Lecture - Controlling

CONTROLLING

…or evaluating is an on-going function of management which occurs during planning, organizing and directing activities.

…is the management function in which performance is measured and corrective action is taken to ensure the accomplishments of organizational goals

CONTROL MEASURES

Standards…general guide to provide a framework for nurse managers or administrators. The responsibilities and expectations of the nurse are embodied in these standards.

Standard I…the division of nursing has a

philosophy and structure that ensure the delivery of high-quality nursing care.

Standard II…the division of nursing is

administered by a qualified nurse executive who is a member of a corporate administration.

Standard III…policies and practices of the

division of nursing provide for equality and continuity of nursing services that recognize cultural, economic, and social differences among patients of health care organization.

Standard IV…the division of nursing ensures

that the nursing process is used to design and to provide nursing care to meet the individual needs of patients/clients in the context of their families.

Standard V…the division of nursing ensures

the development of educational programs to support the delivery of high-quality nursing care.

Standard VI…the division of nursing

initiates, utilizes, and participates in research studies or projects for the improvement of patient care.

Reasons for conducting Evaluation 1. Ensures that quality nursing care is

provided.2. Allows for the setting of sensible

objectives and ensures compliance with them.

3. Provides standards for establishing comparisons.

4. Promotes visibility and a means for employees to monitor their own performance.

5. Highlights problems related to quality care and determines the areas that require priority attention.

6. Provides an indication of the costs of poor quality.

7. Justifies the use of resources8. Provides feedback for improvement.

Evaluation Principles 1. Must be based on the behavioral

standards of performance which the position requires.

2. Enough time should be spent to observe employee’s behavior. Usual and consistent behavior should be evaluated.

3. Employee should be given a copy of the job description, performance standards and evaluation form before the scheduled evaluation conference.

4. Performance appraisal should include both satisfactory and unsatisfactory results with specific behavioral instances.

5. Prioritize areas needing improvement to help the worker upgrade his performance.

6. Scheduled and conduct evaluation conference at a convenient time for the rater and the employee under evaluation.

7. Structure evaluation report and conference in such a way that it is perceived and accepted positively as a means of improving job performance.

Characteristics of an evaluation tool: 1. Objectivity – means that the

evaluation tool is free from bias.2. Reliability – refers to the accuracy

or precision of the tool such that it will produce the same results if

administered twice.3.Validity – refers to the relevancy of

the measurement to the performance of the employee.

4. Sensitivity – means that the instrument can measure fine lines of differences among the criteria being measured.

PRINCIPLES OF CONTROL

Controlling aims to verify whether activities and performances of employees are in conformity with the plans of the organization, principles and practices.

1. Principle of “setting the fox to watch the henhouse”. In this situation, individuals themselves provide their superior with the information that will be used to evaluate their performance.

2. Principle of “measured behavior” drives out “unmeasured behavior” . Focusing on specific and measurable aspects of the job in giving feedback to an individual may drive out

“unmeasured (and unrewarded) behavior

3. Principle of “paradox of control”. In attempting to control others, an individual may impose new requirements on them. Doing so leads to counter measures by the controllee, either to avoid this control, to modify the information, or even to seek substitute for the desired action.

Basic components of the Control Process 1. Establishment of standards,

objectives, and methods for measuring

performance.2. Measurement of actual performance.3. Comparison of results of

performance with standards and objectives and identifying strengths and areas for correction and / or improvement.

4. Action to reinforce strengths or successes, and

5. Implementation of corrective action as necessary.

The controlling process opens opportunities for improvement and comparing performance against set standards. It provides information about how well processes and people function so they can be motivated to perform better in the future.

The means of good performance and management includes leadership and commitment, full employee involvement, good planning, sound implementation strategy, measurement and evaluation, control and Improvement, and the achievement and sustenance of standards of excellence.

PERFORMANCE APPRAISAL

- a control process in which employee’s performance is evaluated against standards.

