Nursing Management Process and Functions

BSN IV

Management Process and Functions

The management process is universal. It is used in ones personal life as well as ones professional life. One applies it to management of oneself, a patient, a group of patients, or a group of workers. Knowledge of this process assures nurses of smooth functioning of their units in attaining their goal of quality care through the judicious use of available human and material resources within a specified time. Management is getting the right things done at the right time

Nursing Management a relationship of inputs and outputs in which the workers, physical resources and technology are emerged to bring about the organizational goals for delivery of quality nursing care

INPUT

OUTPUT

HUMAN RESOURCES

PHYSICAL AND TECHNOLOGICAL RESOURCES Building Grounds Supplies Equipment

Realization of goals Delivery of quality patient care

Medical Nursing Allied Health Patient / Client Significant Others

Schematic Diagram of Nursing Management

ORGANIZATION
ADMINISTRATION

Management Process consist of achieving organizational objectives through planning, organizing, directing, and controlling human and physical resources and technology

MANAGEMENT O R G A N I Z I N G D I R E C T I N G C O N T R O L L I N G

PLANNING

 While planning is the first function, one must recognize that it permeates into other functions, which are dependent on it. Forecasting estimates the future, setting objectives, determine the results to be achieved, developing and scheduling program, define activities needed within a set time frame, preparing the budget, allocates tools and resources while establishing policies and procedure, define the course of action and standards.

 Organizing establishes formal authority. It sets up the organizational structure by identifying groupings, roles and relationships within the agency. This is depicted in an organizational chart.
Job descriptions define the qualifications and scope of responsibilities, relationships and authorities of personnel. Staffing would include determining the number of staff needed thus developing and maintaining a staffing pattern, recruiting, selecting, orienting and developing personnel to accomplish the goals of the organization.

The selected personnel are then distributed in the various areas of the agency as needed and staffing schedule are made to meet the needs of clients, personnel and agency.

 Directing or leading actuates efforts to accomplish goals. This will include utilizing various modalities of nursing care through the nursing process; updating policies and procedure, supervising personnel to harmonize work through the nursing process, supervising personnel to harmonize work through adequate guidance and leadership, coordinating personnel and services to a common goal, communicating via various routes to ensure common understanding, developing people by providing staff development programs and making sound decisions. Controlling assesses / regulates performance of workers to ensure progress toward objectives, it utilizes standards in measuring performance, monitoring and evaluating nursing care including utilization of resources. Controls promptly reveal deviations from set plans and standards necessitating immediate corrective measures, actions and / or discipline.

 is pre-determining a course of action in order to arrive at a desired result is the process of establishing goals, defining and developing strategy and tactic for action thinking ahead, determining what shall be done it directs one thinking of:
> WHAT > WHY > WHERE > HOW > WHEN > WHO is expected to do it will be done it will be done it will be done we expect to do it is going to do it

I. PLANNING

it is a continuous intellectual process of assessment, establishing goals and objectives, implementation and evaluation subject to change as new information is known. Knowing what should be done and determining how to do it Organizational planning is a continuous process of assessing, establishing goals and implementing and evaluating them to ensure about the use of people, resources and environment to help achieve agencys goals for the present and the future

A. Importance of Planning
Nurse manager should know how to plan for the following reasons:
1. It leads to the achievement of goals and objectives > Workers relate what they do to meaningful results since plans are focused on objectives. 2. It gives meaning to work > Employees or workers experience greater satisfaction if what they are doing becomes meaningful to them. 3. It provides for effective use of available resources and facilities > The best use of personnel and material resources avoid wastage. 4. It helps in coping with crisis > Hospitals should provide for disaster plans. These allow the workers to function more clearly and efficiently when actual crisis occur such as fire, or emergencies caused by disaster, New Year or fiestas where more people are likely to get hurt.

5. It is cost-effective > Costs can be controlled through planning for efficient operation. For example, projecting the number of operations in a given day including daily dressing can forecast the needed supplies for a week in the surgical units accurately so as to prevent undersupply or oversupply of pilferages. 6. It discovers the need for change > Many hospitals have found out that inpatient hospital days can greatly be reduced by having laboratory and diagnostic work-up in the outpatient department rather than have these examinations on admission. Minor surgeries are also done at the outpatient department so that more hospital beds can now be allotted to critically ill patients or for those needing specialized services. 7. It is based on the past and future activities > Evaluation of programs, schedules, and activities whether successful or not, prevents and / or reduces the recurrence of problem and provides better ideas in modifying or avoiding them.

8. It is necessary for effective control Nurse managers evaluate the environment or setting in which they work or where the patients are confined and make necessary recommendations to make it more therapeutic not only for the patients but also for the workers as well.

Performance of workers and evaluation of services to patients based on criteria set during the planning stage would indicate whether standards have been made and whether changes are indicated.

B. Resistance to Planning
Planning is something that many managers avoid. Failure of the manager to plan may be attributed to one or more of the following factors: 1. Managers may lack knowledge of the philosophy, goals, and objectives and workings of the organization

2. They may not understand the significance of planning process, that the success or failure of the work activities relate directly to the quality of the plan how this plan is carefully and thoroughly done or how it is poorly done 3. Time spent on planning often seems wasted in relation to the dayto-day doings of ones job 4. Some manager may lack confidence, fearing failure 5. Some managers prefer to act on immediate problems because they generate immediate feedback 6. Planning may bring unwanted change Knowing these factors will help nurse manager to overcome them and utilize planning as basic key to the success of their work.

C. Scope of Planning
Top Management or the Nursing Directors, Chief Nurses or Director of Nursing and their assistants set the over-all goals and policies of the organization. Their scope of responsibility is the overall management of the organization. Middle Management of Nursing Supervisors direct the activities that actually implement the broad operating policies such as staffing and delivery of services to the units headed by the Senior or Head Nurses. Formulation of policies, rules and regulations, methods and procedures for personnel for immediate level planning for ongoing activities and projects are done in coordination with the top management and those in the lower level. At the Lower or First Level Management, the Head Nurses or Senior Nurses (including Charge Nurses or Team Leaders) do the daily schedules, or weekly plans for the administration of direct patient care in their respective units.

D. Major Aspects of Planning

Plans can be understood through four major aspects: 1. Plans should contribute to objectives It should seek to achieve a consistent, coordinated structure of operation focused on desired ends. Action without plans often result to chaos.
2. Planning precedes all other process of management (organizing, directing, controlling) It supports easy accomplishment of the agencys objectives, which are necessary for group effort. Planning and control are as inseparable as Siamese twin. Example: Hospital must be built on planned budget control of expenses and activities must be made, otherwise cost may swell bigger than the appropriated budget and the hospital may not be finished and its operations may not be started as targeted.

3. It pervades all levels It pervades from higher to lower echelons and vice versa and horizontally through peer levels and / or across services and members of the health team.

4. It should be efficient It should contribute to the attainment of objectives not only in terms of pesos, man-hour, units of products but also include values as individuals and group satisfaction. Fear, resentment and low morale result in low production.

E. Characteristics of a Good Plan

A well-developed plan should:
1. have clearly worded objectives, including results and methods for evaluation,

2. be guided by policies and / or procedures affecting the planned action,

3. indicate priorities, 4. develop actions that are flexible and realistic in terms of available personnel, equipment, facilities, and time 5. develop a logical sequence of activities, and 6. select the most practical methods for achieving each objective

F. Elements of Planning F.1. Forecasting

Forecasting estimates the future, including the environment in which the plan will operate. It includes who the patients are their customs, belief, language dialect barriers, public attitude and behavior, the acuity of their conditions / illness, the kind of care they will receive; the number and kind of personnel (professional and nonprofessional); and the resources, equipment, facilities, and supplies needed.

F.2. Setting the Vision, Mission, Philosophy, Goals, and Objectives

A vision statement outlines the organizations future role and function. It gives the agency something to strive for. The mission statement outlines the purpose the agency is in (whether hospital or health care), who the clients are (the poor, the needy, the middle or upper class), what services are provided (inpatient, outpatient, emergency) and why it exists. A philosophy describes vision. It is a statement of beliefs and values that directs ones life or ones practice. In an organization, the philosophy is the sense of purpose of the organization and the reason behind its structure and goal. Hospitals, clinics, and health agencies thus have as their primary reason for existence, the function of providing patient / client care services. These may include diagnostic, therapeutic, preventive, health promotion, personnel education and research services. These services vary among agencies depending on the clients served, the geographical location and the basic mission of the agency.

The philosophy of nursing service dovetails with the philosophy of the agency. It is an intentionally chosen set of values or purpose that serve as the bases for determining the means to accomplish nursing objectives. Nursing philosophy is broad and general in wording, yet directs nursing behavior, giving it a sense of purpose. Generally emphasized in the statement of the philosophy are the quality and quantity and scope of service, decision making based on factual information, appropriate delegation, achievement of organizational goals, communication vertically and horizontally, flexibility to meet changing needs of the organization, individuals, community and society in general. Organizations and people who set goals and objectives do better than those who do not. When manager forms goals, they put them on paper, and review them periodically. It forces him / her into action to try to accomplish them. The more a person sets a goal and specifies objectives for each of the result areas he likes to achieve, the more likely he will reach these.

Goals and objectives differ in that goals are more general and cover broad area while objectives tend to be more specific. Objectives are concrete. They are action commitments through which its mission and purpose will be achieved and the philosophy or belief sustained. They are stated in terms of results to be achieved and should focus on the production of health care services to the patient. Philosophy states beliefs and values while objectives state specific and measurable goals to be accomplished.

F.3. Developing and Scheduling Programs

Programs are determined, developed, and targeted within a frame to reach the goals and objectives set. Time Management is a technique for allocation of ones time through the setting of goals, assigning priorities, identifying and eliminating time wastes and use of managerial techniques to reach goals efficiently.

