and management skills necessary to accomplish the goals  Extrinsic motivation
of the organization o Comes from outside the individual
۩ Leader-manager sets the plans into action o Occurs when individuals are motivated to
۩ Creating a motivating climate is a critical element in perform a behavior or engage in an activity to
meeting employee and organizational goals earn a reward or avoid punishment
o Rewards and reinforcements are given to
Elements of Directing encourage certain behaviors and/or levels of
 Delegation achievement
 Motivation
 Decision-making Motivational Theory
 Conflict Management Maslow’s Hierarchy of Needs (1970)
 Change Management ۩ Believed that people are motivated to satisfy certain needs,
 Time Management ranging from basic survival to complex psychological needs,
 Supervising and that people seek a higher need only when the lower
needs have been predominantly met
Delegation
۩ Getting the work done through others Skinner BF’s Operant Conditioning and Behavior Modification
۩ Directing the performance of one or more people to (1953)
accomplish organizational goals ۩ Skinner’s research on operant conditioning and behavior
modification demonstrate that people can be conditioned
5 Rights of Delegation to behave in a certain way based on a consistent reward or
Right task One that is delegable for a specific punishment system
patient
Right circumstances Appropriate patient setting, available Frederick Herzberg’s Motivation-Hygiene Theory (1987)
resources, and other relevant factors ۩ Aka Two-Factor Theory
considered ۩ Herzberg maintained that motivators (manager), or job
Right person Delegating the tasks to the right satisfiers, are present in the work itself and encourage
person to be performed on the right people to want to work and to do that work well
person ۩ Hygiene or maintenance factors keep to worker from
being dissatisfied or demotivated but do not act as true
Right Clear, concise description of the task,
motivators for the workers
direction/communication including its objective, limits, and
expectations
Motivators Hygiene Factors
Right level of supervision Appropriate monitoring, evaluation,
intervention, as needed, and  Achievement  Salary
feedback  Recognition  Supervision
 Work  Job security
Motivation  Responsibility  Positive working
۩ The force within the individual that influences or directs  Advancement conditions
behavior  Possibility for growth  Personal life
۩ Creating a motivating climate is critical element in meeting  Interpersonal
employee and organizational goals relationships and peers
 Company policy status
Employee Engagement – an employee’s emotional commitment to
the organization and its goals Victor Vroom’s Expectancy Model (1964)
۩ This emotional commitment means engaged employees ۩ A person’s expectations about his or her environment or a
actually care about their work and their company certain event will influence behavior
۩ They don’t work just for the paycheck, or just for the next
promotion, but work on behalf of the organization’s goals David McClelland’s Human Motivation Theory (1971)
۩ The extent to which employees feel passionate about their ۩ People are motivated by three basic needs: achievement,
jobs, are committed to the organization, and put affiliation, and power
discretionary effort into their work ۩ Achievement-oriented
o People actively focus on improving what is
o They transform ideas into action, judiciously and
wisely, taking risks when necessary
NURSING LEADERSHIP AND MANAGEMENT
Topic: Nursing Management Functions (Directing and Controlling)