1. Determine salary standards and merit increases;

2. Select qualified individuals for promotion or transfer;

3. Identify unsatisfactory employees for demotion or termination;

4. Make inventories of talents within the institution;

5. Determine training and development needs of employees.

6. Improve the performance of work groups by examining, improving, correcting interrelationships between members;

7. Improve communication between supervisors and employees and reach an understanding on the objectives of the job.

8. Establish standards of supervisory performance;

9. Discover the aspirations of employees and reconcile these with the goals of the institution;

10. Provide “employee recognition” for accomplishment; and

11. Inform employees “where they stand”.

Factors contributing to an Effective Performance Appraisal System

1. Compatibility between the criteria for individual evaluation and organization goals.

2. Direct application of the rated performance to performance standards and objectives expected of the worker.

3. Development of behavioral expectations which have been mutually agreed upon by both the rater and the worker.

4. Understanding the process and effective utilization of procedure by the rater.

5. Rating of each individual by the immediate supervisor

6. Concentration on the strengths and weaknesses to improve individual performance.

7. Encouragement of feedback from the rated employees about their performance needs and interests.

8. Provision for initiating preventive and corrective action and making adjustments to improve performance.

Methods of Measuring Performance

1. Essay – the appraiser writes a paragraph or more about the worker’s strengths, weakness and potentials

2. Checklist –a compilation of all nursing performances expected of a worker; mark appropriate column whether the worker does or does not show the desired behavior.

3.Ranking – the evaluator ranks the employees according to how he fared with co-workers with respect to certain aspects of performance or qualifications.

4.Rating Scale – includes a series of items representing the different tasks or activities in the nurse’s job description or the absence or presence of desired behaviors and the extent to which these are possessed.

5. Forced-Choice Comparison – the evaluator is asked to choose the statement that best describes the nurse being evaluated.

6. Anecdotal Recording – describes the nurse’s experience with a group or a person, or in validating technical skills and interpersonal relationships. The Anecdotal record should include: – A description of the particular

occasion, – A delineation of the behavior noted

including answers to the questions

who, what, why, when, and how, and

– The evaluator’s opinion or assessment of the incident or behavior

GUIDELINES ON APPRAISING PERFORMANCE

1. The appraisal should be in writing and carried out at least once a year.

2. The performance appraisal information should be shared with the employee who should have the opportunity to respond in writing.

3. There should be a mechanism by which an employee can appeal the results of the performance appraisal.

4. The supervisor should have adequate opportunity to observe the employee’s job performance.

5. Notes (critical incidents) on the employee’s performance should be kept during the entire evaluation period.

6. The evaluators should be trained on how to carry out the performance appraisal process.

7. The performance appraisal process should be behaviorally-based (focusing on what the person did) rather than trait-based (focusing on personality characteristics such as initiative, attitude, etc.).

COMMON ERRORS in performance evaluation

HALO – results when the evaluator allows one trait to influence evaluation of other characteristics.

HORNS – are essentially the opposite of the halo error and occurs when the evaluator is overly critical

CONTRAST – occurs when the evaluator rates the employee opposite from the way they perceive their own abilities

RECENCY – is the tendency to base the performance appraisal on recent events rather than on performance over the entire evaluation period.

CENTRAL TENDENCY – occurs when the evaluator is reluctant to give a true appraisal, rating all employees as average.

NURSING AUDIT COMMITTEE

Patient Care Audits Peer Review Quality Circles

Patient Care Audits A day of observation of the activities

in the ward based on process or outcome criteria

Concurrent Patient Care Audit: done while patient is still in the unit, observation of patient care given is done and observation of the effect of nursing care done

Retrospective Patient Care Audit: for discharged patients; evaluated through review of charts and questionnaires sent to patients

Peer Review Peer evaluates the performance of

job based on accepted standards

Quality Circles Group of workers meet voluntarily to

identify, analyze and solve work related problems and recommend solutions to management

QUALITY ASSURANCE

The estimation of the degree of excellence in patient health outcomes and in activity and other resource outcomes.

Describes all activities related to the establishment, maintenance and

assurance of high quality care for patients which includes assessment of patient care and correction of problems identified.

It should promote collegial and sharing relationships among workers instead of a feeling of threat when

observed or evaluated.

Purpose of Quality Assurance - to assure the consumer of a

specified degree of excellence through continuous measurement and evaluation.

Principles Underlying Quality Assurance Efforts 1. All health

professionals should collaborate in the effort to measure and improve care.