Time Management Principles

a. Planning anticipates the problems that will arise from actions without thought. It anticipates the crisis that may occur of the resources needed to solve the problems b. Task to be accomplished should be done in sequence, which are prioritized according to importance
c. Setting deadlines in ones work and adhering to them is an excellent exercise in self-discipline d. Deferring, postponing, or putting off decisions, actions or activities can be a habit which oftentimes cause lost opportunities and productivity, generating personal or interpersonal crisis e. Delegation permits a manager to take authority for decision-making and to delegate tasks to the lowest level possible consistent with his judgment, facts and experience. Delegation frees her some time that can be devoted to other tasks

F.4. Preparing the Budget

Budget is the annual operating plan, financial road map and a financial plan which serves as an estimate of future costs and plan for utilization of manpower, material and other resources to cover capital projects in the operating programs. is a plan for future activities expressed in operational as well as financial or monetary terms
In health care institution, budget consist of four components: a. Revenue Budget summarizes the income management expect to generate during the planning period

b. Expense Budget describes expected activity in operational and financial terms for a given period of time

c. Capital Budget outlines the programmed acquisitions, disposals, and improvements in the institutions physical capacity d. Cash Budget represents the planned cash receipts and disbursement as well as the cash balances expected during the planning period Nursing Budget is a plan for allocation of resources based on preconceived needs, for a proposed series of programs to deliver patient care during one fiscal year Hospital Budget is a financial plan to meet the future service expectations. These expectations are derived from the best judgment of the need of the community. Budgeting translates these needs of manpower, equipment and supplies so that both services are provided with the highest level of quality with the minimum amount of cost

The Budgetary Process To assure an orderly and timely development of the budget, the budget committee must be well defined. This committee can assist the budget officer in budget preparation and in monitoring the budget. The Chief Nurse or her assistant is usually a member of the Budget Committee. Within the nursing service, the Chief Nurse works with supervisors and Head Nurses in the preparation for the nursing service. The following factors should be considered: assurance of standards according to the philosophy and objectives of the hospital and the division of nursing, past experiences in the unit, anticipated needs of the unit, and percentage of the unit occupancy.

The estimation of staff for each unit should be based on the number of patients, the number of nursing care hours needed, the provision of vacation, sick and other leaves, holidays and the average number of absences per staff member per year and other privileges as attendance to continuing education programs. These give a visible method of interpreting nursing care needs to the budget committee and to the hospital administration. The next step is to ascertain the amount and kind of supplies needed for the operation of each nursing unit. A review of past expenses and consumptions provide data for planning. Capital equipment to be replaced is requested with documented justification.

The Chief Nurse compiles and completes the final draft and presents this to the Budget Officer or Hospital Administrator. A carefully planned budget presentation will usually reflect favorable action from the administration.

F.5. Establishing Nursing Standard, Policies, and Procedures

a. Nursing Standards The function of these established standard in an evaluation process is to supply professionally desirable norms against which the departments performance can be measured. Areas for improvement are identified, and a plan of action to correct this be made and implemented. b. Nursing Service Policies Policies are broad guidelines for the managerial decision that are necessary in organizational and departmental planning. They govern the action of worker and supervisors at all levels and are intended to achieve predetermined goals. They serve as basis for future actions and decisions, help to coordinate plans, control performance and increase consistency of action by increasing the probability that different managers will make similar decisions when independently facing similar situations.

There are three general areas in nursing that require policy formulation: i. areas in which confusion about the focus of responsibility might result in neglect or malperformance of an act necessary to a patients welfare ii. areas pertaining to the protection of patients and families rights e.g. right to privacy, property rights iii. areas involving personnel management and welfare c. Nursing Procedures Procedures are specific directions for implementing written policies. Two areas where procedures are needed are: i. those that are related to job situations such as reporting complaints or disciplinary instances ii. those that involves patient care procedure that involve patient care should consider the safety of the patient, his comfort while undergoing it, and the proper care, use of supplies and equipment and good workmanship on the part of the person doing it

Nursing procedure manuals should be available in each unit to be familiarized in the nursing unit. It should be reviewed, updated and revised with the maximum involvement from the unit nursing staff.

G. Planning Process
1. Analysis and assessment of system Five basic considerations in an analysis of the system as a whole: 1.1. objectives, performance measures 1.2. environment, fixed constraints 1.3. resources 1.4. activities, goals and performance of its subsystem 1.5. operation (process or action, strategies of work) 2. Formulation of organizational and individual goal It helps identify the ends toward which the administrator would like the system to move during a specific period of time. This stage requires that a schedule of achieving these goals be established.

3. Assessment of present organizational potentialities and capabilities Realistic goals and objectives cant be established without knowing the current capabilities of the organization and specifically those of his own department. True planning takes into account all the limitation as well as the resources of the situations and factors such as shortage of equipment and personnel or lack of adequate funds.

4. Formulating alternative courses of action This stage considers specifying means by which organizational goals and objectives are to be achieved. 5. Setting of priorities on the basis of effectiveness and evaluation In this stage the consequences of the various plans are projected. This phase is largely concerned with the establishment of priorities.

6. Implementation This phase is concerned with resources allocation commitment. This is the action and direction stage. 7. Evaluation control and surveillance Evaluation or provision of measuring the outcome of service against the objectives should be built into every plan. Format of Planning Background Objectives Activities Time Frame / Target Time Resources Personnel Materials Fixed Assets Budget Possible Problem Contingency Plan

II. ORGANIZING
Organizing is the second managerial function. Having planned, the manager must now organize so that personnel can accomplish the plans with efficiency and effectiveness. Organizing involves establishing a formal structure that provides the coordination of resources to accomplish objectives, establish policies and procedures, and determine position qualifications and descriptions.

Organization comprises structure and process, which allows the agency to enact its philosophy and utilize its conceptual framework to achieve its goals refers to a body of people, method, policies and procedures arranged in a systematic process through delegation of functions and responsibilities for the accomplishment of purpose

Organizing it is a process of establishing formal authority. It involves setting up the organizational structure through identification of groupings, roles and relationships, determining the staff needed through developing and maintaining staffing patterns and distributing them in the various areas as needed, and developing job descriptions by defining the qualifications and functions of personnel Organizational Structure refers to the process or the way a group is formed including its channels of authority, span of control, and lines of communication Organizational Chart it is a line drawing that shows how the parts of an organization are linked. It depicts the formal organizational relationships, areas of responsibility, people to whom one is accountable, and channels of communication

A pattern of nursing care is that system used for the delivery of nursing care to patients / clients. Patterns of care vary from hospital to hospital and this depends on the organizational structure adopted by the agency to meet its prescribed needs. The method selected for assignment of nursing staff to patients / clients directly relates to staffing pattern adopted by the health agency. Assignments can be stable only when there is a strong support system of qualified nursing personnel to carry forth the plan. In nursing services, nursing assignments may be called by various terms as modalities of nursing care, systems of nursing care, or patterns of nursing care. Historically, four basic methods are used: 1. Case Method means that one nurse performs all services for the patient.

Advantages of the Case Method: a. The nurse has close contact with the patient b. Able to provide complete nursing care over a longer period of time c. Gives greater opportunity to directly assess patients progress, since the plan of nursing care is complied and carried out from day-to-day by one nurse Disadvantages of the Case Method: a. Not administratively or economically feasible b. Not possible when highly skilled functions are necessary c. The nurse may know only a few types of cases d. Tendency to disregard patient as a person with unique identity

Instructor

Charge Nurse

Charge Nurse

Student

Registered Nurse

Patients / Clients

Patients / Clients

PL / CL

PL / CL

Lines of authority in a typical hospital with case nursing

2. Functional Method of care relieves the professional nurse of daily task to several patients but does not give all the nursing care to any one patient. Nursing assistants may carry out measures relating to personal hygiene, observations of vital signs, moving patients, and administering treatments Advantages of the Functional Method: a. Nurse develops expertise or very efficient in one phase of nursing like administration of medication b. Economy in time and equipment c. Confusion is avoided d. Very good method in case of shortage of personnel e. Nurses can change from one assignment to another without loss of efficiency f. Necessary during mealtime, PM shift and night g. There is a smooth division of labor

Disadvantages of the Functional Method: a. Patient care is fragmented often incoordinated b. Patient does not know his particular nurse c. Creates sense of boredom for patients and nurses d. Patient feels as belonging to no one e. Nurse doesnt bother about rationale of the procedure they do f. Nurses are not concerned with patients not assigned to them Charge Nurse

RN Medication Nurse

RN Treatment Nurse

NA Hygienic Care

Clerical Housekeeping

Patients / Clients Family, Visitors

Patients / Clients

Lines of authority in a typical hospital with functional nursing

3. Team Method of care is patient centered even if several people give care. The professional nurse directs the care and may give some of it. The directions of care make the professional nurse the leader of the nursing team. The nurse makes decisions and must be able to understand and communicate with others effectively and be able to help the team work out the organized plan. The other team members may be other professional nurses, nursing assistants, or student nurses. Every team member should have some knowledge of the patients condition, including problems and suggestions Advantages of the Team Method: a. Sense of satisfaction on the part of the nurse b. Close relationship among the members c. Better utilization of personnel d. Greater amount of supervision is provided e. Care provided is comprehensive

Disadvantages of the Team Method: a. Conference schedule never ends b. Inconsistencies in team work c. Not all are qualified to become team leader d. Large amount of time is wasted e. Team leader overpowers the head nurse Team Concept a. There is interchange of ideas b. Joint problem solving c. Centered on continuity comprehension Charge Nurse Team Leader Nursing Staff Patients / Clients Team Leader Nursing Staff Patients / Clients Team Leader Nursing Staff Patients / Clients

