LEADERSHIP AND MANAGEMENT

UNIT PURPOSE:
Acquire knowledge that will assist in providing effective leadership and
management in provision of health services to meet the emerging
challenges locally and globally
LEARNING OUTCOMES:
1. INTRODUCTION – definition of terms
- History of management
- Theories of management
- Principles of management
- Functions of management
- Management skills and levels
2. LEADERSHIP
- Definition, difference, styles, and principles
3. HUMAN RESOURCE MANAGEMENT
- concepts and principles
- Practices in human resource management
- Recruitment
- Performance appraisal
- Motivation
- Conflict resolution
- Handling grievances
- Supervision
- Job description
- Disciplinary process
- Application of legal and ethical issues in nursing
4. CHANGE MANAGEMENT:
- Definition
- Change agents –internal, external, effects
- Challenges and reasons
- Process of change
- Addressing resistances to change
5. ORGANISATION OF HEALTH SERVICES
- Structure
- Levels
- Models of Nursing Care Delivery-
 Primary
 Secondary
 Case assignment
 Functional nursing
6. HEALTH MANAGEMENT INFORMATION SYSTEM
- Definition, sources, types,
- Collection, analysis, presentation and utilization
7. DISASTER MANAGEMENT

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 - Definition, types and phases, Disaster management cycle
MANAGEMENT
EXPERTS define management in different ways
Some well-known definitions include:
- Getting things done through other people (simple and easy to
understand)
- Sir Charles – process of getting things done through the agency of
a community
- Elmor – a technique by which the purposes and objectives of a
particular human group are determined, clarified and effectuated
- James Mooney – the art of directing and inspiring people
- And many others
From the many definitions, management refers to all the activities that are
concerned with:
 Formulation of objectives, plans and policies
 Assembling men, money, materials, machines and methods for the
accomplishment
 Directing and motivating men at work
 Coordinating the physical and human resources
 Supervising and controlling performance

Management as a process
No definition of management is considered adequate unless it states the
functions performed by the managers
Management may be defined as a process of guiding, directing, and unifying
human efforts and activities to achieve results
Management process comprise of several intertwined elements to
accomplish objectives
Management is a rational (logical), intellectual(thinking) and continuous
process
Management coordinates factors/elements to obtain maximum possible
results

Characteristics of Management
The features that highlight the nature of management are as follows:
1. Management is universal
The basic principles of management are universal in character
Henry Fayol stated that the fundamentals of management are equally
applicable in different organizations
2. Management is purposeful
Management exists for the achievement of specific objectives. It is a
means towards the accomplishment of predetermined goals
3. Management is an integrative force

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 The essence of management is in the coordination of individual efforts
into a team effort
Management reconciles the individual goals with the organization
goals, combining human and physical resources

4. Management is a social process

Management is done by the people through people and for people
It is a social process because it is concerned with interpersonal
relations
Human factor is the most important element in management
5. Management is multidisciplinary
Deals with human behavior under dynamic conditions
Depends on a wide knowledge of different disciplines
6. Management is a continuous process
Management is dynamic and a continuous process
The cycle of management continues to operate so long as there is
organized action for achievement of goals
7. Management is intangible
Management is an unseen or invisible force
It cannot be seen but its effects can be felt everywhere inform of
results but the managers who perform are very much tangible and
visible
8. Management as an art as well as a science
Contains a systematic body of theoretical knowledge and also involves
the practical application of such knowledge
Management is also a discipline involving specialized training and an
ethical code arising out of its social obligations

MANAGEMENT- ART OR SCIENCE

There are different views whether management can be considered as
art or science or both
Management as an Art
An art is defined as a skill or knowledge in a particular field of activity
or a method of doing a thing
It means an art involves the practical application of knowledge and
skills to achieve results
An art concerns with creation of objects or events, so it is creative
Management is essentially an art because:
 The process involves the use of knowhow (knowledge and skills)
Every manager must apply certain knowledge and skills while
dealing with people
 Management seeks to achieve concrete practical results ie.
Profit, growth etc

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  Like other art management is creative. It brings out new
situations and make resources productive
 Management is personalized process. Every manager has his
own approach and technique depending upon his perception
 Good management is efficient and the success of a manager is
measured by the effective realization of organizational goals

Management as A science
A science may be defined as representing knowledge gathered by
observations and experiment, critically tested systematized and brought
under general principles
It means that science is an organized or systematized body of theoretical
knowledge pertaining to a particular field
The principles are developed through scientific methods of observations,
experiment and testing
Management as a science refers to the application of scientific methods in
making decision and evaluating different course of action

Management is a science because:

 There is a systematic body of knowledge
Principles are now present in every function of management and help
to improve effectiveness eg. Delegation principle, budgeting etc
 The principles of management have been developed through
continuous observation and empirical verification
 The principles of management are capable of universal application
 Management theory helps to examine and evaluate alternative courses
of action to resolve a given problem
Scientific techniques are being used to solve business problems

IMPORTANCE OF MANAGEMENT
The success of a group depends upon mutual cooperation among the
members of the group
Management creates team work and coordination among specialized efforts.
Management is indispensable in all organizations. It is a creative force that
which helps utilization of resources
Without it, resources of production remain resources and never become
production
The following facts prove the importance of management:
1. Accomplishment of group goals-
[Link] concerned with conversion of diverse resources
Management takes recourse adaptation to business environment
It takes control and direct its daily activities to ensure efficiency
2. Efficient running of organization

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 Efficiency of an organization depends on its management success in
providing leadership to the subordinate workers and involving them
mentally and emotionally
It involves the workers in person and not only the skills
This improves quality production with reduced wastage

3. Sound organizational structure

Management establishes a sound structure in accordance with desired
objectives
It establishes a pattern of authority – responsibility relationship – who
will command whom, who will be responsible for what and who will be
accountable to whom
It provides a conducive environment and encourages the spirit of
cooperation and mutual understanding

Management Theories
Management theories describe how managers conduct activities, and keep
institutions operating in an effective way in order to meet their objectives.