respect” is a predicative of strong employee

۩ Affiliation-oriented engagement with their manager
o People focus their energies on families and Promotion as a Motivational Tool
friends Promotion – reassignments to a position of higher rank
o Their overt productivity is less because they view ۩ Include a pay raise
their contribution to society in a different light ۩ Include increased status, title changes, more authority,
from those who are achievement oriented and greater responsibility
۩ Power-oriented
o People are motivated by the power that can be Decision-making
gained as a result of a specific action ۩ A complex, cognitive process often defined as choosing a
o They want to command attention, get particular course of action
recognition, and control others ۩ “The thought process of selecting a logical choice from the
available options”
Saul Gellerman’s Theory of Stretching (1968)
۩ States that most managers in organizations overmanage, Problem solving – is part of decision making and is a systemic
making the responsibilities too narrow and failing to give process that focuses on analyzing a difficult situation
employees and decision-making power or to stretch them ۩ Problem solving always includes a decision-making step
often enough
۩ Stretching Managerial Decision-Making Model
o Involves assigning tasks that are more difficult 1. Determine the decision and the desired outcome (set
than what the person is used to doing objectives)
o This includes personal and professional o Identify decision to be made, who needs to be
development in areas of vocational knowledge, involved in the decision process, timeline for
skills and expertise decision, and goals or outcomes to be achieved
o Giving people responsibility often causes them 2. Research and identify options
to rise to the challenge 3. Compare and contrast these options and their
consequences
Douglas McGregor’s Theory X and Theory Y (1960) 4. Make a decision
۩ How the manager views and treats the worker will have an o Rank options/alternatives
impact on how well the organization functions 5. Implement an action plan
6. Evaluate results
Theory X Employees Theory Y Employees
 Avoid work if possible  Like and enjoy work Conflict Management
 Dislike works  Are self-directed Conflict – generally defined as the internal or external discord that
 Must be directed  Seek responsibility results from differences in ideas, values, or feelings between two or
 Have little ambition  Are imaginative and more people
 Avoid responsibility creative
 Needs threats to be  Have underutilized Categories of Conflict
motivated intellectual capacity  Intrapersonal Conflict
 Need close supervision  Need only general o Occurs within the person
 Are motivated by supervision o It involves an internal struggle to clarify
rewards and punishment  Are encouraged to contradictory values or wants
participate in problem
solving  Interpersonal Conflict
o Happens between two or more people with
Creating a Motivating Environment differing values, goals, and beliefs
 Worker Empowerment o Ex. Horizontal violence or bullying
o Process of allowing employees to have input and  Intergroup Conflict
control over their work and the ability to openly o Occurs between two or more groups of people,
share suggestions and ideas about their work departments, and organizations
and the organization as a whole o Ex. Two political affiliations with widely differing
 Incentives and Rewards or contradictory beliefs or nurses experiencing
o Used to foster a motivating climate intergroup conflict with family and work issues
 Relationship between Employees and Supervisor
Conflict Resolutions Strategies
o “Feeling valued, being treated fairly, receiving
feedback and direction and having a strong  Compromising – each party gives up something it wants
working relationship between an employee and  Competing – used when one party pursues what it wants
his/her manager that is based on mutual at the expense of the others
o Managers may use competing when a quick or
unpopular decision needs to be made
NURSING LEADERSHIP AND MANAGEMENT
Topic: Nursing Management Functions (Directing and Controlling)

 Cooperating/Accommodating – one party sacrifices 3. Refreezing – the last phase, the change agent assists in
his/her beliefs and allows the other party to win stabilizing the system change so that it becomes
 Smoothing – occurs when one party in a conflict attempts integrated into the status quo
to pacify the other party or to focus on agreements rather Stages of Change and Responsibilities of the Change Agent
than differences Stage 1 – 1. Gather data
o Managers often use smoothing to get someone Unfreezing 2. Accurately diagnose the problem
accommodate or cooperate with another party 3. Decide if change is needed
o More on diplomacy, come in harmony 4. Make others aware of the need for
 Avoiding – the parties involved are aware of a conflict but change; often involves deliberate tactics
choose not to acknowledge it or attempt to resolve it to raise the group’s discontent level; do
o Those who actively avoid conflict frequently not proceed to stage 2 until the status
have low esteem or hold a position of low power quo has been disrupted and the need for
o Avoidance may be indicated in trivial change is perceived by others
disagreements, when the cost of dealing with Stage 2 – 1. Develop a plan
the conflict exceeds the benefits of solving it, Movement 2. Set goals and objectives
when the problem should be solved by people 3. Identify areas of support and resistance
other than you, when one party is more 4. Include everyone who will be affected by
powerful than the other, or when the problem the change in its planning
will solve itself 5. Set target dates
 Collaborating – an assertive and cooperative means of 6. Develop appropriate strategies
conflict resolution that results in a win-win solution 7. Implement the change
o In collaboration, all parties set aside their 8. Be available to support others and offer
original goals and work together to establish a encouragement through the change
supraordinate or priority common goal 9. Use strategies for overcoming resistance
o In doing so, all parties accept mutual to change
responsibility for reaching the supraordinate 10. Evaluate the change
goal 11. Modify the change, if necessary
Stage 3 – Support others so that the change continues
Change Management Refreezing
۩ The process of making changes in deliberate, planned, and
systematic manner Time Management
۩ It is important for nurse leaders and nurse managers to ۩ Techniques for allocating one’s time through the setting of
remember a few key points about change management goals, assigning priorities, identifying and eliminating
۩ Employees will react differently to change, no matter how wasted time and using managerial techniques to reach
important or advantageous the change is purported to be goals efficiently
۩ Basic needs will influence reaction to change, such as the Steps in Time Management
need to be part of the change process, the need to be able
to express oneself openly and honestly, and the need to
feel that one has some control over the impact of change
۩ Change often results in a feeling of loss due to changes in 1. Allow time for planning and
established routines. establish priorities.
o Employees may react with shock, anger, and
resistance, but ideally will eventually accept and
adopt change 2. Complete the highest priority task
۩ Change must be managed realistically, without false hopes whenever possible and finish one
and expectations, yet with enthusiasm for the future task before beginning another.
o Employees should be provided information
honestly and allowed to ask questions and
express concerns
3. Reprioritize based on the remaining
Kurt Lewin’s Change Theory of Unfreezing, Movement, and tasks and on new information that
Refreezing may have been received
1. Unfreezing – occurs when the change agent convinces
members of the group to change or when guilt, anxiety, or
concern can be elicited. Thus, people become discontent
and aware of a need to change Supervision
2. Movement – the change agent identifies, plans, and ۩ Guiding and directing the work to be done
implements appropriate strategies, ensuring that driving ۩ Helping the individual do his work better
forces exceed restraining forces ۩ Assess the capability of the individual if he needs
supervision
NURSING LEADERSHIP AND MANAGEMENT
Topic: Nursing Management Functions (Directing and Controlling)