Lines of authority in a typical hospital with team nursing

4. Primary Nursing is a way of delivering nursing care by a registered nurse with the concept of one patient relationship. The 24-hour responsibility of evaluating patient care is placed on the registered nurse. Its emphasis is on the professional clinical practice in that nurse performs the essential role of practitioner, teacher, and manager of the patients care and services in the hospital and other health care setting. It includes the following characteristics: a. Professional nurses are identified as primary nurses who assess the patients need for care, sets care goals, writes a nursing care plan, administers care according to that plan, evaluates the outcomes of care and makes the necessary changes or adjustments as necessary. He / she provides pre-discharge planning and teaching b. Assigned with a relatively small case load (4-8 patients) c. Nursing process is used d. Focus is on the one-to-one relationship of my patient my nurse from admission to discharge

e. Care is based on patients needs and patients problems f. Primary nurse is accountable for assigned patients 24 hours a day, 7 days a week g. Emphasis is on professional clinical practice rather than performance of routine and tasks Since the primary nurse assumes a 24-hour responsibility for nursing care, secondary or associate nurses executes the nursing care plan during the afternoon and night shifts and during the days when the primary nurse is off-duty. The primary and secondary nurses are freed from administrative and housekeeping responsibilities to maximize their time for patient care. Authority, accountability, and autonomy rest with primary nurse. Therefore, he / she communicates directly to any member of the health team within the hospital and the community.

The head nurses role in this kind of assignment shifts from taskmaster, decision maker and coordinator of patient care to role model, consultant and quality control expert for the primary nurse in the unit. He / she encourages clinical decision making and ensures needed support in fulfilling patient care management coordination function. Advantages of the Primary Nursing: a. Provision or increased autonomy on the part of the nurse thereby increasing motivation, responsibility, and accountability b. It assures continuity of care c. Makes available increased knowledge of patients psychological and physical needs d. Leads to increased rapport and trust between the nurse and the patient, thereby establishing therapeutic relationship e. It improves communication with members of the health team and eliminates the use of nursing aides in the provision of direct nursing care

Physician

Charge Nurse

Hospital Resources

Primary Nurse

Patient / Client

Associate Nurse Evenings

Associate Nurse Nights

Associate Nurse(s) as needed Days

Lines of authority in a typical hospital with primary care nursing

Elements of Organizing
The elements of organizing are: setting-up the organizational structure, staffing, scheduling, and developing job description.

A. Setting-up the Organizational Structure

The creation of an organizational system compatible with the philosophy, conceptual framework, and goals of the organization provides the means for accomplishment of purpose. Understanding of the organizational structure as a whole facilitates the development of roles and relationships enabling goal achievement. Departmentalization and division of work provide orderliness in administration. Through a breakdown of activities, each individual is responsible for and performs a specified set of activities.

Purposes of Organizational Structure

1. It enables members what their responsibilities are so that they may carry them out 2. It frees the manager and the individual workers to concentrate on their respective roles and responsibility 3. It coordinates all organizational activities so there is minimal duplication of effort or conflict 4. It reduces the chances of doubt and confusion concerning assignment Two Types of Organizational Structure 1. Informal Organizational Structure
comprises personal and social relationship that do not appear on the organizational chart informal structure provides social control of behavior which can either be internal or external

Internal Control if pressure is intended to make a member conform to group expectation (ex. dirty shoes) External Control an attempt to control the behavior of someone outside the social group

it has its own channel of communication, which may disseminate information mere broadly and rapidly than the formal communication system. The best way to correct an invalid rumor is for the manager to provide accurate information informal organization structure is important to management, thus the manager must be aware of its existence, study its operating techniques, prevent antagonism, and use it to meet the agencys objectives

2. Formal Organizational Structure it is the official arrangement of positions or working relationship that will coordinate efforts of workers of diverse interests and abilities it describes positions, tasks, responsibilities, and relationships it provides orderliness in administrations thru establishment of formal organizational pattern by departmentalization and division of work bases of formal organization structure: philosophy and objectives of the nursing department and goal of the institution

Activities to Promote a Positive Organizational Climate 1. Develop the organizations mission, goals, and objectives with input from the nurses, including their personal goals 2. Establish trust and openness through communication that include prompt and frequent feedback and stimulates motivation 3. Provide opportunities for growth and development, including career development and CEP 4. Analyze the compensation system for the entire nursing organization and structure to reward competence, longevity, and productivity 5. Promote self-esteem, autonomy, and self-fulfillment, including feelings that help work experience high quality

6. Assess unneeded threats and punishments and eliminate them 7. Provide job security with an environment that enables free expression of ideas and exchange of opinion without threat of recrimination, which may occur as negative performance reports, negative counseling, confrontation, conflict, or job loss 8. Encourage and support loyalty, friendliness, and civic consciousness 9. Help nurses to overcome their shortcomings and develop their strengths 10. Be a role model of performance desired of practicing nurses

Organizational Change change means substituting one thing for another, experiencing a shift in circumstances that cause differences or becoming different then before Forces That Influence Change a. External Forces are those happenings (outside the organization) that influence the organization as a whole or the top administrators Ex 1. population explosion additional maternity ward Ex 2. legislation that restricts patient from admission primary nursings use of observation room Ex 3. economic forces training and education contribute to the cost containment and improvement of quality care Ex 4. a breakthrough in research this can alter care given to certain patient

b. Internal Forces are those that originate primarily from inside operations or are the result of external forces Ex 1. composition of staffing pattern decrease number of RN and increase number of NA Ex 2. productivity need 1:4 ~ 1:6 N ~ P ratio Ex 3. quality of working life may need to be improved, such as: sufficient number of qualified nurses staff development program time spent by nursing personnel with non-nursing duties instability and inflexibility of staff absenteeism among staff

Resistance to Change Factors: 1. If the person to be influenced by a proposed change are not given adequate information regarding the nature of the change 2. When one feels pressured to make a change and will be decreased when one has a say in the nature and direction of the change 3. If change is made on personal grounds rather than on impersonal requirements 4. If the change ignores existing alliances within the group 5. If there is relative satisfaction with the existing system Change Process: A Planned Procedure

The process of change is change with a purpose devised to solve problem affecting nurses and their work. It deals with making alterations by choice and deliberation, rather than by indoctrination, coercion, natural growth or accident.

1. Perceive a need for change sensing an unrest among staff that there is a need for change 2. Initiate group interaction technique employed is through an informal discussion group, committee or task force group and general meeting to explore a situation 2.1. Identify external and internal forces from change 2.2. State the problem this is the critical step in the change process. External and internal forces are examined. Statement of the problem is formulated 2.3. Identify constraints constraints are something that restrict limits or regulate a person and activities 2.4. List change strategies or possible approaches to solve the problem. Allow sufficient time for dialogue to occur. Promote a free, open receptive climate. Make no comments about responses. Continue the discussion until all possible solutions are exhausted

2.5. Select the best change strategy or strategies the leader should be someone other than the HN. In this situation, because he / she is the focal point of the problem. Care must be taken not to invite people who are not skilled in the art of facilitating. Approaches to solving the problem are the priority and analysis is made with regards to the course of action taken 2.6. Formulate plan for implementation if priority number is selected, plan on the strategy. Select representative of the group who are to meet with the HN 2.7. Develop or select tools for evaluation 3. Implement the change one step at a time, if possible. The HN must meet with her staff periodically to hear their reaction 4. Evaluate the overall results of the change and make adjustments as necessary; retain, alter, or delete parts or discontinue the process

Strategies for Affecting Change Whether working with the individual, group, or the system, the HN is sure to be involved with management of change. The following are strategies in managing change:

1. Empirical Rational Change based on the assumption that people are rational and behave according to rational self interest it follows then that people are willing to adopt a change if it is justified and if the person is shown how he / she can benefit from the change Ex. system analysis operation research implementation of research findings

2. Normative Re-educative Change are based on the assumption that people act accordingly to their commitment to socio-cultural norms. Intelligence and rational are not denied but also attitude and values are considered the manager pay attention to changes in values, attitudes, skills, and relationships in addition to providing information Ex. personnel counseling training groups or small groups 3. Power Coercive Change involves compliance of the less powerful to the leadership, plans, and directions of the more powerful Intelligence, rationality nor values and attitudes are not denied but they acknowledge the need to use sources of power to bring about change Ex. strikes, sit-in, administration decisions and rulings negotiations conflict confrontation

Organizing Principle In designing the organizational structure of the nursing department / service / division, organizational principles must be observed: 1. Unity of Command although employees may interact with many different employees in the performance of their duties, they should be responsible to only one superior. This is to avoid confusion, overlapping of duties, and misunderstanding

2. Scalar Principle authority and responsibility should flow in clear unbroken lines from the highest executive to the lowest. Proper definition and delegation of authority and responsibility facilitates the accomplishment of work. In this connection, the following must be observed: a. When responsibility for a particular job is delegated to a subordinate, the latter should have authority over resources needed to accomplish the task b. When a particular function is delegated to a subordinate, the superiors own responsibility is in no way diminished c. When a person is bestowed the authority for action, he is accountable for his actions to the person that bestowed him such. The conscientious nurse exhibits accountability toward her employing hospital, the patient, the government, her profession, and to God

3. Homogenous Assessment or Departmentation workers performing similar assignments are grouped together for a common purpose. Departmentation specializes activities, simplifies the administrators work and maintains effective control. 4. Span of Control the number of workers that a supervisor can effectively manage should be limited, depending upon the pace and pattern of the working area. If the workers are highly skilled, are working near each other, the number of workers may be increased. At the top level of the structure, a 1:6 ratio of the supervisor-workers is common, while at the base of the organization a 1:10 ratio is common 5. Exception Principle recurring decisions should be handled in a routine manner by lower-level managers whereas problems involving unusual matters should be referred to higher levels. This will enable subordinates to learn how to make decisions at their own level

Organizational Culture

is the sum total of an organizations beliefs, norms, values, philosophies, traditions, and sacred cows. It is a social system that is a subsystem of the total organization. It has artifacts, perspectives, values, assumptions, symbols, language, and behaviors that have been effective. it includes communication networks, both formal and informal. They include a status / role structure that relates to characteristics of employees and customers or clients. Such structures also relates to management style, whether authoritarian or participatory. In a health care setting, these structures promote either individually or teamwork. They relate to classes of people and could be identified through demographic surveys of both employees and patients

The basic mission of the organization is part of its culture: employment, service, learning, and research. There is a technical or operational system for getting the work done. Also, there is an administrative system of wages and salaries of hiring, firing, and promoting of report making and quality control of fringe benefits and of budgeting.
The artifacts of an organizational culture may be physical, behavioral (rituals), or verbal (language, stories, myths). Verbal artifacts result from shared values and beliefs. They include traditions, heroes, and the party line, and result in ceremonies that embody rituals. They include ceremonies to reward years of service, annual picnic, the Christmas Party, and the wearing of badges and insignia.