The different approaches used by managers have gone through an

evolutionary process.

In practice, no single approach will be sufficient.

Most managers use a combination of approaches to create
effectiveness within the organization.
The four main classifications are:
 Classical Theories (Scientific Management)
 Human Relations or Behavioral Approach Theories
 Systems Theories
 Contingency Theories
The theories outlined above are covered in the pages that follow.

1. Classical Theories (Scientific management)

Classical theories, also known as the scientific approach to management
started in the later part of the nineteenth and early twentieth centuries.
The approach relied on systematic information collection, analysis and
identification of causes and effects, followed by effective organization of
management structure.
The objective was to develop basic principles that could guide the design,
creation and maintenance of organizations.
The emphasis was on efficiency and effectiveness. Some of the prominent
figures that may be identified with the classical school of thought are:
 Frederic W. Taylor

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  Henri Fayol
 Max Weber

Frederic W. Taylor 1856-1915

Frederic W. Taylor, an engineer, was instrumental in conducting research on

methods of training workers for increased production.
He believed in the principle ‘best management is a true science’.
According to Taylor the objective of management is to secure the maximum
prosperity for the employer, as well as each employee.

Taylor's system for work improvement consisted of the following steps:

 Observing the workers’ performance through time and motion to

determine the best way to carry out each task.
 Scientifically selecting the best worker to perform each job, that is, the
person with the characteristics and abilities needed to carry out tasks
efficiently.
 Training the selected worker to perform tasks in the most efficient
manner.
 Appointing a few highly skilled workers in managerial positions.
Most of the views expressed by Taylor can be, and are, applied in nursing,
where our aim is to recruit the best qualified workers, train them and appoint
them to precise specialized positions.

Henri Fayol 1841-1951

He saw the need to balance the worker regimen and scalar chain of authority
against concern of equity and work spirit. Managers according to Fayol
needed certain qualities knowledge and experience. Physical qualities,
mental qualities, moral qualities, general education, special knowledge and
experience
Henri Fayol came up with the functions of a manager, which he identified as
planning, organizing, coordinating and controlling.
He also identified a set of fourteen principles which managers might apply
as they perform their duties.
Some of these include the division of labor and specialization, chain of
command, centralization and responsibility.

Max Weber 1846-1920

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Max Weber advocated bureaucracy as the ideal form of organization for a
complex institution. He described bureaucracy as having a well-defined
hierarchy of authority, pyramidal in shape, division of labour based
on specialization and highly specific rules governing employers’ duties and
rights. He claimed that bureaucracy was superior because it provided
stability and reliability in controlling employees.

He insisted that employees duties to be clearly written to avoid confusion

and conflict. He sorts the technical competence in leaders who would lead by
virtual of facts not by favourism.

The essentials for Weber were;

Division of labour in which authority and responsibility were clearly defined

by each member

The offices of all posts would be organized in hierarchy of authority resulting

in a chain of command or scalar principle.

All organizational members were to be selected on basis of technical

qualification through formal organization.

The administrative officials work for fixed salaries and were career officials
and that the administration officials were not the owners of the organization.

The administration will be subject to strict rules discipline and controls

regarding to the official duties.

Although Weber meant well, the term bureaucracy implies slowness and
inefficiency in today’s society. Bureaucracies are often seen as too rigid to
respond to current and rapid changes in the society.

2. Human Relations or Behavioral Approach Theories

This is the second set of management theories.

These differ from scientific theories in that they focus on the use of people as
a support service to machines.
They also see economic forces as motivators of human performance.
The behavioral approach focuses on the manner in which managers interact
with subordinates.
It is based on an analysis of the relationship between human factors and
productivity.

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Besides meeting the economic goals of the organization, the managers must
try to improve the social and psychological needs of workers, which in turn
improve productivity.
The following is a brief overview of four of these theories which may be
applied in health care institutions.
 Abraham Maslow's Theory
 Douglas McGregor: Theory x and Theory y
 Vroom's Expectancy Theory
 Fredrick Herzberg's Two Factor Theory

Abraham Maslow's Theory

According to Maslow's theory, every human being has basic needs. People
are motivated by the desire to satisfy these needs. Once a need is satisfied it
ceases to be a motivator. As one need is satisfied, another appears and
takes its place, and the individual is then motivated to satisfy the new need.
The theory also assumes that a person can satisfy one need at a time.
Maslow, a psychologist, developed the hierarchy of needs with the
physiological needs at the bottom, which the individuals must satisfy before
realizing higher level needs. Maslow visualized needs as arranged in
hierarchical order starting with basic needs, progressing to higher needs
depending on the individual.
There are more people at the base of the triangle still trying to satisfy the
basic needs and fewer people were on the higher subsequent levels. Only a
small percentage of people can reach the top of the hierarchy.