2. Coordination is essential in planning a comprehensive quality assurance program.

3. Resource expenditure for quality assurance activities is appropriate.

4. There should be focus on critical factors such as functions and activities that promise to yield the greatest health and financial benefit to reveal significant findings.

5. Quality patient care is accurately evaluated through adequate documentation.

6. The ability to achieve nursing objectives depends upon the optimal functioning of the entire nursing process and its effective monitoring.

7. Feedback to practitioners is essential to improve practice. It perpetuates good performance and replaces unsatisfactory interventions with more effective methods.

8. Peer pressure provides the impetus to

effect prescribed changes based on the results of assessment and needed improvements on the quality of care.

9. Reorganization in the formal organization structure may be required if assessment reveals the need for a different pattern of health care.

10. Collection and analysis of data should be utilized to motivate remedial action.

Quality Assurance Methods 1. Concurrent

and retrospective patient care audits,2. Peer Review3. Quality circle4. Utilization of results 10 Tips for Success as a Nurse Manager Take an active, not reactive,

approach. Hold employees accountable for their

actions. Document, document, document! Keep confidential information

confidential. Seek support from many sources. Treat staff members as you’d want to

be treated. Maintain a balance between being a

manager and being a friend. Let equal treatment, not favoritism,

be your guide Make staff members aware of policies

and revise them as needed Turn negative events into positive

learning experience

Discipline: Rigid obedience to rules and

regulations, the violation of which results in punitive actions.

A constructive and effective means by which employees take personal responsibility for their own performance and behavior. Also known as self-discipline.

Factors influencing Discipline:

1. Understanding of requirements - know and understand ground rules, the limits and the actions and behavior that are approved and disapproved

2. Atmosphere of confidence - rests on a foundation of mutual trust and confidence (confidence of managers in their subordinates, subordinates in the decisions and actions of their supervisors)

3. Informal sanctions - social pressures generate within a group or organization

4. Formal sanctions - authority is used to enforce discipline

4. Goals, cohesion and morale - strong commitment to the objectives, acceptance of approved standards of conduct, positive attitudes and behavior

Characteristics of Disciplinary approaches

• Impartiality• Consistency• Promptness• Non- punitivenes • Fairness• Advance warning• Follow- through

…More on Disciplinary Approaches Any employee charged for

breach of the rules and regulations, policies, norms of conduct shall be given due process.

There must be existing rules of conduct governing his behavior

Documentation of actual violation of such rule must support charges

Employee must be notified in writing about the violation and given the right to counsel.

DISCIPLINARY APPROACHES

1. Problem solving Aid employees in analyzing work

problems; obtain information not readily available to employees, serve as counselor to personal problems

2. Disciplinary action Oral warning- conducted in an

informal atmosphere to encourage employee his view of the problem; important to obtain all relevant facts

Written warning- includes: – statement of the problem,

identification of the rule which was violated

– Consequences of continued deviant behavior

– Employee's commitment to make correction

– Follow up action to be taken

3.Suspension Given after oral and written warnings Applied when management feels that

the employee can still be rehabilitated.

Note: Accurate documentation of oral and written warnings including suspension, if done, are necessary evidences of due process.

4.Dismissal Invoked only when all other

disciplinary efforts have failed Make sure that the cause for

dismissal conforms with the criteria of a major discipline violation as contained in the policy manual,

For government employees, those contained in the Civil Service Rules and Regulations and the code of conduct.

A review is usually done by higher management.

For government employees, this is further reviewed by respective departments and final affirmation is done by the Civil Service Commission.

Reasons for dismissal from a position Negligence Incompetence Malpractice Unprofessional behavior, breach of

contract

COLLECTIVE BARGAINING AGREEMENT

DOCUMENTATION IN NURSING

Charting Incident Report Memorandum Hospital manual Endorsement & end- of- shift report Referral

Computer & Information Management Implication to nursing education and

practice

Current Issues and Trends in Nursing Management

CAREER PLANNING

Career Path/ Classification of Field of Nursing

1. Hospital/ Institutional Nursing- nursing in hospitals and related health facilities Ex. Nursing homes, neighborhood clinics BSN Participates in all phases of patient

care of the acutely ill, convalescing and ambulatory patients

2. Public Health/ Community Health Nursing- emphasis is on promotion of health & prevention of disease rather than care of the sick.