Perspectives are shared ideas and actions. They relate to decision-making methods. For example, social, technical, and managerial systems or subsystems will either support innovation or demand conformity. Dress, personal appearance, social decorum, and the physical environment are all part of the organizational culture. They will require strict compliance through written or implied rules. Values are the general principles, ideals, standards, and sins of the organization. Basic assumptions are the core of the culture. They include the beliefs groups have about themselves, others, and the world.

Culture and the Manager When output or productivity decreases in amount or kind, managers look at the social, technical, and managerial systems that are part of the organization culture. They know that the people behave in accordance with their understanding of the organizations norms and values. If they want to be successful, they identify these norms and values and apply their efforts in conformity with them. The successful managers identify and accept the prevailing culture before making changes. It is more difficult to change a culture at the level of basic beliefs, values, and perspectives. It is easier to change technical and administrative systems.

Organizational Climate

is the emotional state shared by members of the system. It can be formal, relaxed, defensive, cautious, accepting, trusting, and so on. It is employees subjective impression or perception of their organization. The employees of the major concern to the nurse managers are the practicing nurses. Practicing nurses create, or at the very least contribute to the creation of, the climate perceived by patients. The work climate set by the nurse managers determines the behavior of the practicing nurses in setting the work climate.
Practicing nurses want a climate that will give them job satisfaction. They achieve job satisfaction when they are challenged and their achievements recognized and appreciated by managers and patients. They achieve satisfaction from climate of collegiality with the managers and other health care providers in which they participate in decision-making.

Types of Formal Organizational Structure Classified by Nature of Authority 1. Line Organization oldest, simplest, and most direct type in which each position has general authority over lower positions in the hierarchy in the accomplishment of the main goals of the agency connects positions and tasks of each level with those above or below it it is the backbone of the hierarchy, staff, and functional organization merely supplement the line the line positions are related to direct achievement of organizational objectives. The manager has the right to give the order, demand, accountability, and discipline violators

2. Staff Organization is purely advisory to the line structure with no authority to place recommendations into action provides advisory functions to line supervisors and executives, offers suggestion to aid and not to criticize they handle details, locate required data and other counsel on managerial problems they function through influence for they do not have authority to accept, use, modify, or reject plans they make the line more effective, but organization can function without staff authority, staff assistant, and administrative assistant 3. Functional Organization permits a specialist to aid line positions within a limited and clearly defined scope of authority it decreases the line managers problem because it permits orders to flow directly to lower levels without attention to routine technical problems by the line positions

Major Forms of Organizational Structure: 1. Centralized control emanates from top down most common in hospital emphasis is concentrated on traditional nursing Functional arrangement is by such activities as: > transportation > food > budget control > personnel > various specialties in Nursing Service MSP Advantages: a. It can be highly cost-effective > The special services are grouped together which eliminates duplication of effort b. It makes management easier > Managers have to be experts in only a concentrated range of skills

Disadvantages: a. As the organization becomes large and more complex, the hierarchal arrangement can prove cumbersome b. The arrangement does not readily adapt to change > Because such decisions have to be made by the higher managers 2. Decentralized or Participatory Structure > this is a system whereby the large structure is broken down into smaller units, and authority is delegated to those closer to the majority of workers > the top management still retains ultimate responsibility for the operations of the various hospital departments but planning and implementation for each department is carried out by the department head who functions autonomously with authority to administer that department 24 hours a day

Advantages: As middle managers, the department head can: a. Reflect their interest and have a voice in decision making b. Improve quality of care through 24 hours continuity c. Increase communication departmentally and interdepartmentally d. Problem solved with greater imagination and creativity
Disadvantages: a. The initial cost in developing managers and staff training (turn over rate under decentralization has been found to be low) b. Communication breakdown the most serious problem that can occur. Effective communication cannot occur with the face exchange of information among all the concerned parties c. Problems with the role clarification can also occur. Question of who has the authority of the authority of the system is not yet well established

3. Matrix System > the benefits of centralized and decentralized control are used. It provides for both hierarchal coordination in a separate department as well as lateral coordination across department > it contains three unique sets of relationships a. Unit or department manager who heads and balance the dual line of authority b. The matrix manager who shares workers e.g. project manager in charge of cost control c. The staff who reports to these 2 different managers Advantages: a. The management can apply specialized skills to solve a problem b. Interdisciplinary cooperation is encouraged Disadvantage: a. All members must possess good interpersonal skills to receive orders from two different bosses

Organizational Chart Most nursing organizations have made graphic representative of the organizing process in the form of organization chart. These charts usually show reporting relationships and communication channels. Line charts show supervisor and supervisee relationships from top to bottom of the nursing organization. These are hierarchical relationship on which communication channels follow the line of authority to and through the chief nurse executive. Organizational charts are sometimes referred to as schemas. Two Forms of Schemas or Organizational Charts 1. Flat 2. Pyramidal

Differentiation

Flat

Pyramidal
More Narrower Lesser Centralized Lesser More control of subordinates

1. Number of levels Fewer 2. Span of control 3. Delegation 4. Authority 5. Accountability 6. Control Broad Greater Decentralized Greater Less control of subordinates

7. Communication

Easier

Harder

Five Major Characteristics of Organizational Charts 1. Division of Work each box represents an individual or sub-unit responsible for a given task of the organizations workload 2. Chain of Command lines indicate who reports to whom and by what authority 3. Type of Work to Be Performed this is indicated by labels or description for the boxes 4. Grouping of Work Segment this is shown by the clusters of work groups (department or single units) 5. Levels of Management these indicate individual and entire management hierarchy. Hierarchy refers to a body of people or thing organized or classified in pyramidal fashion according to rank, capacity or authority assigned to vertical levels with offices ranked in grades or classes, one above the other

B. Staffing
It is the process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patients demand of care. The purpose of all staffing activities is to provide each nursing unit with appropriate and acceptable number of each category of workers to perform the nursing tasks required. Too few or an improper mixture of nursing personnel will adversely affect the quality and quantity of work performed. Factors Affecting Staffing 1. Type, philosophy, and objectives of the hospital and nursing service

2. Population served kind of patients served whether charity or pay 3. Number of patients and acuity of their illness knowledge and ability of the nursing personnel are matched to the actual care needs of patients 4. Availability and characteristics of the nursing staff education, level of preparation, mix of personnel, number, and position 5. Administrative policies such as rotation, weekend, and holiday off-duties 6. Standard of care desired should be available and clearly spelled out. Institutions may utilize the ANSAPs Standard of Nursing Practice 7. Lay-out of the various nursing units and resources available within the department adequate equipment, supplies, and materials should be provided

8. Budget amount allotted for salaries, fringe benefits, supplies, materials, and equipment 9. Professional activities and priorities in non-patient activities involvement in professional organizations, formal educational development, participation in research and staff development 10. Teaching program extent of staff involvement to teaching activities 11. Expected hours of work per annum of each employee this is influenced by the 40 hours a week law 12. Pattern of work schedule traditional 5 days a week, 8 hours per day; 4 days a week, 10 hours per day and three days off; or 3 days of 12 hours per day and 3 days off per week

Patient Care Classification System

The patient care classification system is a method of grouping patients according to amount and complexity of their nursing care requirement, of nursing time and skill they require. This assessment can serve in determining the amount of nursing care required, generally within 24 hours, as well as the category of the nursing personnel who should provide the care.
To develop a workable patient classification system, the nurse manager must determine the following: 1. The number of categories into which the patients should be divided 2. The characteristic of patients in each category 3. The type and number of care procedures that will be needed by a typical patient in each category 4. The time needed to perform procedures that will be needed by the typical patient in each category

Classification Categories

The various units may develop their own way of classifying patient care according to the acuity of their patients illness.
Categories or level of care of patient, nursing care hours needed per patient per day, and ratio of professional to nonprofessional Level of Care Level I: self care or minimal care Level II: moderate or intermediate Level III: total or intensive care Level IV. highly specialized or critical care NCH needed Ratio of prof. / pt / day to non-prof. 1.5 3 4.5 6 7 or higher 55:45 60:40 65:35 70:30 80:20

Percentage of Nursing Care Hours The percentage of nursing care hours at each level of care also depends on the setting in which the care is being given. Percentage of Patients at Various Levels of Care Per Type of Hospital Type of Hospital Minimal Moderate Intensive Highly Sp. Care Care Care Care

Primary Hospital
Secondary Hospital Tertiary Hospital

70
65 30

25
30 45

5
5 15

10

Special Tertiary Hospital

10

25

45

20

Computing for the Number of Nursing Personnel When computing for the number of nursing personnel in the various nursing units of the hospitals, one should ensure that there should be sufficient staff to cover all shifts, off-duties, holidays, leave, absences, and time for staff development programs. The Forty-Hour Week law, Republic Act 5901, provides that employees working in hospitals with 100-bed capacity and up will work only 40 hours a week. This also applies to employees working in agencies with at least one million population. These employees working in agencies located in communities with less than one million will work forty-eight hours a week and therefore will get only one off-duty a week.