The various needs can be further defined as follows:

 Physiological needs are those needs that are required for survival.
These include food, oxygen and sleep, sex and rest.
 Safety needs refer to the need for job security, shelter and a stable
environment.
 Love and belonging indicate a need for affectionate relations with
others as well as the need to belong to a group.
 Self esteem refers to the need for self respect and recognition. At this
stage people strive for power, achievement and status.
 Self-actualization is a need for self fulfilment and is the culmination of
all other needs.

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People at work experience a variety of needs. Managers should identify ways
in which to meet group or individual needs in order to motivate them to
work.
It is the responsibility of the manager to enable employees to fulfill their
needs.

Douglas McGregor -1906 to 1964: Theory X and Theory Y

McGregor's theory 'X' and 'Y' are a set of management assumptions about
the behaviour of subordinates.
He noted that most managers make these assumptions about their
employees.

The first sets of assumption are known as Theory 'X’ they include:
 An average human being has an inherent dislike for work and will avoid
it if possible.
 As a result of the assumption above, most people must be coerced,
controlled, directed and threatened with punishment in order to
produce.
 The average human being has to be closely directed, wishes to avoid
responsibility and only wants security.

The second set of assumptions known as Theory 'Y’ regard people in a more
favourable way. They state that:
 Employees like work, which is as natural as rest or play.
 Human beings do not have to be controlled or coerced as long as
commitment to the organisation is present.
 Under proper conditions, they will not only accept but also
seek responsibility.

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Theory ‘X’ and Theory ‘Y’ concern the attitudes management has towards
the employee.
The manager holding Theory X assumptions tends to be tough,
authoritarian and supports tight controls with punishments.
As a result, they tend to supervise workers very closely.

On the other hand, the manager using Theory Y believes in self control, is
democratic, and consults staff.
They encourage participation in decision making by subordinates.
Generally a blend between ‘Theory X’ and ‘Theory Y’ is more likely to provide
effective management although this also depends on the prevailing
environmental conditions.

THEORY X THEORY Y

Inherent dislike for work Work is natural like rest or play

Unambitious and prefer to be Ambitious and capable of directing
directed their own behaviour
Avoid responsibility Accept and seeks responsibility
Lack creativity and resist change Creativity widely spread
Focus on lower level needs Focus on higher level needs
Close supervision Self direction and control suggested
Autocratic leadership Democratic leadership
Financial incentive effective Non financial incentive effective
Key to motivation lies in factors Job itself is the key to motivation
around the job
Negative and pessimistic Positive and optimistics assumptions
assumption
Traditional theory Modern theory

Vroom’s Expectancy Theory

This theory of motivation was put forward by Victor Vroom.

It examines motivation from the perspective of why people choose to follow
a particular course of action.

Vroom introduces three variables.

These are:
Valence

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This is the importance that the individual places upon the expected outcome
of a situation.
Expectancy
This is the belief that output from the individual and the success of the
situation are linked, for example, if I work harder then the outcome will be
better.

Instrumentality

This is the belief that the success of the situation is linked to the expected
outcome of the situation, for example, it's gone really well, so I'd expect
praise.
At first glance, this theory would seem most applicable to a traditional
attitude work situation where the level of motivation depends on whether the
employee wants the reward on offer for doing a good job and whether they
believe more effort will lead to that reward.

However, it could equally apply to any situation where someone does

something because they expect a certain outcome.
For example, I recycle paper because I think it is important to conserve
resources and take a stand on environmental issues (valence), I think that
the more effort I put into recycling, the more paper I will recycle
(expectancy) and I think that the more paper I recycle, the less resources will
be used (instrumentality).

Fredrick Herzberg’s Two Factor Theory

Frederick Herzberg proposed a theory of motivation based on the idea

that some factors motivate and some demotivate. He called this theory the
‘Two Factor Theory’. According to Frederick Herzberg, these factors fall
into two categories.
These are:

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Hygiene Factors

Hygiene factors are needed to ensure an employee does not become

dissatisfied. They do not lead to higher levels of motivation, but without
them there is dissatisfaction. Typical hygiene factors are:
 Interpersonal relationships
 Work conditions
 Salary
 Status
 Security

Motivation Factors

Motivation factors are needed in order to motivate an employee into higher

performance.
These include:
 Achievement
 Growth
 Responsibility for task
 Interest in the job
According to Herzberg, merging the hygiene and motivation factors results in
four scenarios:

High Hygiene + High Motivation

This is the ideal scenario where employees are highly motivated and have
few complaints.

High Hygiene + Low Motivation

In this scenario, employees have few complaints but are not highly
motivated.
The job is perceived as a pay check.

Low Hygiene + High Motivation

In this scenario, employees are motivated but have a lot of complaints. This
is a situation where the job is exciting and challenging but salaries and work
conditions are not up to par.

Low Hygiene + Low Motivation

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This is the worst situation where employees are unmotivated and have lots
of complaints.

3. Systems Theory

The third management theory is known as the systems theory.

This theory places an emphasis on organisations as cooperative systems.

A system is defined as ‘a set of arrangements of things so related or
connected as to form a unit or organic whole’.
The organisation is, therefore, defined as ‘a system of consciously
coordinated personal activities or forces’(Basawanthappa, 2000).
The systems theory explains that organisations come into existence when
there are persons able to communicate with each other who with each
contribute an action to accomplish a purpose.