relationship exists between the process used by

CONTROLLING the nurse and the quality of care provided
Controlling
۩ The fifth and final step in the management process
۩ Because the management process, like the nursing process,  Structure Audits
is cyclic, controlling is not an end in itself; it is o Assume that a relationship exists between
implemented throughout all phases of management quality care and appropriate structures
۩ Assessing and regulating performance o Are often set by licensing and accrediting bodies
۩ Process of seeing that actual expenditures and activities to ensure a safe and effective environment
conform to plan o Includes resource inputs such as the
۩ Examples of management controlling functions: environment in which healthcare is delivered
o The periodic evaluation of unit philosophy, o Includes elements that exists prior from the
mission, goals, and objectives interaction between the patient and the
o The measurement of individual and group healthcare worker such as staffing ratios, staffing
performance against preestablished standards mix, emergency department wait times, and the
o Auditing of patient goals and outcomes availability of fire extinguishers in patient care
areas
Continuous Quality Improvement o Ex: call lights, breast feeding rooms
Total Quality Management (TQM) – aka CONTINUOUS QUALITY
IMPROVEMENT (CQI), is a philosophy developed by Dr. W. Edward Joint Commission
Deming. It assumes that production and service focus on the ۩ An independent, not-for-profit organization that accredits
individual and that quality can always be better healthcare organization and programs has historically had
۩ Identifying and doing the right things, the right way, the a tremendous impact on planning for quality control in
first time, and problem prevention and reactive problem acute-care hospitals
solving—lead to quality outcomes ۩ JC was first to mandate that all hospitals have a QA
program in place by 1981. These QA programs were to
Quality Control – specific type of controlling, refers to activities that include:
are used to evaluate, monitor, or regulate services rendered to o Review of the care provided by all clinical
consumers departments, disciplines, and practitioners
o Coordination and integration of the findings or
Hallmarks of Effective Quality Control Programs quality control activities
1. Support from top-level administration o Development of specific plans for known or
2. Commitment by the organization in terms of fiscal and suspected patient problems
human resources
3. Quality goals reflect search for excellence rather than ISO Certification
minimums ۩ ISO – International Organization for Standardization
4. Process is ongoing or continuous ۩ In the Philippines, ISO Certification is becoming
increasingly common for hospitals
Quality Control Process ۩ Many hospitals are now looking to achieve ISO
1. The criterion or standard is determined certification in order to improve their quality management
2. Information is collected to determine if the standard has system
been met ۩ This can help to improve the quality of care and increase
3. Educational or corrective action is taken if the criterion has patient satisfaction
not been met ۩ ISO certification can also help to reduce costs and improve
efficiency
Audit – a quality control tool, is a systematic and official
examination of a record, process, structure, environment, or Benefits of having ISO Certification
account to evaluate performance  Improved quality of care
۩ In healthcare organizations, auditing provides managers o ISO certified hospitals must meet strict quality
with a means of applying the control process to determine standards, which leads to improved patient care
the quality of services rendered  Increased patient satisfaction
o Patients are more likely to be satisfied with the
Audits most Frequently used in Quality Control care they receive at an ISO certified hospital
 Outcome Audits  Greater staff satisfaction
o Reflect the end result of care or how the o Employees of ISO certified hospitals report
patient’s health status changed as a result of an higher job satisfaction rates
intervention  Lower costs
 Process Audits o ISO certified hospitals tend to have lower costs
o Used to measure the process of care or how the due to their streamlined processes and improved
care was carried out and assume that a efficiency
NURSING LEADERSHIP AND MANAGEMENT
Topic: Nursing Management Functions (Directing and Controlling)