Total Number of Working and Non-working Days and Hours of Nursing Personnel Per Year Rights and Privileges Given Each Personnel / Year 1. Vacation Leave 2. Sick Leave 3. Legal Holidays 4. Special Holidays Working Hrs / Week 40 Hrs 48 Hrs 15 15 15 10 2 15 10 2

5. Special Privileges 6. Continuing Education Program for Professionals 7. Off-duties as per RA 5901 Total Non-working Days / Year Total Working Days / Year Total Working Hours / Year

3 3
104

3 3
52

152 213 1,704

100 265 2,120

Relievers Needed

To compute for relievers needed, the following should be considered:

a. Average number of leaves taken each year15 a.1. Vacation Leave..10 a.2. Sick leave.5 b. Holidays.12 c. Continuing Education....3 d. Special Privileges as per CSC MC #6 series 1996..3 Total Average Leave 33 days It will be noted therefore that although an employee is entitled to 15 days sick leave and 15 days vacation leave, 12 holidays, 3 days for continuing education, plus 3 days of special privileges or 48 days total, he / she gets only an average of 33 days leave per year.

To determine the relievers needed, divide 33 (the average number of days an employee is absent per year) by the number of working days per year each employee serves (whether 213 or 265). This will be 0.15 per person who works 40 hours per week and 0.12 per person for those working 48 hours per week.

Multiply the computed reliever per person by the computed number of nursing personnel. This will give the total number of relievers needed.
Distribution by Shifts Studies have shown that the morning or day shift needs the most number of nursing personnel (45% ~ 51%), for the afternoon shifts (34% ~ 37%), and for the night shifts (15% ~ 18%). In the Philippines, the distribution usually followed is 45% for the morning shift, 37% for the afternoon shift, and 18% for the night shift.

Staffing Formula To compute for the staff needed in the inpatient units of the hospital, the following steps are considered: 1. Categorize the number of patients according to the level of care needed a. Multiply the total number of patients by the percent of patients at each level of care (whether minimal, intermediate, intensive, or highly specialized) 2. Find the total number of nursing care hours needed by the patients at each categorized level a. Number of patients at each level by the average number of nursing care hours needed per day b. Get the sum of the nursing care hours needed at the various level 3. Find the actual number of nursing care hours needed by these given number of patients a. Multiply the total number of nursing care hours needed per day by the total number of days in a year

4. Find the actual number of working hours rendered by each nursing personnel per year a. Multiply the number of hours on duty per day by the actual working days per year 5. Find the total number of nursing personnel needed a. Divide the total number of nursing care needed per year by the actual number of working hours rendered by an employee per year b. Find the number of relievers multiply the number of nursing personnel needed by 0.15 (for those working 40 hours per week) or by 0.12 (for those working 48 hours per week) c. Add the number of relievers to the number of nursing personnel needed 6. Categorize into professionals and non-professionals a. Multiply the number of nursing personnel according to the number of professionals to non-professionals 7. Distribute by shifts

To illustrate: Find the number of nursing personnel needed for a 100-bed capacity tertiary hospital 1. Categorize the patients according to level of care needed

100 patients x 0.30 = 30 patients needing minimal care 100 patients x 0.45 = 45 patients needing moderate / intermediate care 100 patients x 0.15 = 15 patients needing intensive care 100 patients x 0.10 = 10 patients needing highly specialized care __________________________________________________
Total No. of Patients =100

2. Find the number of nursing care hours needed (NCH) by the patient at each level of care 30 patients x 1.5 (minimal care) = 45 NCH needed / day 45 patients x 3.0 (moderate care) = 135 NCH needed / day 15 patients x 4.5 (intensive care) = 68 NCH needed / day 10 patients x 6.0 (highly sp. care) = 60 NCH needed / day __________________________________________________ Total NCH needed per day = 308 3. Find the total number of NCH needed by 100 patients per year 308 NCH / day x 365 days / year = 112,420 NCH / year 4. Find the actual working hours rendered by each nursing personnel per year 8 hrs / day x 213 working days / yr = 1,704 working hrs / yr

5. Find the total number of nursing personnel needed a. b. c. 112,420 NCH / year = 66 nursing personnel 1,704 working hrs / yr 66 x 0.15 = 10 relievers 66 + 10 = 76 total nursing personnel needed

6. Categorize to professional and non-professional personnel. Since this is a tertiary hospital, the ratio of professional to nonprofessional is 65:35 76 x 0.65 = 49 professional nurses 76 x 0.35 = 27 nursing attendants (non-professional nurses)

7. Distribute by shifts 49 nurses x 0.45 = 22 professional nurses on morning shift 49 nurses x 0.37 = 18 professional nurses on PM shift 49 nurses x 0.18 = 9 professional nurses on night shift 27 nursing attendants x 0.45 = 12 nursing attendants on morning shift 27 nursing attendants x 0.37 = 10 nursing attendants on PM shift 27 nursing attendants x 0.18 = 5 nursing attendants on night shift

It should be noted that the above personnel are only for Inpatient. Therefore, additional personnel shall be hired for those supervisory and administrative positions and those in special units such as Operating Rooms, the Delivery Rooms, Emergency Rooms, and Outpatient Departments. Although roomed-in babies in the mothers unit are not included in the patient census, they are given service such as bathing, changing of diaper, and the like. Additional staff should be provided for the babies. Hospitals now are also centers of wellness. Therefore, additional personnel shall be needed for health education classes both the inpatient and outpatient units.

C. Scheduling
is a timetable showing planned work days and shifts for nursing personnel The objective in scheduling is to assign working days and days-off to the nursing personnel so that adequate patient care is assured, a desirable distribution of off-duties is achieved, the individual members of the nursing are treated fairly and that they know in advance what their schedules are. Factors Considered in Making Schedules 1. Different levels of the nursing staff an adequate mix of nurses and nursing attendant should be observed so that they only assume duties they are legally responsible for, according to their position, education, training, and experience

2. Adequate coverage for 24 hours, seven days a week afternoon and night shifts requirements for staff are usually lower than in the morning shift. Also, Saturdays and Sundays tend to have lower requirements since there are lesser medical rounds, fewer medical orders, and lower patient census 3. Staggered vacations and holidays since everybody can enjoy the holiday off on exactly the same day that they occur, schedules for holidays are staggered at least once a month. Vacation is likewise staggered to ensure adequate coverage at all times. Weekends are scheduled in such a way that everyone gets a fair share of at least one weekend off a month 4. Long stretches of consecutive working days this should be avoided as much as possible because it might affect the health of the nursing personnel. Afternoon and night shifts are more difficult than the day shifts. The nursing personnel should get their fair share of these shifts including the relief duty for the three shift periods

5. Evening and night shifts and floating there are some problems that occur in the schedules. Busy units may require additional help. Unscheduled absences may occur and suddenly a staff may be pulled out from her regular area of assignment to cover for another unit. The nurse may feel insecure in the area where she is asked to help or relieve. Disruption in the unity of work groups may occur and this may cause job dissatisfaction and high turnover rates. This is especially true if the nurse does not have the necessary skill and knowledge that the unit may require

In order to minimize problems as a result of emergency assignment, cross-training and / or orientation to complementary units is advised. During orientation to the Nursing Service, new nurses are told of the possibility that they may be asked to relieve in areas of the hospital other than their regular assignments. Emphasis however is given to the fact that crosstraining enhance their skills and capabilities aside from meeting the needs of the service.

Assessing Scheduling System

While scheduling may vary from agency to agency, the scheduling system must function smoothly in terms of:
1. Ability to cover the needs of the unit. A minimum required number of staff to meet the nursing needs of the patients on the units at all shifts 2. Quality to enhance the nursing personnels knowledge, training, and experience. While being permanently assigned to one unit enhances skills in caring for a particular kind of patient (whether obstetrical, medical, surgical, or pediatrics) many nurses who have future plans of going into teaching or specialization or even working abroad, would prefer to experience being assigned to various units first before settling down to a particular unit of their choice 3. Fairness to the staff. All nursing personnel should get a fair share of weekends, holiday offs, rotation patterns for the whole year including assignment to difficult or light or undesirable units or shifts

4. Stability. The nursing personnel should like to know in advance their schedule of assignment so that their personal schedules (whether home, social, and civic responsibilities) are in harmony with each other 5. Flexibility. Flexibility means the ability to handle changes brought about by emergency leaves, scheduled or unscheduled leaves of absence Types of Scheduling There are several types of scheduling which are: 1. Centralized Schedules one person, usually the Chief Nurse or her designate, assigns the nursing personnel to the various units of the hospital. This includes the shifts of duty and off-duties 2. Decentralized Schedules one person, usually the Chief Nurse or her designate, assigns the nursing personnel to the various nursing units. The shift and off-duties are arranged by the Supervising Nurse or Head or Senior Nurse of the particular units

3. Cyclical Schedules the cyclical schedule covers designated number of weeks called the cycle length and is repeated thereon. It assigns the required number of nursing personnel to each nursing unit consistent with the units patient care requirements, the staff preference, their education, training, and experience

The following scheduling variables should be considered:

a. Length of scheduling period whether 2 to 4 weeks b. Shift rotation c. Weekends off d. Holidays off e. Vacation leaves f. Special days (birthdays, wedding anniversary, etc.) g. Scheduled events in the hospital (training programs, meetings, etc.) h. Job categories i. Continuing Professional Education (CPE) programs

Advantages of Cyclical Schedule: 1. It is fair to all. Favoritism is minimized as all nursing personnel gets their fair share of rotation to the various shifts 2. It saves time as the schedule does not have to be redone every week or two 3. It enables the employees to plan ahead of their personal needs preventing frequent changes in schedule 4. Schedule leave coverage such as vacation, holidays, and sick leaves are more stable 5. Productivity is improved

D. Developing Job Description

A job description is a statement that sets the duties and responsibilities of a specific job. It includes the needed characteristics or qualifications of the individual to perform such duties successfully. It is an important management tool to make certain that responsibilities are wisely delegated, work efficiently distributed, talents fully used, and morale maintained.