3. Private Duty Nursing- undertakes to give comprehensive care to a client on a one-on-one ratio. Nurse is an independent contractor

4. Occupational Health Nursing/ Industrial Nursing- provides and delivers health care services to workers. Practice focuses on promotion, protection and supervision of workers’ health within the context of a safe and healthy work environment

5. Nursing Education- career ladder starts with a Clinical Instructor position up to the dean of a College of Nursing

6. Military Nursing- Nurse Corps, AFP. Function is to provide comprehensive and quality nursing care to all military personnel, their dependents and authorized civilians

7. School Health Nursing- responsible for the school’s activities in the areas of health service, health education and environmental health and safety

8. Clinic Nursing- nurse acts as a receptionist, answers phone calls, does the billing, changes dressings, gives injections (BCG, DPT, measles) & assists in physical examination

STAFF DEVELOPMENTTHE NURSE SHOULD ENGAGE IN ACTIVITIES SUCH AS:

* attending conferences seminar-workshops

* in-service training programs

* reading professional publications; and

*engaging in other activities that will enhance his or her competencies as a nurse

IN- SERVICE EDUCATION

Steps in Planning: 1. Assess needs– Changes in technology, legislation,

research, patient load2. Set goals and define specific objectives– Should express expected outcomes

3. Plan courses and design learning experiences– Schedules should be flexible

enough that changes and additions can be made

4. Select resource people– Expertise & clinical competence– Model for learners– Knowledgeable about concepts of

adult learning– Relates well with adult learners– Able to communicate knowledge– Starts where learners are and let

them progress at their own pace– Willing to assist in evaluation

process– Accepting and listening person

5. Implement plans– Design curriculum– Select committee for each activity

6. Evaluate program– Did the educational activity make a

difference in the knowledge, skills and attitudes of the participants

– Includes diaries, tapes, reaction sheets, participant satisfaction ratings, pre- & posttests of knowledge

Membership in Professional Organizations

Alumni Associations

Professional Associations

1. Philippine Nurses’ Association– To attain level of professional

standards– To work for the welfare of member

nurses– To respond to the changing health

needs of the Philippine society– To establish linkages with

government, national & international agencies

2. The National League of Government Nurses- unite government nurses so they can be presented well in the government 3. Association of Nursing Service Administrators of the Philippines (ANSAP)- composed of nursing service administrators both in government and private agencies– Initiated development of Standards

of Nursing Service & Nursing Practice in 1976

4. Association of Deans of Colleges of Nursing in the Philippines- promote, elevate & maintain the standards of clinical instruction program of nursing students & to improve nursing service & facilities of the clinical fields in hospitals & public health agencies

5. Philippine Association of Public Health Nursing Faculty- dedicated to maintenance of high standards of objectives to standardize & broaden instruction in Public Health Nursing & to undertake that which will enhance professional growth

6. Occupational Health Nurses Association of the Philippines- organize nurses in industrial & commercial enterprises into an Industrial Nursing Unit

7. Military Nurses Association of the Philippines (MNAP)- for active, inactive and retired Nurse Corps officers of the AFP

8. Private Duty Nurses Association of the Philippines- addresses issues of increasing private duty nurses in hospitals, provision of definite policy guidelines in employment, uniformity in rate & pay

9. Operating Room Nurses Association of the Philippines- committed to improvement of OR management technique & facilities; insure maximum service to patients, promote professional development, personal growth and well- being of its members 10. Psychiatric Nursing Specialists Foundation of the Philippines- a nurse can interact & assist the individual, his family & the community & assist them to use their own resources to maintain health & to acquire a healthy state of adaptation when mental illness occurs

11. Catholic Nurses Guild– Promote spiritual welfare of nurses

& those under their care– strive to advance in professional &

technical competence

12. Integrated Registered Nurses of the Philippines– the nurse can exercise a positive

voice & be influential in addressing & articulating for a better & improved health care services & in maintaining nursing integrity

CHOOSING, RETAINING, RESIGNING & DISMISSAL FROM A POSITION

GUIDELINES IN CHOOSING A JOB Qualifications- does it fit the job you

are applying for? Years of experience & training- – are your experiences and training

relevant to what you are applying for?

– Consider your age & physical condition

Emotional stability & goals in life-

– can you be calm under severe stress?

