Leadership and management

Nursing Leadership & Management

Peter Eustaquio Capistrano, PT, RN, Theo

1Peter Eustaquio Capistrano

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 2Peter Eustaquio Capistrano

• 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


• You need to know what motivates people, &

• How you can help create an

environment that inspire and sustain the individuals who work with you.


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



+ emerging new threats such as terrorism, biological warfare, global pandemics

+ addressing the ever-increasing international nursing shortage

+ high turnover rates of staff + new legislations of minimum

staffing ratios6Peter Eustaquio Capistrano


Concerns (for employers, HCW, public & policy makers):• Costly live-saving medicines• Robotics• Remote care• Innovations in imaging

technologies• Non-invasive treatments &

surgical procedures


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 careProvide coverage for the buyers of

health care services; and,8Peter Eustaquio Capistrano

Health Care Networks

• Accept the risk inherited in taking a fixed payment in return for providing health care for all persons.

Variety of arrangements and affiliations have occurred


The focal point for care: -- 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.


• It is now the GOAL of the health care

industry to keep patients out of the hospitals!!!


Demands to reduce errors

Peter Eustaquio Capistrano 12

Demand to ↓ Errors 4 Systems Used to ↓ medical errors

I. Control of Medical errors:- US reported in 1999 – 98,000

death occurred each year from preventable medical mistakes in hospitals

- Medical injuries found to ↑ length of stay, patient’s costs & mortality


Demand to ↓ ErrorsA. Computerization system for

pharmacy that will alert staff for possible:

drug interactions, or adverse reactionsB. Computerized medication

administration recordsC. Patient ID band w/ bar codes


Demand to ↓ ErrorsD. Beginning fiscal year 2008,

CMS-US would no longer reimburse hospitals for the cost related to hospital-acquired infections or medical errors.

CDC-US, approx: 2m people suffer from nosocomial infections w/c costs $27.5b

(CDC, 2007)15Peter Eustaquio Capistrano

Demand to ↓ Errors

II. Leapfrog Group- A consortium of public &

private purchasers - Provides benefits to more than

37m Americans in all 50 states. - Rewards health care

organizations that demonstrate quality outcome measures



• 3 quality indicators:

1. ↑ computer-physician order entry system

2. Using evidence-based hospital referrals

3. Using ICU physician intensivists staff


Demand to ↓ ErrorsMost significant impact on

preventing medical errors:• ≥ 65,000 lives could be saved

• ≥ $41b could be saved

• ≥ 900,000 medical errors could be avoided



III. Quality management Preventive approach to address

problems before they become crises

Began in post-WW II Japan



• To improve the quality of manufactured products

• Consumers’ needs should be the focus of management

• Employees should be empowered to evaluate and improve quality


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



IV. Benchmarking• Compares an organization w/

similar organizations (in contrast w/ TQM)

• Outcome indicators are identified to be used to compare performances across disciplines


Benchmarking

• Used for standard development & performance improvement

• Once the results are known, weaknesses can be addressed & enhance areas of strength


Benchmarking

Questions to be asked in benchmarking:

+ “How did they do it?” + “What tools did they

use/” + “What were their lessons

learned?”


• Populations & Cultural Diversity

• Generational Diversity• Aging Patients & Aging

Nurses


Immigrant Populations & Cultural Diversity

• US Census Bureau minority population = 100m in 2007

• Hispanics – 44m (largest group)• African origin – 40 m fastest growing minority• Asians – 14m 2nd fastest growing minority



• The challenge for health care policy makers & the public:

to find ways to provide universal access to care regardless of care, ethnic origin, or socioeconomic status.



• Current trend: assume trans-cultural focus

They consider: - values - beliefs - lifestyle of the diverse cultures



• Trans-cultural diversity affects nursing:

- 81.8% of US nurses caucasians (2004 survey)

- 18.2% - from minority population

- only 5.4 nurses are male (2000 survey)


Generational Diversity

• Seeing four generations working together side by side in today’s workplace is common:

traditionalsBaby boomers have different

Generation X values &

millenials expectations in the workplace



• Baby boomers:

+ value professional & personal growth

+ expect that their work will make a difference



• Traditionals:

+ value loyalty + respect authority + follows bureaucracy

policies



• Generation X – desire a (+) work environment

• Want their work to have worth• Want independence, fun • Value independence• Tend to focus on outcomes

rather than processes



• To have balance between work & other important areas of their lives:

- personal relationships - child rearing - pleasurable pursuits



• Millenials (a.k.a. Generation Y)

• Technically savvy• Responsible• Competent• Expert in connecting online• Prepares to participate in

collaborative structures


Generational Diversity• Challenge for managers: - avoid stereotyping within the

generations - value unique contribution of

each generation - encourage mutual respect for

differences - leverage differences to enhance

teamwork36Peter Eustaquio Capistrano

Generational Diversity• Challenge for managers:

- changes in the workplace also add to conflicts due to the generations’ different expectations


Aging Patients, Aging Nurses

• Older generation 65 y/o & ↑ 37m in 2006 (12% in US

population) approximately 1 in every 10

Americans by 2030 – more than 71m older

adults



• Reasons for continuation of demand for health care for aging patients:

- people are living longer - advancement in technology are

enabling people to survive previously fatal diseases & conditions

- older x often require on-going care for chronic / acute illnesses



↑ older people are due to:• Increase in life expectancy • older workers retiring later• good health practices (exercise,

healthy eating, screenings)

These people will require episodic & chronic care



• Nurses are growing older

• Ave. age : 46.8 (US, 2007) compared to 44.3 in 1996

• % of nurses over 54 y/o increased to 25.2% in 2004.



• 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)


• Changes for future nurses


More Change on the Way

• Evidence-based practice applying the best scientific

evidence to a px’s unique diagnosis, condition & situation to make clinical decisions


Evidence-based practice

• The process of EBP: - identify the clinical question - find the evidence to answer the

question - evaluate the evidence - apply the evidence - evaluate the outcome


Evidence-based practice

• ΣθΤ International (honor society for nurse)

EBP: The integration of best evidence available,

nursing expertise, and the values & preference of the individuals, families & communities who are served. EBP will be successful when nurses & health care decision makers have access to a synthesis of the latest research, a consensus of expert opinion and then exercise their judgment as they plan & provide care that takes into account cultural & personal values & preferences. (2004)


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,

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 table47Peter Eustaquio Capistrano

Electronic Health Records

• Integrates health info from all sources and cane be accessed from multiple locations from authorized providers.



• Electronic records: - ↓ redundancies - improve efficiency - ↓ medical errors - lower health care costs



• Patient’s personal health record:

- online system allowing patients to track medications, record medical interventions, 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


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


Terrorism & Disaster Preparedness

• Extensive staff training is required

• Assess nurses’ concerns & provide accessible info, support & opportunities for debriefing

Natural disaster, attack of terrorism, epidemic are examples


Challenges Facing Nurses

Nurse mangers are challenged to: manage with decrease resourcesTo supervise teams of

professionals & non-professionals from a variety of cultures

Must a coach, teacher & facilitator because they are responsible for others’ work


• 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, & of the organization


• Organizations And

organizational theories


Organizational Theories

• Organization – a collection of people working together

under a defined structure to achieve pre-determined

outcomes using financial, human and material

resources.


Organizational Theories

• Types: + classical Theory + Humanistic Theory + Systems Theory + Contingency Theory + Chaos Theory + Complexity Theort\y


Organization

• The lifecycle of the org is dependent on its adaptability & response to changes in its environment

• When org tends to grow, it tends to stabilize & develop more formal standards.


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


4 elements of Classical Theory

• Division & Specialization of Labor

• Chain of Command• Organizational Structure• Span of Control


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 63Peter Eustaquio Capistrano

Chain of Command

hierarchy of authority & responsibility w/n the organization

Authority – as the right or power to direct activity

Responsibility – as obligation to attain objectives or perform certain functions


Chain of Command

• The line of authority – higher levels of management delegate work to those below them in the organization.

• Line of authority – linear hierarchy

• Staff authority – advisory relationship; recommends & advices


Chain of Command

Chief Nurse executive

Nurse Manager

Staff Nurse

Staff Nurse

Nurse Manager

Staff Nurse

Staff Nurse

Acute Care Nurse Practitioner


Organizational Structure

• describes the arrangement of the interrelated work group

• The design of the organization is intended to foster the organization’s survival & success


Span of Control

• Addresses the pragmatic concern of how many employees a manager can handle effectively


Span of Control

• Complex organizations – have numerous departments that are highly specialized & differentiated

• Authority is centralized

• a.k.a tall organizational structure


Span of Control

• Less Complex organizations – flat structure

• Authority is decentralized• With several managers

supervising large work groups


• Organizational theories


Humanistic Theory

• Criticism of the Classical Theory led to the development of the Humanistic Theory in the 1930s.

• Major assumption: People desire social

relationships, respond to group pressures, & search for personal fulfilment.


Humanistic Theory

• Hawthorne effect – if special attention is given to workers

they will work better resulting to increased productivity.


Systems Theory

• Defined as a set of interrelated parts arranged in a unified whole;

• Productivity is the result of interplay among structure, people, technology & environment


Types of Systems

• Closed System – self-contained & usually can be found in the physical sciences

• Open System – interacts both internally & & with its environment (a living organism)


• Organizations are complex, social, open system

• Framework are interrelated by part of the system and their functions can be studied

• Health care org’zn requires human, financial & material resources


Health Care System as Open System

INPUT• MATERIALS • MONEY• EMPLOYEES• PATIENTS• EQUIPMENTS

THROUGHPUT

• HEALTH CARE DELIVERY

• EDUCATION

OUTPUT

• RESTORED HEALTH• REHABILITATION• DISEASE

PROTECTION• DEATH W/ DIGNITY• RESEARCH


Contingency Theory

Contingency Theory believe organizational performance can be enhance by matching an organization’s structure to its environment.