For cooperation to be effective the following must be present:

 Place where work is done
 Time when work is done
 Person with whom work is done
 Things upon which work is done
 Method or process by which work is done
This helps in understanding the organisation in a better way.

4. Contingency Theory

The contingency theory asserts that when managers make a decision, they
must take into account all aspects of the current situation and act on those
aspects that are key to the situation at hand. The continuing effort to identify
the best leadership or management style might now conclude that the best
style depends on the situation. If one is leading troops in the Persian Gulf, an
autocratic style is probably best (of course, many might argue here, too). If
one is leading a hospital or university, a more participative and facilitative
leadership style is probably best.

DIFFERENCES BETWEEN LEADERSHIP AND MANAGENT

LEADERSHIP MANAGEMENT
Based on influence and shared Based on authority

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meaning

An informal role A formally designed role

An achieved position As assigned position

Part of every nurse’s Usually responsible for budgets,

responsibility hiring, and firing people
Requires initiative and Improve by use of effective
independent thinking leadership skills
Directs followers by influencing Scope of management is wide
their behaviour than of leadership

CONCEPTS OF MANAGEMENT

Management by exceptions
Arises from the principle holding that the controlling manager be informed
about the operation progress only when there is a significant deviation from
a plan or a standard

Management by objectives
Actions evolve around found set of procedures that establishes and reviews
progress towards common goals for managers and support staff.

Management by learning from experience

Passed occurrence or outcomes are used as the basis for the guide to
emphasis the choice for an action or procedure.

Substitution of resources
This involves making change as regards allocation and or use of resources
for an activity.

Appreciate of individual role.

Involves personalized recognition of a subordinate contribution by rewarding
him or for the role played in the organization or exemplary performance so
as to inspire others to be committed too

Short decision paths.

Involves use of easily remembered situations to make judgments for
instance appraising a worker based on recent performance and not for a
whole period for appraisal or judging a worker to be similar as the same rank
or based on a managers hestly criteria.

Convergence of work

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Here activities of various people who do the work are grouped together in
the achievement of objectives. Activities should be designed, assigned and
directed in a way that they support each other in moving towards a common
goal.
The working relations should contribute to the success of each other and
thus to general effective.

Delegation.

It is when someone with authority lenders authority to another person

conditionally or not to enable that person to take responsibility when the
need arises.

Functions determine structure.

In a clearly defined work, the working relation, strictly occur when the
functions and duties of individual members of the team are clearly defined
and duties known.

MANAGEMENT LEVELS

First management level

This comprises the supervisors of works agency. Example in charge of the
ward

Middle level managers

Includes managers / directors of departments Example nursing officer in
charge

Top Level management

They are the ultimate authority persons .Example, company executive
officers.

Managerial skills
Technical skills-consider the ability to use procedures, techniques and
knowledge of a specialized field.

Human skills –The ability to work with, understand and motivate other
people both as individual and a member of the group

Required to win cooperation of others to win and build a strong team

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Conceptual skills- to consider the ability to co-ordinate and integrate all
organization interest and activities. It involves to see the organization as a
whole, understand how its parts depend on one another and to anticipate
how a change in any of its parts will affect the whole institution.
Competence to understand a problem to thinking process in decision making
Managerial roles
A role is the behavioral pattern expected of someone in a functional unit.
Roles are thus inherent in functions that managers play .The roles include;

1. Interpersonal roles

It helps the organization run smoothly the ones included here are;

The figure head

Being a figure head involves performing ceremonial duties as being head of

the unit attending meetings and other routine duties of legal/social nature.

Leader

Responsive for motivation and activation of subordinates, staffing, training

and associated duties

Liaison

Dealing with people superiors and subordinates as peers within the

organization or outside

Employee development – providing for continuing learning and upgrading

of skills of employees is a managerial responsibility

2. Information roles

Deals with receiving and communicating information it includes;

Monitoring-managers constantly look for useful information through

questioning workers and collecting information usually through networks of
contact.

Disseminator-Important information is distributed to the subordinates by

managers.

Spokes person-The manager transmits information to the people outside

their groups. It involves keeping the superiors well informed. Communicating
with world outside the organization

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 3. Decision making roles

Its concerned with the assertion that information is the basic input to
decision making for the manager.

It includes;

Entrepreneur-Managers try to improve the unit example when receiving

good idea may launch a development project to make the idea a reality. In
this way, they initiate change at their own free will.

Disturbance handlers-Managers respond to problems beyond their

controls example strikes, bankrupt customers, patients unable to pay yet
services have been rendered.

Resource allocation-The managers decides on how and when to be given

what and what time

Employee evaluation – conducting performance appraisal of the staff.

Planning for future – daily operations is time consuming the managers

must look a head

FUNCTIONS OF MANAGEMENT
Objectives
By the end of the section you should know the five main functions of
management. These are:

 Planning
 Staffing
 Organising
 Delegating
 Controlling

Definition of a Function

What is a function?

A function is a broad area or responsibility with many activities aimed at

achieving a predetermined objective.
Management is viewed as consisting of many functions.
The three main functions of management are:
 Planning
 Implementation
 Evaluation

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These have however been expanded to include:
 Planning
 Organising
 Staffing
 Delegating or Directing
 Controlling
 Budgeting
All together, they form the acronym POSDCoB.

Functions of Management

P stands for Planning

I stands for Implementation

E stands for Evaluation

Planning

This is the first function of management.