ISO Certified Hospital in the Philippines Types of Evaluation Responses

 Manila Doctors Hospital Checklists
 Makati Medical Center ۩ Is a compilation of all nursing performances expected of a
 St. Luke’s Medical Center-Global City worker
 Asian Hospital and Medical Center ۩ Appraiser’s task is to mark the appropriate column
 The Medical City whether the worker does or does not show the desired
Nursing Audit – method for assuring documentation of quality of behavior
nursing care in keeping with established standards

Types of Nursing Audit

 Retrospective Audits
o Performed after the patient receives the service
 Concurrent Audits or Open Chart Review
o Are performed while the patient is receiving the
service, check charting, observation of patient

Auditing Quality Control Steps

Establish control criteria

Identify the information relevant to the criteria

Determine ways to collect the information

Collect and analyze the information

Compare collected information with the established criteria Ranking

۩ The evaluator ranks the employees according to how he
Make a judgement about quality fared with co-workers with respect to certain aspects of
performance
Provide information and, if necessary, take corrective action ۩ Ex: educational requirements, clinical proficiency
regarding findings
Rating Scale
Reevaluation ۩ Includes series of items representing the different tasks or
activities in the nurse’s job description
Performance Appraisal
۩ Evaluated by supervisors
۩ Method of evaluating accomplishments to help employees
improve his work methods
۩ When done correctly, it is one of the greatest tools an
organization has to develop and motivate staff
۩ When done poorly, it has the potential to discourage and
demotivate

Evaluation
۩ Plays an important role in quality and productivity
improvement for several reasons:
o Ensures quality nursing care is provided
o Allows for setting of sensible objectives and Free Response Report
ensures compliance ۩ Comment in writing on the quality of the nurse’s
o Provides standards for establishing comparisons performance
o Promotes visibility and means for employees to
monitor their own performance Forced-choice Comparison
o Highlights problems related to quality care and ۩ The evaluator is asked to choose the statement that best
determines the areas that require priority describes the nurse being evaluated
attention
o Provides an indication of the costs of poor Common Errors of Evaluation
quality  Halo Error – based on the good traits one sees in person,
o Justifies the use of resources good things done overshadow errors
o Provides feedback for improvement  Horn’s Effect – poor performance overshadowed good
performance
NURSING LEADERSHIP AND MANAGEMENT
Topic: Nursing Management Functions (Directing and Controlling)

 Logical Error – first impression, first encounter may o The disciplinary committee should be very sure
provide the rater the qualities or specific traits which that the cause for dismissal conforms with the
serves as bars to the quality of performance of the ratee criteria of a major discipline violation as
 Central Tendency Error – all treated as average, used by contained in the policy manual
the rater when feedback tools are adequate and when
there’s insufficient time for the rater to observe the ratee
 Leniency Error – given mercy rating
Benchmarking – a technique whereby an organization seeks out the
best practice in its industry to improve its performance

Discipline – part of the controlling process in management

۩ Regarded as a constructive and effective means of by
which employees take personal responsibility for their own
performance and behavior

Principles of Disciplinary Actions

1. Have a positive attitude
2. If they are treated as suspects, they are more likely to
provide the trouble that the manager anticipates
3. Investigate carefully
4. Be prompt
5. Protect privacy
6. Focus on the act
7. Enforce rules carefully. Use extreme caution in instituting
disciplinary measures
8. Be flexible
9. Take corrective, constructive actions
10. Should be progressive in nature preceded with counselling

Disciplinary Actions
1. Counseling and Oral Warning
o Best given in private and in an informal
atmosphere
o Employee is given a fair chance to air his side
o The relevant facts are analyzed and evaluated
against his performance
o Employee is then counseled regarding
expectation of improved behavior/performance,
ways of correcting problem and a warning that a
repetition of the same offense may warrant
further disciplinary action
2. Written Warning
o Second step in the disciplinary action
o The employee must be told after the interview
that he will be given a written warning
o This includes the statement of the problem,
identification of the rule which was violated,
consequences of continued behavior,
employees’ commitment to take corrective
action, and any follow up action to be taken
3. Suspension
o Given after an evidence or oral and written
warnings
o Suspension, rather than dismissal is applied
when management feels that the employee can
still be rehabilitated
4. Dismissal
o Invoked only when all other disciplinary efforts
have failed