Contents of Job Description: 1. Identifying Data: Position Title: Staff Nurse Department: Nursing Supervisors Title: Head / Senior Nurse 2. Job Summary: This will include the essential feature of the job that distinguishes it from the others 3. Qualification Requirements: Education preparation, training, and experience necessary to fill the position 4. Job Relationships source of workers 5. Specific and Actual Functions and Activities

Uses of Job Description:

1. For recruitment and selection of qualified personnel 2. To orient new employees to their job 3. For job placement, transfer, or dismissal

4. As an aid in evaluating the performance of an employee. Objective evaluation benefits both the employer and employee 5. For budgetary purposes. Salaries are equated with the level of responsibilities and skills defined in the job description and thus become the basis for improvement and / or further action 6. For determining department functions and relationships to help define the organizational structure. One of the organizing principles is grouping employees performing similar function to avoid duplication or overlapping of functions and improves workflow 7. For classifying levels of nursing functions according to skill levels required. This enables nursing administrators to determine whether a realignment of responsibilities is indicated 8. To identify training needs 9. As basis for staffing 10. To serve as channel of communication

III. DIRECTING
After the manager has planned, organized, and staffed, he / she must direct personnel and activities to accomplish the goals of the organization. Knowledge of ones leadership style, managerial philosophy, sources of power and authority, and political strategies are important. To get the work done by others, the manager must deal with conflict and motivate and discipline staff: all of these tasks require good communication skill and assertive behavior. Direction it is the issuing of assignments, orders, and instructions, that permits the worker to know what is expected of him / her, and the guidance and overseeing of the worker so that he / she can contribute effectively to the attainment of organizational objectives it actuates efforts to accomplish goals

Purposes of Directing: 1. To achieve objectives in the manner it was planned and organized 2. To accomplish assignment given by the management 3. To regulate the activities 4. To contribute effectively and efficiently to the attainment of the organization

Elements of Directing: A. Delegation

is the process by which a manager assigns specific tasks / duties to workers with commensurate authority to perform the job is a means of allocating and decentralizing authority, imposing responsibility and accountability and assigning tasks down to the lowestpossible level at which there is sufficient competence and information for effective decision making on task performance

A.1. Basic Concept of Delegation Responsibility obligation to do what is asked Authority the right to decide and command Accountability responsible / answerable for ones actions A.2. Steps to Better Delegation: 1. Think before you delegate Part of planning to delegate is determining what to accomplish and how well you expect each person to do. You must decide specifically what you can and cannot delegate. Matters that cannot be delegated: a. Overall responsibility, authority, and accountability for satisfactory completion of all activities in the unit. Nurse management cannot be absolved with poor performance of subordinates by blaming them b. Authority to sign ones name is never delegated the worker that performed the task should be the one to sign it

c. Evaluating the staff and / or taking necessary corrective or disciplinary action d. Responsibility of maintaining morale or the opportunity to say a few words of encouragement of the staff especially the new ones. Showing confidence in the workers boost their morale and build up their self confidence e. Too technical jobs and those that involved trust and confidence 2. Plan and organize until activities are in logical order Decide what is most important and therefore what must be done first. Then arrange the rest of the work in order of importance and available time. 3. Determine why you are delegating certain action activities to a particular person Perhaps the individual needs to acquire knowledge and skills or has asked for certain assignments.

Reasons why managers fail or refuse to delegate: a. Lack of confidence in their staff b. They feel that they can do the task better and faster c. They are too busy and enough time is needed to teach d. They resent necessary interruption to explain e. They fear of losing control if some of their duties are delegated 4. Be specific when you delegate Let people know exactly what they are responsible for very often, information should be out in writing, use feedback to ensure each person understand what is to be done. > Direction must be complete, understandable > Speak distinctly and slowly > Avoid giving too many direction at one time > The wordings of direction indicates its importance

5. Be willing to accept the risks and accountability for the actions of others Individuals are obligated to carry out the delegated tasks and are accountable for their own performance, she is accountable to her supervisors not only for her own actions but also the final result of all the services rendered by individual staff members. 6. Keep informed after you delegate Get periodic reports, but also examine results of the work, both in the progress and upon completion. When something is wrong, discuss it with the person and if the work is done well, you must give recommendation.

B. Supervision
> is a process of getting the work done through others which is done properly, on time, and within the budget

Supervision is
What Planning Directing Guiding Teaching Observing Encouraging Correcting Commenting Evaluating When Who How Why
Skillfully Safety Correctly Patiently so that every Competently Every Tactfully worker can According to worker Fairly do his / her his / her work and capability give any care & limitation of work

Continuously

The purposes of supervision are to inspect, to guide, evaluate, and improve work performance of employees through a criteria against which the quality of work production and utilization of time and resources are made. Nurse manager provides guidance and direction to workers to achieve the goals and objectives of the institution and that of the nursing unit.

The atmosphere created by the supervision as he / she makes his / her rounds or talks to the staff will determine to a large extent the acceptability of the comments, criticism and / or corrections he / she makes. Given a soft, courteous manner, these will be taken willingly and be accepted as a challenge to improve performance. Given a harshly, especially in public, builds up resentment, ill-will, and poor quality of work. Emphasis of supervision is getting the work done according to definite policies and procedures. Types of Supervision: 1. Autocratic Supervision > supervisor plans all the work > makes all the decision > issues commands to workers who are to obey without question > regards individual as machine and not as human being > more on direction and inspection

2. Democratic Supervision > emphasis is instead of getting the work done, is now placed on helping the individual to do the work better > there is a greater degree of freedom wherein workers are given a voice in setting up work goals and planning method for reaching them > teaching and helping people develop new skills and greater understanding of their job Supervisors challenge is to create a climate in which spontaneous teamwork is possible and harmonize the goals of the individual with those of the group Importance of Supervision: 1. It is concerned with people as well as the work area, working condition, and work itself > supervision must try to provide as much as possible suitable working condition not only physical surroundings but also good atmosphere in which the staff works (environment where people work should give them a feeling of freedom and the desire to do the best they can)

2. It is also concerned with the planning, execution, and evaluation of work > the staff should also have the part in this planning and help to perform and evaluate their own work

3. Orientation, training, and guidance of individual according to their needs are directed toward utilization of their capabilities and the development of new skills Supervisor should be acquainted with every individual and must be able to stimulate each individual the desire for self improvement. If the person recognizes his / her needs for improvement, the leader must supply the necessary help and instruction at the same time guide the worker in acquisition of acceptable attitude and interests and good working habits.

C. Coordination

Coordination unites personal and services to a common objective. Synchronization of activities with the various services and departments enhances collaborative efforts resulting in efficient, smooth, and harmonious work flow. Coordination also prevents overlapping of functions, enhances good working relationships and work schedules are finished on time.
At the unit level, supervising nurse coordinate their work with other departments, services or units utilizing clearly defined policies, standard operating procedures, and guidelines through proper channel of communication.

Types of Coordination: 1. Intradepartmental coordination is usually within the department 2. Interdepartmental coordination between one department to another 2.1. Coordination with Medical Services All nurses should know the medical staff in their respective units, their services, and scheduled time of medical rounds. On the other hand, nurse should know the patients in the unit, their diagnosis, actual conditions, medical plan or care, and treatments so that they can participate intelligently in planning the care of each individual patient. Too often, nurses just become implementers of care. They do not actively involve themselves in planning the care of patients. They must remember that in carrying out written prescriptions of medications and treatments, they must exercise reasonable judgment and care to avoid errors or misinterpretations.

2.2. Coordination with Administrative Service > pertains to resources both human and material. At the unit level, nurses participate in budgeting planning for staffing, adequate facilities, and material resources > repairs and maintenance of equipments are made in appropriate forms Use of logbook date and equipment should pass thru the administration services > overstocking of supplies should be avoided to prevent wastage

2.3. Coordination with the Laboratory Service Request for laboratory examinations should be given specific instruction relevant to the examination to be done such as fasting blood sugar. Laboratory results are properly filled with latest exam on top for easy references.

2.4. Coordination with the Radiology Service Request for x-ray examination are likewise forwarded to x-ray services for proper scheduling and specific instruction if needed. 2.5. Coordination with Pharmacy Service Policies regarding procurement of drugs are formulated jointly by the administrative, medical and nursing services with the pharmacy. There are some hospitals that clinical pharmacist in their units are manned by clinical pharmacist. They prepare medicines prescribed by the physician and these are administered by the nurse in the unit.