In the previous blocks, you learnt about the nursing process and the various
stages involved. Planning is also a continuous process, it involves going
through similar stages. You live in an era of change and therefore, you need
to plan your activities.
Planning is a never ending process.
It is the beginning of management.
Planning is simply defined as deciding in advance what will and will not be
done in the next minute, hour, day, month or year.
Planning is advance thinking as a basis for action. It involves what needs to
be done, how it will be done and mechanisms of evaluating work done.

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Planning, therefore, is having a specific objective or purpose and mapping
out a method before hand. When planning, you should consider the seen and
unseen factors, and keep in mind that all factors influence one another.

Purpose of Planning

To capitalize on creativity that resides in people and Provide enabling

mechanism to question the assumptions on which previous decisions were
made.

The Planning Process

It is setting goals and deciding courses of actions, developing plans both for
the organization and those work in it, forecasting that is predicting
/projecting what the future hold for the institution.
The planning process includes a series of activities that the nurse manager
sets out to do. The process is subject to change as new facts become
available. If plans are fixed and unchangeable, then they may fail.

The activities involved in planning include:

 Gathering information.
 Setting goals and objectives, that is, what you want to achieve.
 Policy formulation, which is a guiding statement in decision making.
 Developing strategic plans, that is, long term plans designed to
achieve goals and objectives.
 Developing tactical plans.
 Developing procedures.
 Budgeting or resource allocation.

The nurse plans and develops specific goals and objectives for their area
responsibility. The process of planning includes:
 Assessment
 Setting goals
 Implementation
 Evaluation

Assessment

This is the first stage in the process.

It involves identifying and clarifying or diagnosing
the problem.
A good diagnosis pinpoints what is wrong.

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It may identify a particular situation that needs improvement, for example,
the standards of nursing care.

The main questions you should ask are:

 Where is the problem?
 What are the obstacles that are preventing achievement?

Setting Goals

The next stage of the planning process is establishing goals to be achieved.

These goals determine the direction of activities and serve as a guide for
action. This stage also involves developing a set of actions for achieving the
objectives and selecting promising solutions from the alternatives. One
should be concerned with what can be done to overcome the problems
identified.
This requires imagination and originality.
Alternatives must be analysed, compared and costed.
The alternatives can range from doing nothing or finding a means around the
problem, for example, dismissing a member of staff or discharging a patient.

Implementation

This is the third stage, it is very important because if plans are not
implemented, they remain theoretical.
Some of the principles of management already covered, for example, the
division of labour, responsibility and accountability are put into practice.

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Implementation involves decision making, which is the core of planning.
These decisions deal with the following issues:
 Activities, that is, noting whether they are carried out as planned and
whether services are delivered as intended.
 Manpower should be adequate, at the right place and right time to
perform the activities.
 Resources, that is, the physical, financial and information resources
needed to perform the activities.

Evaluation

This is the last stage in the planning process.

It involves determining the extent to which objectives have been achieved.
The main concern for the nurse is to find out the effectiveness of the results,
as well as the efficiency in the performance of activities and the economic
use of resources. You should ask the following questions:
 Are the results as intended?
 Are the results of value?
If the answer to both questions is 'yes', then the decision would most likely
be to carry on as planned. If the answer is in the negative, then a decision
will have to be made on whether to re-examine the objectives, activities or
both.
Planning is necessary for several reasons. Planning:

 Contributes to purposeful organisation of work

 Reduces costs because efforts are directed towards desired results
 Provides for integration and coordination of activities
 Minimises haphazard approaches and avoids duplication

The nurse utilises the nursing process in planning for care of specific
patients.

TYPES OF PLANNING

Planning can be classified based on:

a. Time
b. Nature
c. Use of plans

A. Based on Time
On the basis of time dimension, planning generally is divided into Long
period and Short period planning
I. Long Period Planning

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 Normally covers a period more than 5 years though can extend up
to 20 years
Long term planning is not planning for future decisions but for future
impact of today’s decision
Such plans may require changes in the organization structure and
activities
It is mainly the responsibility of top management
Long term plans are developed to guide the future efforts of the
organization
The need for long period planning has increased on account of growing
competition and specialization
Involves changes in firm’s resources

II. Short Term Planning

Refers to determination of courses of action for time period extending
up to one to three years
Sometimes plans beyond one years are called medium term plans

In short term planning the structure is fixed and specific activities

required to achieve the goals are developed
It is formulated by lower level management to programme efforts and
operations of the organization
It takes into account the available resources only and is concerned
with the current operations

The choice of time frame for planning depends upon special

characteristics of the company/organization

B. Based on Nature

Under this there are three types of planning:

1. Strategic Planning
Refers to the process formulating a unified comprehensive and intergrated
plan relating the strategic advantagesof the firm to the challenges of the
environment.
It involves appraising the external environment, identifying the strategies to
be adopted in future to meet the objectives.

Strategic planning offers the following advantages:

1. Identifies opportunities and threats likely to be faced
2. Determines future direction of the organization
3. Defines the manner of resources utilization
4. Lays down a systematic and logical procedure for carrying out the
operations

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 5. Provides a basis for the formulation of operational plan
6. Facilitates coordination between different divisions and departments of
the organization

2. Operation Planning
Also called tactical Planningis a short term exercise designed to
implement the startegies formulated under strategic planning
It is based on strategic plans

3. Functional Planning
Are prepared for various functional areas of business
Production planning, financial planning, marketing planning etc
Every functional plan servesas a guide for people in a particular department
or functional area

C. Based on Use
Based on use there are two types of planning:
a. Standing or Multi use Planning
Standing or multi use plans are the recurring plans and used repeatedly in
situations of similar nature
It is a guide to recurring problems and is used again and again
Objectives, policies, procedures and rules are important standing plans

b. Single Use or Advoc Planning

It is used once and then discarded
It is designed to meet the demands of specific situation and is scrapped
when the situation is over.
Programmes, budgets schedules and projects are examples of single use
plans

Staffing Process
Staffing involves hiring and retaining staff in an organisation.