Environment people, objects, ideas that influence the org.


Contingency Theory

• Environment of a health care org’n:

patientsPotential

patients third-party

payers

competitors regulators suppliersPharmaceuti-

cals


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 80Peter Eustaquio Capistrano

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, self-organizing systems that are complex and ever-changing.


Chaos Theory

• Chaos theory suggests that the drive to create a

permanent organizational structure is doomed to fail.


Chaos Theory

• Organizations, to succeed, must ensure:

+ flexibility + fluidity, + speed of adaptability, & + cultural sensitivity


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


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


Complexity Theory

• Organization is a mixture of all the theories that consider it as a total system.

reasons: random events interfere with

expectationsPatient’s condition change in an

instant


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


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.


Complexity Theory

• Hierarchy is less important in complexity theory.

• Every encounter between a px & a caregiver offers information about possible solutions to problems


Complexity Theory

• Manager’s task:Encourage the flow of info

between and among all team members, leaders &

followers, whether top-down, bottom-up, or sideways.


Traditional Organizational

Structures• When structure is not aligned with organizational needs, the organizational response to environmental change:

diminishes decisions are delayed, poor,

overlooked conflicts result performance deteriorates


Traditional Organizational

Structures• Types:

+ Functional Structure + Service-line Structure + Hybrid Structure + Matrix Structure + Parallel Structure


Functional Structure

• Employees are grouped in departments by specialty with similar tasks

• Reports to the same manager

• Tends to centralize decision-making (top organization)



• Weaknesses:

+ coordination across functions is poor

+ decision-making responsibilities can pile up at the top

+ overloaded senior managers



+ Coordination across functions are slow

+ General management training is limited

+ top managers may be uninformed of day-to-day operations


Service-line Structure

• a.k.a. Product-line structure, service-integrated structure

• All functions needed to produce a product or service are grouped together in self-contained units


Service-line StructureCEO

Executive secretary

Cardiology

Nursing

Dietary

Pharmacy

Oncology

Nursing

Dietary

Pharmacy

Burn Unit

Nursing

Dietary

Pharmacy


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 99Peter Eustaquio Capistrano

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 100Peter Eustaquio Capistrano

Hybrid Structure

During growth of organizations, both self-

contained units & functional units converge


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 102Peter Eustaquio Capistrano

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


Hybrid StructureCEO

NURS

ING

STORE

ROOM

DIETARY

ADMITTIN

G

PHARMA CY

BILLING


Matrix Structure

• Integrates both product & functional structures into one overlapping structure.

• Different managers are responsible for function & product

• (e.g. Nurse manager for oncology clinic may report to the vp for nursing as well as to the vp for outpatient services)


Matrix Structure• Weakness:

+ dual authority + excellent interpersonal

skills are needed from managers involved

+ time consuming due to frequent meetings to resolve conflicts & problems


Matrix Structure

• Weakness:

+ one side of the organization may become dominate over the other


Matrix Structure

Vice-President, Outpatient Services

Oncology Pediatrics Family medicine

Vice-President for Nursing

ServicesNurse

ManagerNurse

Manager

Nurse Manager


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.)

• two lines of authority: organizational dilemma


Parallel StructureCEO

Chief Nurse

executive

NM

RN

LPN

UAP

NM

NM

Hr dIRECTOR

chief financial Officer

BUDGET

BUDGET pERSON

NEL

Chief Suport

Services

HOUSEKEEPING

MAINTENANCE

MEDICAL dIRECTOR

CHIEF OF SERVICES

INTERNAL mEDICINE

SURGERY

OB


Leadership And

Management


• 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!!!


• 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!!!


Leader • Anyone who uses

interpersonal skills to influence others to accomplish the specific goals.

• Exerts influence by using a flexible repertoire of personal behaviors & strategies.


Manager

• Latin: manu, agere, “to lead from the hand”

• An individual employed by an organization responsible & accountable for efficiently accomplishing the goals of the organization.


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.

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, responsibilities


Leader • Focus on group

process, informal gathering, empowering people

• Emphasize interpersonal relationship

Manager • Emphasize control,

decision-making, decision analysis & results

• Manipulate the environment, people, money, time & other resources to achieve organizational goals


Leader • Directs willing

followers

• Goals that may or may not reflect the those of the organization

Manager • Have a greater

formal responsibilities & accountability for rationality & control than leaders

• Direct willing & unwilling subordinates









Leadership and management

Documents

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health care system

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continuum of care

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errorsmedical errors