– Do you get along well with people?– What is your primary aim in taking

up nursing: for money or the satisfaction in helping people?

Factors in Selecting a Job Kind of work to be performed– Are you prepared for the job?– Can you work under stress– Do you get along well with people?

Availability of the work– Is there a shortage of workers?

GUIDELINES IN CHOOSING A JOB Hours of work– Are you rotated on shifts? – How many hours a day or week do

you go on duty? Qualifications– What are the requirements in

terms of educational qualifications?– Experience?– Training?

Factors in Selecting a Job Opportunities for advancement– What chances do you have of being

promoted after several years of employment?

– Will be allowed to pursue continuing education?

Method of entering– Do you need an examination to

enter?– Do you need someone to

recommend you? Earnings– How much is the initial salary?– Is salary paid weekly or every 15

days? Fringe benefits– How many days of vacation & sick,

maternity leaves are given? Other benefits– Are insurances, medicare,

retirement benefits provided for?

LETTER OF APPLICATION

Pointers in making a Letter of Application Use clean, white, unlined paper Use ink or ball pen in writing Use proper salutation Write in a courteous manner Enclose return postage

Contents of Letter of Application 1st paragraph- Source & purpose– Source of info concerning vacancy

& nurse’s intent to apply 2nd & 3rd paragraphs- Qualifications– College from where he/ she

graduated, year of graduation, experience & training

Reference– 3 names

Last paragraph- Request for personal interview

SELECTION OF PERSONNEL

1. RECRUITMENT --- process of enlisting personnel for employment

METHODS: advertising word of mouth employee recommendation

2. SCREENING- recruiter uses data about the applicants to

determine if he/ she is qualified and meets the minimum requirement

PHILOSOPHIES:1. screen out applicants who do not

fit the image of the agency2. try to fit the job to a promising

client3. try to fit the applicant to the job

3. INTERVIEW Face to face conference between

two people about something Employer- – assess applicant’s personality– Alertness in answering questions

– Poise– Command of the spoken

language Applicant-– Background of institution;

potential as a working place– Philosophy & objectives– Working conditions

Pointers in preparing for an Interview Make appointment either by

mail or phone Be at the place at the appointed

time Know something about the

institution where you are applying

Be at your best Knock before you enter Bring credentials (PRC card,

residence certificate, TIN, etc) & other things needed (ID pictures, ball pen)

Ask questions about the job Thank interviewer for giving you

some of his time Give yourself time to think about

the position Write a follow- up letter if

prospective employer does not answer your call

3. ORIENTATION --- process of becoming familiar with a new environment and adapting well to it Part of staff development;

when policies, regulations and job descriptions are communicated to the newly employed nurse, uncertainties are diminished,

anxiety is reduced and misunderstandings are prevented.

A well-defined orientation program would include:

a tour to the physical facilities introduction to co-workers description of the organizational

structure of the institution

information on the philosophy, goals, policies and standards of the institution

functions of the members of the health team

RESIGNING FROM THE JOB

Reasons for Resigning from the Job Seek better positions locally or

abroad Inability to adjust to work situation,

marriage, children, etc

Points in writing a Letter of Resignation Give date of resignation State reason for resigning Express gratitude for kindness &

consideration given during period of employment

Attach clearance for money, work & property responsibilities

ISSUES,CONCERNS AND FUTURE DIRECTIONS INNURSING

EVIDENCED-BASED NURSING

An important concept to grasp when talking about new approaches to practice is “understanding reality while imagining other possibilities.”

“Evidence based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences, in the context of available resources”.(DiCenso A, Cullum N, Ciliska D (1998))

Why we need EBN Explosion of Literature - Difficult to

keep up with health care literature. Unmet Information Needs -

Practitioner information needs are currently not being met.