The steps involved in the staffing process are:

1. Estimating manpower requirement:

Staffing process begins with the estimation of manpower requirement which

means finding out number and type of employees needed by the
organisation in near future.
Manpower requirement is not only to find out number of people needed but
also the type of people.
Type means what should be the qualification educational background of the
people whom we need to appoint.

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While assessing the type of manpower required company should also make
policy regarding number of people to be appointed from backward classes,
women force, minority, etc.

For estimating manpower Requirement Company will take following

three steps:

(i) Work load Analysis.

(ii) Workforce Analysis.

(iii) Comparing both to find out requirement.

Workload Analysis:

This requires finding number and type of employees required to perform

various jobs designed in organisational structure.

Workforce Analysis:

It means analysing existing workforce or employees already occupying the

job positions and how many of them are overburdened or under burdened.

Comparison:

After doing work load analysis and workforce analysis, the manager
compares both as excess of work load over workforce indicated under
staffing and you need to appoint more people whereas excess of workforce
over work load indicated over staffing and you need to remove or transfer
some employees elsewhere.

As both overstaffing as well as understaffing are undesirable.

The manager tries to find out the manpower requirement by equating
workload analysis to workforce analysis.

2. Recruitment:

It refers to the process of inducing the people to apply for the job in the
organisation. After assessing the number and type of employee required, the
manager tries that more and more people should apply for the job so that
the organisation can get more choice and select better candidates.

If we can fulfill the requirement from inside the organisation through

transfers and promotion, then it is very economical and fast but generally
organisation has to fulfill its requirement from outside the organisation.

24
To recruit people from outside the organisations contact various placement
consultants, employment exchanges, contractors etc. but the most common
way to recruit fresh talent is through advertisement. Company advertises in
newspapers etc. and many job seekers after reading the advertisement
applies for the job.

3. Selection:

It refers to choosing the most suitable candidate to fill the vacant job
position.
The selection is done through a process, which involves test, interviews, etc.
In selection number of selected candidate is less than the number of rejected
candidates that is why selection is called negative process also.
The main objectives of selection are:

(i) To select the best among the available.

(ii) To make selected candidate realise that how seriously things are done in
the organisation.

4. Placement and Orientation:

Placement refers to occupying of post by the candidate for which he is

selected.
After selection the employee is given appointment letter and is asked to
occupy the vacant job position.

Orientation refers to introduction of new employees to the existing

employees large organizations organise orientation programmes to
familiarize the new employees with the existing whereas in small
organisations superior takes the new employees on round and introduces
him to the existing employees.

5. Training and Development:

To improve the competence of employees and to motivate them it is

necessary to provide training and development opportunities for employees
so that they can reach to top and keep improving their skill. Organisations
may have in house training centres or arrange with some institutions to
provide training for their employees.
Training and development not only motivate employees but these improve
efficiency of work also.

By offering the opportunities for carrier advancement to their employees

organizations can improve their effectiveness and efficiency.

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In most of the large, scale organisations there is a separate human resource
department which performs staffing function but in small organisations the
line managers only perform all the functions.
So small organisations in which there is no human resource department
include following steps also in the staffing process.

i. Performance Appraisal:

After taking training and performing the job for sometimes there is need that
employees’ performance must be evaluated.
Performance appraisal refers to evaluating the performance of employees
against some standards.
The standards are made known to employees in advance. Superiors prepare
a feedback report on the basis of performance appraisal.

ii. Promotion and Career Planning:

Promotion refers to being placed at a higher job position with more pay, job
satisfaction and responsibility. Generally on the basis of feedback report of
employees’, performance they are given promotion and opportunities for
higher job positions.

iii. Compensation:

It refers to price of the job. It includes pays, reward and other incentives
given to employees. It includes direct as well as indirect payments. Direct
payments such as wages, salary, etc. Indirect payments such as medical
facility, insurance, etc.
The managers must fix the right compensation on the basis of qualification,
type of job, etc.

Direct financial payments are of two types:

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(i) Time based payment

(ii) Performance based.

Time based - This plan means salary/wages are paid on daily, weekly or
monthly basis.

Performance based- Under this method the payment is made to

employees on the basis of number of pieces or units produced by the
employees.

Some pay plans use time based payment in combination with some
incentives such as bonus, commission, etc.

Organisations must consider various factors before fixing the compensation

such as Labour laws, Minimum Wages Payment Act, Union’s policy,
Competitor’s policy, etc.

Factors Affecting Staffing

There are many variables that may affect staff numbers and placement.
These include:
 The need to provide nursing services coverage.
 Staff factors, for example, job descriptions, education level of staff,
experience and expectations from the organisation.
 Patient factors, including variety of patient conditions, length of stay,
the patient population, care needs and fluctuation in numbers.
 Health care organisation factors, including policies and procedures,
financial resources available, number of beds per unit, staffing norms,
issues of professional coverage and nursing assignment systems.
Since each setting is unique, there is no guide that can stipulate the correct
number of personnel needed to provide quality care. However, systems have
been developed for guidance, for example, the patient classification system
which is a method of grouping patients according to the amount and
complexity of their nursing care requirements. In this case, patients are
grouped according to the nursing time, effort and ability required to provide
care.