2.6. Coordination with the Dietary Services The head nurse is responsible for forwarding the diet list of the patients in the unit, taking into consideration prescribed, special diets, patients idiosyncrasies for food allergies, food preferences, and religious restrictions. 2.7. Coordination with the Medical Social Service >Nurses coordination with the medical social services through referral of patient with psycho-social-economic problems

h. Coordination with Medical Records Services Nurses are responsible for accurate documentation and completeness of patients chart including their safety and confidentiality. 3. Extra-installation Coordination is from hospital to another agency. Patients are often referred to the health center nearest their residence upon discharge from the hospital for follow up.

D. Communication

Is the process whereby a message is passed from sender to receiver with the hope that the information exchange will be understood as the sender intended.
Elements of Communication 1. Sender 2. Message 3. Receiver

If one of these three elements is missing, no communication can take place

Channels of Communication Communication channels used by the manager may be: Upward the manager is a subordinate to a higher management . Needs and wants are communicated upward to the next level in the hierarchy Downward the manager relays information to subordinates. This is a traditional form of communication in organizations and helps coordinate activities in various levels of the hierarchy Horizontal managers interact with others on the same hierarchical level as themselves who are managing different segments of the organization Diagonal the manager interacts with personnel and managers of other departments and groups, such as physicians, who are not on the same level of the organizational hierarchy. Although these people have no formal authority over the manager, this communication is vital to the organizations functioning. Diagonal communication tends to be less formal than other types of communication.

 Grapevine the most informal communication network. Communication flows haphazardly between people at all hierarchical levels and usually involves three or four people at a time. Grapevine communication is subject to error and distortion because of the speed at which it passes and because the sender has little formal accountability for the message Interpersonal Communication in a Multicultural Workplace

Because it is impossible for the individual manager to communicate face to face with each member in a large organization, managers must develop other interpersonal communication skills. These skills include nonverbal communication, verbal communication, and listening skills.

The following is a partial list of nonverbal clues that can occur with or without verbal communication: Space Environment Appearance Eye Contact Posture Gestures Facial Expression Timing Vocal Clues such as tone, volume, and inflection Verbal Communication Skills Highly developed verbal communication skills are critical for the leader / manager. One of the most important verbal communication skills is the art of assertive communication. Assertive behavior is a way of communicating that allows people to express themselves in direct, honest, and appropriate ways that do not infringe on another persons rights.

Rights and Responsibilities of the Assertive Person Rights Responsibilities To speak up To listen To take To give To have problems To find solutions To be comforted To comfort others To work To do your best To make mistakes To correct your mistakes To laugh To make others happy To have friends To be a friend To criticize To praise To have your efforts rewarded To reward others efforts To be independent To be dependable To cry To dry tears To be loved To love others

IV. CONTROLLING
> is an ongoing function of management occurring during planning, organizing, and directing activities > it is assessing / regulating performance in accordance with the plans that have been adopted, the instructions issued, and the principles established > is the process by which managers assures that the actual expenditures and activities conform to plan The controlling process plays an important role in identifying opportunities for improvement, comparing performance against set standard, providing information about how well processes and people are doing so that they can be motivated to perform better in the future.

Reasons for Conducting Evaluation There are some reasons why evaluation is needed and why it plays an important role in quality and productivity improvement 1. Ensure quality nursing care is provided 2. Set sensible objectives and comply with them 3. Provides standards for establishing comparisons 4. Provides visibility and a means for employees to monitor their own performance 5. Highlights quality problems and determine the areas that require priority attention 6. Gives an indication of the costs of poor quality 7. Justifies the use of resources 8. Provides feedback for improvements

Evaluation Principles

In order the employees are evaluated accurately and fairly, certain principles must be observed.
1. The evaluation must be based on the behaviorally oriented performance standard of the position occupied > the employee is presented as objectives to strive for and achieve, therefore performance must be based on these 2. In evaluating performance, adequate samples and representative samples of the employees behavior should be observed > usual and consisted behavior should be evaluated instead of an isolated or a typical behavior 3. A copy of the job description, performance standards and evaluation form are given to the employee before the scheduled evaluation conference for review so that discussion by the rater and the rate will be from the same frame of reference

4. Documentation of an employees performance appraisal should include both satisfactory and those needing improvement with specific behavioral instances to clarify these evaluative comments 5. Prioritize areas needing improvement as the worker attempts to upgrade his / her performance 6. Schedule and conduct the evaluation conference at a time convenient for both the rater and the ratee, in pleasant surrounding with ample time for discussion of the evaluation 7. The evaluation report and conference should be structured that it can be perceived and accepted as a means of improving job performance Characteristics of an Evaluative Tool

1. It should be objective > Objectivity means that the evaluation tool is free from bias

2. It should be reliable > reliability refers to the accuracy or precision of the tool that if administered twice, it will produce the same results 3. It should be valid > validity refers to the relevancy of the measurement to the performance of the employee 4. It should be sensitive > sensitivity means the ability of the measured fine line differences among the criteria being measured Basic Components of Control Process The control process may be divided into the following basic components: 1st. Establishing Standards for Measuring Performance > standards are desirable sets of conditions and performance essential in ensuring the quality of nursing care services which are acceptable to those instrumental responsibilities in setting / maintaining them

3 Types of Standards 1. Structure refers to the basic support components of nursing are those that focus on the structure or management system used by the agency to deliver care which includes the number and categories of nursing personnel, their education, personal and professional qualities and proficiencies, their functions and physical facilities and equipment 2. Process Standards refers to the desired effects as specified clinical manifestations, mobility levels, patient knowledge or self care skills refers to decisions and actions of the nurse relative to the nursing process which are necessary to provide good nursing care. These include assessment, plan of care, and nursing intervention

3. Outcome Standards are designed to measure the results of care provided in terms of changes in the health status of clients served; changes in the level of their knowledge, skills and attitudes; and satisfaction of those served including the members of the nursing / health team

2nd. Establishing Objectives and Methods for Measuring Performance > measurable criteria and objectives specific to giving nursing care must be developed to evaluate process and outcome > establishment of objectives provides clear direction and communication of expected level of achievement > there should be full commitment in the form of a performance contract > the greater the participation of the employee, the greater the motivation achieved agreed upon performance objectives; therefore should be participatively developed, be challenging but attainable, be clear of statements or performance expectation and lie within the individuals scope of control

Most Commonly Used Methods for Measuring Nursing Care 1. Task Analysis > actions and procedures such as written guides, schedules, rules, records, and budgets are inspected > are used to determined issues: how long it takes a nurse to perform a procedure and how many members are needed for a specific number of patient Tools Used: 1.1. Time Studies 1.2. Checklists 2. Quality Control > is essentially the activities and techniques employed to achieve and maintain the quality of a product service or processes

> conceived and assessment of the level of nursing care provided and its effects on the patient through process and outcome > it includes monitoring activity but it is also concerned with finding and eliminating causes of quality problems so that the requirements of the customer are continuously met > level of nursing care provided is assessed in quality control > effects of the nursing care on the patient Focus: 2.1. patient / client / family satisfaction of nursing care 2.2. facilities and climate 2.3. methods used to deliver nursing care 2.4. outcome of nursing care

3rd. Measuring Actual Performance > measurement of performance is an on-going repetitive process with the actual frequency dependent on the type of activity being measured Example: nursing care of patient is monitored continuously formal performance appraisal done only twice a year > measurements may be scheduled in advance or may be done at periodic but unannounced intervals or may occur at random > The purpose of measurement should be clarified and the staff should be informed on the tasks and levels that need attention 4th. Comparing Results of Performance with Standards and Objectives > is one of the easiest steps in the control process > if performance matches the standards and objectives, managers are assured that the needs of patients are being met > if performance is contrary to standards and objectives set, then necessary actions are needed

5th. Reinforcing Strengths or Successes and Taking Corrective Actions as Necessary > positive feedback stimulates motivation, consistently high performance, and growth of the employee. Corrective actions are applied to improve performance

Responsibility of Head / Senior Nurse Being the first line supervisor, hes / shes in best position to know whether their staff nurses are performing satisfactorily in their work. Their influence can be dramatically in promoting quality care to patients.
1. They have the responsibility to instruct subordinates in the appropriate methods and procedures in providing nursing care 2. Inform them of the likely causes of errors or defects and the preventive measures necessary 3. Initiate and facilitate any steps necessary to improve methods, equipments, materials, and conditions in the work area for which they are responsible

4. Draw attention to existing or potential quality problems and report all errors and defects waste 5. Suggest ways in which risks or error or quality problems may be reduced 6. Assist in training new staff particularly by setting as good examples Performance Appraisal > is a control process in which employees performance are evaluated against standards. It is the most valuable tool in controlling human resources and productivity. It evaluates how well the nursing personnel have performed during a specific period of time Purposes of Performance Appraisal are used to: 1. Determine salary standards and to merit increases 2. Select qualified individuals for promotion or transfer

3. Identify unsatisfactory employees for demotion or termination 4. Make inventories of within the institution 5. Determine training and developmental needs of the employees 6. Improve the performance of work groups by examining, improving, and correcting interrelationship between members 7. Improve communication between supervisor and employee and to reach an understanding on the objectives of the job 8. Establish standards of supervisory performance 9. Discover the aspirations of employees and to reconcile this with the goals of the institution 10. Provide employee recognition for accomplishments 11. Inform employees where they stand

Methods of Measuring Performance These may be done through: 1. Informal Appraisal which consists of: 1.1. incidental observation of work performance while engaged in performing nursing care 1.2. responses made by workers during conferences 1.3. noting the interaction of workers with clients, their families, visitors, and co-workers 2. Formal Appraisal is accomplished regularly and methodically by collecting objective facts that can demonstrate the difference between what was expected and what was done 2.1. Essay the appraiser writes a paragraph or more covering the workers strengths, weaknesses, and potentials in most situations, particularly the managerial positions, essay appraisals carry significant weight on the presumption that an honest statement from someone who knows the person well is fully valid

 its drawback is in its variability in length and content and is more difficult to compare because it touches on different aspects of a workers performance It may also concentrate on those areas of performance which the supervision entertains strong feelings