Implementation Delays - Average of 17 years before research findings are fully integrated into clinical practice

Goal- To provide the highest quality & most cost efficient nursing care possible

Founded on the collection, interpretation & integration of valid, important & applicable patient- reported, clinician- observed & research- derived evidence

The scale shows Research and “Knowledge” – the specific type of knowledge required in a given situation will depend upon the context of that situation. In some areas of clinical practice the proportion of research-based evidence will be high compared to other areas where experiential evidence will be paramount (physiological v. physical)

The idea of RCTs, meta-analyses and systematic reviews as the ’gold standard’ methods of assessing the effectiveness of treatment methods and nursing interventions is based on the assumption that rigorous systematic reviews provide nurses with a summary of all the methodologically sound STUDIES RELATED TO A PARTICULAR TOPIC

Case Study74 y.o. male with chronic venous ulcer

Best Available Research Evidence

1st line: High Compression Bandaging2nd line: Graduated compression hosiery

Judgment and Expertise of the Nurse

=CLINICAL DECISION

Patient Preference and Circumstances

Available Resources

Best Available Research Evidence

1st line: High Compression Bandaging2nd line: Graduated compression hosiery

Judgment and Expertise of the Nurse

Nurse is inexperienced in compression bandage application

Patient Preference and Circumstances

Patient has arthritic hands and is unable to apply the bandage

Available Resources

No facility for washing stocking

=CLINICAL DECISION

What EBN is NOT Is not a recipe or cookbook Does not eliminate clinical

judgment/reasoning Does not ignore patient preferences Is not rigid, unchangeable Is not focused only on randomized

controlled trials (RCTs)

5-Step EBN ProcessStep 1: Asking and formulating an

answerable questionStep 2: Database/ resource searchingStep 3: Critically appraising the

evidenceStep 4: Applying the evidenceStep 5: Re-evaluating the evidence

Step 1: Formulating the QuestionP PopulationI InterventionC ComparisonO OutcomeT Time Frame

EG:1. Does the use of pain diaries in the

palliative care of patient with cancers lead to improved pain control compared with not using diaries?

2. In children with pyrexia, is Paracetamol more effective than Ibuprofen in achieving apyrexia within 1 hour of administration?

Types of Clinical Questions Health Care Interventions– Does compression bandaging

increase the healing of venous leg ulcers compared with no compression?

Causation and Harm– Does the combined MMR childhood

vaccine lead to an increased risk of autism compared with separate vaccines at different times?

Prognosis– Does having a stroke increase the

risk of dementia in older people? Diagnosis or Assessment– Is audiometry more accurate than

the whispered voice test in diagnosing hearing impairment in older people?

Meaning– What are the experiences of using

pain diaries in people with cancer receiving palliative care?

Economics– Are four-layer elastic bandages

more cost-effective than multilayer inelastic bandages for healing venous ulcers?

Step 2: Database/Resource Searching General Information (Background)

Resources

Filtered Resources Unfiltered Resources

EG:Background Information

Filtered Resources Unfiltered Resources

www.uptodate.comElectronic textbooks

www.clinicalevidence.comwww.cochrane.comwww.ebn.bmjjournals.comwww.tripdatabase.comNational Guideline Clearinghouse

www.pubmed.comwww.cinahl.com

Step 3: Critical Appraisal? Diagnosis? Therapy? Harm ? Prognosis

Did the patient sample include an appropriate spectrum of patients similar to the general population?

Was the assignment of patients to groups randomized?

Were all the assigned patients accounted for at the end of the study?

Were the treatment groups similar at the start of the study?

Were exposures and outcomes measured similarly in the groups compared?

Were the comparison groups similar in outcome except for the variable studied?

Was the follow-up adequate? Was the patient sample

representative at a well-defined point in the course of the disease or disorder?

Was the length of follow-up adequate?

Was the follow-up complete?

Step 4: Applying the Evidence? Diagnosis? Therapy? Harm ? Prognosis

Is the test available, affordable, and accurate in my hospital?

Is my patient so different from those in the study group that the results cannot be applied?

According to the study results, how much would my patient benefit from the intervention or treatment?

Can the study results be applied to my patient?

What is my patient’s risk for side effects?

Are there alternative therapies? Is my patient similar to those in the

study group? How will the evidence influence my

choice of intervention?

Step 5: Re-evaluating the Evidence Was the diagnosis correct and the

intervention successful? Is there new information in the

literature? How can I improve/update my clinical

decisions?

So what’s the difference between research and EBN?

RESEARCH EBN

Discovery Research Utilization

Usually single study Several studies critically appraised

Research results are presented

Research results are used to change practice

EBN will change nursing practice from ‘think and feel’ to ‘knowledge and documentation’