Organising
Nurse managers are expected to organise their work activities based on the
staffing patterns.
Organizing is the process of grouping the necessary responsibilities and
activities into workable units, determining the lines of authority,
communication, developing patterns of coordination and giving feedback.

27
By organising, you are attempting to answer the question:

How will the work be divided and accomplished?

To answer the question, the manager must define groups and assign duties.
There are certain basic issues to consider:
 Set up structure, that is, the structured aspects of the organisation that
must be set up to indicate activities to be performed and lines of
responsibility and authority.
 Develop procedures and policies.
 Determine requirements and decide how duties will
be performed.

Organisation

Organisation refers to the structure that is designed to support

organisational processes.
It is important to design organisational structures that will respond to
changes taking place in the current health care environment.
The key factors influencing organisations are the:

Delegation

Once you are responsible and accountable for patient care activities, you will
find that there are times when a job gets too big and part of it must be
entrusted to someone else.

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Delegation is the process through which responsibility and authority for
performing a task, function, activity or decision is transferred to another
individual who accepts that authority and responsibility (Sullivan and Decker
1992: 216).
Delegation – is the reassigning of the responsibility for the performance of a
job from one person to another
Although the delegator remains accountable for the task, the delegatee is
also accountable to the delegator for responsibilities assumed.

Delegation is a dynamic process, which involves three factors:

 Responsibility for work delegated, that is, willingness to do the
assigned work or an obligation to accomplish a task.
 Accountability or the obligation to carry out the responsibility or
authority or act of accepting ownership for the results or lack thereof.
 Authority, that is, the right to act or empower.

NEED FOR DELEGATION

Delegation is key in every organization and it is a dynamic process

WHY IS DELEGATION NECESSARY?

1. To enable the manager distribute his workload amongst the

subordinates
2. Pushes authority near the point of action hence decisions are made
promptly without being pushed to higher authorities
3. Helps to improve motivation and morale of subordinates satisfying
their need of recognition and responsibility
4. A means of training and developing the subordinates executives –
acquiring skills and experience
5. Facilitates growth and expansion of the organization

Thus duty, responsibility authority and responsibility are basic elements of

delegation
Each depend on each other to support the whole

PRINCIPLES OF DELEGATION
Delegation is essentially an art and based on certain principles serving as
broad guides to managers who want to delegate authority

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Some of the principles include:

1. Functional definition
Functions to be performed by a subordinate should be clearly defined

2. Unity of command
Every subordinate must at a time receive orders and be accountable to
only one superior
No individual can serve more than one boss at a time

3. Delegation by results expected

Authority should be delegated according to the expected results
Helps the subordinate know to what standard the performance will be
judged
4. Absoluteness of responsibility:
Responsibility can never be delegated
By delegating authority a manager therefore becomes responsible for
the actions of the subordinates

5. Parity of authority and responsibility:

Both should be co-extensive and coterminous
Responsibility without authority causes frustrations and authority
without responsibility results in misuse of power
Responsibility and authority must go togather if efficient results are
expected

You can delegate only those tasks for which you are responsible.

In delegation, responsibility and authority are transferred, while

accountability is shared.

To clearly understand who is responsible for certain tasks, it is important to

look at:
 Practice acts, that is, the scope of nursing practice.
 Standards of care.
 Job descriptions for various positions.
 Policy statements regarding the quality of care.
For delegation to be effective, the following must be considered:
 The manager and immediate subordinate must have a good
interpersonal relationship.
 The manager must have good administrative skills to be able to
delegate.
 The assigned duties should be well understood, well defined and well
written to both of them.
 The person to whom work is to be delegated must be assisted to
become self sufficient.

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Every activity you perform has some benefits to the people involved as well
as the organisation.

The delegator benefits as they are able to devote more time to those tasks
that cannot be delegated and with more time available can develop new
skills and abilities.

Meanwhile, the delegation benefits subordinates because they gain

new skills and abilities that can facilitate upward mobility and build
self esteem and confidence resulting in job motivation and
satisfaction.
They also have the freedom to exercise initiative and learn how to make
decisions independently.
The organisation benefits in that teamwork improves and the organisation
achieves its goals more efficiently.
Finally, the patient benefits as the quality of care improves leading to
increased patient satisfaction.

Five Rights of Delegation

The Board of Registration in Nursing presents this framework for delegation

decision-making and accountability based on a model which identifies the
five (5) key elements of any delegated act:

 Right Task
 Right Circumstances
 Right Person
 Right Direction/Communication
 Right Supervision/Evaluation

The Five (5) Rights of Delegation clarify the critical components of the
delegation decision-making process.
The Five Rights delineate professional and legal accountability for nurses at
all levels, from nursing service administrators to staff nurses.
Nursing service administrators and staff nurses must work together
collaboratively and cooperatively to protect the public and maintain integrity
of the nursing care delivery system.