2.2. Checklists contains compilation of all nursing performance expected of a worker The appraisers task is to place a checkmark in the appropriate column whether the worker does or does not show the desired behavior a quick glance at the completed forms would reveal the overall quality of the nurses performance 2.3. Ranking in simple ranking, the evaluator ranks the employees according to how he / she talked with co-workers with respect to certain aspects of performance or qualifications

Example: Nurse A may rank lowest in educational requirements for the next higher position among the five candidates for promotion but may rank first in clinical proficiency while Nurse B may rank first in educational qualifications but rank third in clinical proficiency. 2.4. Rating Scales it includes a series of items representing the different tasks or activities in the nurses job description or the absence or presence of desired behavior and the extent to which these are possessed Examples: 2.4.1. On a scale of 0-5, indicate the degree of the nurses skill in assessing the patients condition where each of the corresponding number means: 5 Excellent 4 Very Satisfactory 3 Moderately Satisfactory or Average 2 Minimally Satisfactory 1 Unsatisfactory

2.4.2. A descriptive graphic rating scale may be used to describe punctuality in reporting for duty, such as: 1 Often times late 2 Sometimes late 3 Always reports on time

2.5. Forced Choice Comparison the evaluator is asked to choose from the statements that best describe the nurse being evaluated. The items are so grouped that the evaluator is forced to choose from favorable as well as unfavorable statements and to counterpart the tendency towards leniency of some evaluators Example: Select from the following statements which will best describe the nurse being evaluated and the least that describes him / her 1. respects the ideas of others 2. communication ability limited 3. even-tempered 4. capable of enduring long hours of hard work 5. tends to be loner

2.6. Anecdotal Recording describes the nurses experience with a group or a person or in validating technical skills and interpersonal relationship it should include: 2.6.1. description of the particular occasion 2.6.2. delineation of the behavior noted including who, what, why, when, where, and how 2.6.3. evaluators opinion or estimate of the incident or behavior The descriptive notes are organized to get impressions of the overall behavior in a given period of time. Caution should therefore be taken against tendency not to give the negative behavior more often than the positive behavior. Example: Miss A was on her way to lunch. She passed by a client who was reaching for his food tray but was having a hard time as this was placed on his left side. His right hand has an IV line. Miss A stopped, positioned the food tray comfortably and assisted the patient to eat although she herself was late for lunch. Miss A acted in a commendable manner.

Quality Assurance problem solving process that systematically assesses the quality of care and corrects any defect that is observed is the estimation of the degree of excellence patient health outcomes and in activity and other resource outcomes (William Some) is the measurement of the actual level with service provided plus the efforts to modify when necessary the provision Purpose of Quality Assurance to assure the consumer of a specified degree of excellence through continuous measurement and evaluation Purpose of Quality Assurance Program in Nursing is to measure and improve the quality of nursing delivered in the agency Quality is the degree of excellence Assurance formal guarantee of a degree of excellence Quality Assurance assures patients of an acceptable standard of care that will be provided to them

To provide quality service the workers must accept responsibility that they have to do the right job, right the first time and everytime. They have to accept that quality is everyones responsibility Quality Assurance describes all attitudes related to establishing, maintaining, and assuring high quality care for patients which includes assessment of patient care and correction of identified problems. Efficiency is concerned with the percentage resources actually used over the resources planned to be used. Performance Evaluation focuses on the worker it asks question how well the worker is satisfying the requirements of their job within the organization Quality Assurance focuses on the care and the service the patient received, rather than how well the professional is performing the duties that the position requires Patient is the best, sometimes the only judge of interpersonal aspects of care. (Example: empathy and communication) Patient Satisfaction is an essential goal of health care and therefore a part of quality of care

Methods of Quality Assurance

1. Patient Care Audits 1.1. Concurrent, Open Chart or Benedicter is one in which patient care is observed and evaluated a review of the patients charts while the patients are still confined in the hospital observation of the staff as patient care is given inspection of patient and / or observation of the effects of patient care where the focus is on the patient (done during rounds or patient interview) 1.2. Retrospective Audits, Phaneuf or Closed Chart is one in which patient care is evaluated through: 1.2.1. a review of discharged patients charts 1.2.2. questionnaire sent to or interviews conducted on discharged patients

2. Peer Review Peers (employees of the same profession, ranks, and setting) may do patient care audits evaluating anothers job performance against accepted standards. 3. Quality Circles is one of the most publicized approaches to quality introduced by Japanese a group of workers doing similar work meets regularly, voluntarily, in normal working time, under the leadership of their supervisor; to identify, analyze and solve work-related problems and so recommended solutions to management where possible quality, circle members should implement the solutions themselves Nursing Audit Committee is created composed of a representative from all levels of the nursing staff 1. Member of the training staff 2. Supervising nurse 3. Head / Senior nurse 4. Staff Nurse

In smaller hospitals: Chief Nurse may be a member of the committee Assistant The audit team usually designates a day within the week to be the audit day. However, the nurses do not know which unit will be audited. This way, the activities in the units are not deliberately changed because they know they are being observed. The audit team utilizes the developed process or outcome criteria that evaluate nursing care. The staff nurse or the senior nurse participate during the audit and are shown the findings both the strong and weak points. They sign the audit form to confirm the authenticity of the findings of the audit team. Utilization of Results the nursing staff in the unit is given a feedback on the results of the quality assurance study. This may be oral or written and is directed to the staff who administer the care or their immediate supervisors

Positive feedback reinforces desirable performance. Consistent positive findings deserve a commendation from the nursing service. Negative feedback should tactfully be conveyed into a face to face situation so that clarifications can be made on the assessment made. Negative findings have implications for review of existing standards in the unit for closer supervision for designing system to remedy identified problems and staff development. Control of Resources Part of the control process is the periodic review of the utilization of materials and supplies in the various nursing units. Consumption of supplies and materials should be proportionate to the number of patient to be served be these in the form of dressing, treatment done, injection given, etc. Requisition of / or stocking a large number of supplies and materials should be avoided to prevent pilferage (steal), misuse or spoilage. A large order is merited (deserve) when there is a large demand.

The head / senior nurse must know the average daily usage and the time required to receive supplies from the time these were requisitioned. Ordering the correct materials and checking inventory levels prevent stocking items that are not frequently used. All equipments utilization report is made including frequency of breakdown. This will help evaluate the quality of equipment purchased, the way it is handled, used, and operated. Preventive maintenance requires regular inspection of equipment to prevent breakdown and / or to detect needed repairs. Monthly linen inventory is done to determine the adequacy of linen issued and utilized in the various units. Measures should be instituted to prevent losses. Absences due to leaves whether scheduled or not, should be analyzed as these may have implications for staffing. Provisions for relievers should be included in the staffing pattern to maintain quality service.

Discipline Part of the controlling process in management is discipline. In the past, discipline connotes rigid obedience to rules and regulations, the violation will result to positive actions.

Today, discipline is regarded as a constructive and effective means by which employees take personal responsibility for their own performance and behavior. This is termed as self-discipline.
Factors That Influence Self-Discipline Are: 1. A strong commitment to the vision, philosophy, goals, and objective a strong commitment results in obsession and teamwork which in turn encourages greater conformity to expected norms of conduct within the organization

2. Laws that governs the practice of all professionals and their respective Codes of Conduct among government employees, the CS Rules and Regulations as per P.D. 807 and the Code of Conduct for Public Officials R.A. 6713 are also to be complied with

3. Understanding the rules and regulations of the agency all employees are oriented to the rules, regulations, and policies of the agency. Some organizations give their employees a handbook containing these and the possible sanctions for their infractions
4. An atmosphere of mutual trust and confidence self-discipline thrives best in an atmosphere of trust and confidence between superiors and subordinates the subordinates will consult their superiors with their problems without fears the superiors trust their subordinates will do their best performing their job without being snoopervised

Disciplinary Action any employee charged for break of the rules and regulations, policies, norms of conduct shall be given the corresponding due process there must be existing rules of conduct governing his / her behavior and an actual violation of such rule. The employee charged must be notified in writing about the violation. He is given the right to be counseled Disciplinary action should be progressive in nature, such as: 1. Counseling and Oral Warning counseling and oral warning is best given in private and in an informal atmosphere employee is given a fair chance to air his side. The relevant facts are analyzed and evaluated against his past performance. He is then counseled regarding expectations of improved behavior / performance, ways of correcting the problem and a warning that a repetition of the same offense may warrant further disciplinary action. The employee commits to correct the behavior he is informed of any follow-up action that may be taken

2. Written Warning is the second step in disciplinary action it is preceded by an interview similar to oral warning he is told after the interview that he will be given a written warning, this includes: a. statement of the problem b. identification of the rule which was violated c. consequences of continued deviant behavior the employees commitment to take corrective action and any follow-up action to be taken 3. Suspension Suspension over minor violation is given after an evidence of oral and written warnings. Although a violation is a major infarction, suspension, rather than dismissal is applied when management tools that the employee can still be rehabilitated. Accurate documentation of oral and written warnings including suspension if done is necessary evidence of due process.

4. Dismissal This penalty is invoked only when all other disciplinary efforts have failed. The Disciplinary Committee should be very sure that the cause for dismissal conforms with the criteria of a major discipline violation as contained in the policy manual and for the government employees those contained in the Civil Service Rules and Regulations and the Code of Conduct. a review is actually done by higher management

In the case of government employees, this is further reviewed by then respective department and final affirmation is done by the Civil Service Commission.