Delegation Process

The process of delegation involves the following steps:

Defining the Task

This involves determining what can and should be delegated, for example,
routine tasks, tasks for which you do not have time and tasks that have

31
moved down in priority. It also includes problem solving and staff
development.
Evaluating the Task

You should analyze whether the task involves technical skill or cognitive
abilities, for example, the performance of specific procedures and the
knowledge level needed to carry out certain tasks

Determining Who Should Perform the Task

You should be able to match the tasks to the individual. To do this, you
should analyze individual skills and capabilities, experiences and individual
characteristics, for example, initiative, enthusiasm and knowledge.

Providing Clear Communication About Expectations Regarding the

Task

You should plan your meeting with the delegate. Describe the task and give
reasons for the task. Inform the delegate by what standards the task will be
evaluated and identify any constraints to completing the tasks.

Reaching Agreement
Seek agreement from the delegate that they are accepting responsibility and
authority for the task.

Monitoring Performance and Providing Feedback

Analyze performance according to established goals.

Monitoring provides a mechanism for feedback and control and ensures that
delegated tasks are carried out as agreed.
Delegation is good because it enables the manager to concentrate on the
most important tasks. However, there are some problems which may affect
both the delegator and delegate.
On the part of the manager they may:
 Be reluctant to delegate adequately to their subordinates. In some
cases, the manager might delegate responsibility and not authority.
 Fail to delegate because they can do a better job.
 Lack the ability to communicate to people what is to be done.

As a general guideline, only routine activities may be delegated.

Sensitive issues, for example, disciplinary and staff performance
appraisal should not be delegated.

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Elements of delegation

The process of delegation involves the following steps:

a. Assignment of Duties

Defines the duties or tasks to be performed by the subordinate

Subdivides his job and allocates part of it to the subordinate
Also defines the expected results

b. Granting authority
The manager confers on his subordinate the rights necessary to perform the
assigned duties
The subordinate is authorized to use resources and take decisions and
represent the superior

c. Excavative Responsibility
Exaction of responsibility implies creating an obligation and hold the
subordinate accountable for the results

On the other hand, the subordinate may not accept delegation:

 Decline delegated tasks because it could be easier to ask the manager

than to decide for them how to deal with a problem.
 Fear criticism for mistakes made, which keeps them from accepting
responsibility.
 Lack the necessary information and resource which creates an attitude
that might make a person reject further assignments (non supportive
environment).
 Lack self confidence.
 Fear liability, keeping in mind that some individuals are not risk takers.
 Inadequate incentives

REASONS FOR NOT DELEGATING

 Feeling of superiority – the feeling that subordinates cannot do any

work without close supervision so all decision making is confined
 Fear of exposure – if the manager is not competent to plan ahead so
delegating may expose his weaknesses and incompetence
 Risk avoidance – feeling of insecurity may be a major factor so
delegate is not allowed to make decisions
 Loss of importance – feeling of diminution of his own authority and
deny him the enjoyed by him
 Feeling of indispensability –has developed a sense of ownership
and want others to feel his importance

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  Habit pattern – because of close supervision practice the manager
develops contact with all aspect of the work and so avoid delegating

ADVANTAGES OF DELEGATION

1. Basis of effective functioning

It establishes coordinated relationship in an organization for
achievement of objectives
2. Reduction of managerial load
Relieves the manager of the need to attend to minor or routine types
of duties
More attention to broader and more important responsibilities
3. Benefit of specialised service
Enables the organization to benefit from specialised individuals with
expertise at lower levels

4. Efficient running of branches

Provides key to smooth and efficient running of branches far apart
5. Aid to employee development
Allows employees their capabilities to undertaken new and more
challenging position
It also promotes job satisfaction and contributes to high employees
morale

Controlling
Controlling is the managerial function concerned with making sure plans
succeed.
It means measuring and correcting the performance of employees to
ensure that the planned objectives of an organization are achieved
or it is setting standards, and taking corrective action as required.

Controlling involves the regulation of activities so that some targeted

element of performance remains within acceptable limits.
It also guides activities and assures certain minimum standards.
The nurse manager needs to take into account both external and internal
environments because they will influence the way they exercise control.

External Environment
This includes the laws and acts that regulate institutions, for example, the
Nursing Practice Act, which regulates nursing practice in terms of registration
and licensure, in order to maintain standards of nursing services.

34
Internal Environment
This includes self regulation within the organisation or nursing department,
for example, quality control relating to care of patients, staffing and budget
reports

Nature of control

Careful analysis of the definition reveals the following characteristics:

1. Control is an essential function of management – it is a
follow up action to other management functions
Control function completes the management process
2. Control is a continuous process – is an ongoing and dynamic
It involves continuous review of performance and revision of
standards of operations
3. Control is based on planning – planning serves as a basis of
control
Management of performance requires certain standards laid
down under planning
4. Action is the essence of control – the essence lies in the
action to correct the performance
An effective control system facilitates timely action to adjust
performance to predetermined standards
Its essence is in determining whether the activity is achieving the
desired results
5. Key to control lies in delegation – an executive can take
control action only when he has been delegated necessary
authority for it
6. Information is the guide to control – control action to be
taken depends upon the timely availability of information
regarding actual performance
7. Control aims at future – control involves a post mortem of
what has happened and is in that sense looking back
Control action seek to regulate events in future as past is
uncontrollable

Importance of Control

Control is important for several reasons including the following:

 To ensure work is done according to the objectives set and activities
are carried out as planned, within the allocated time and with the
resources provided.
 To enable supervisors to recognise gaps in the knowledge and
understanding of the staff, and arrange for appropriate training.
 To enable management to ensure that the resources provided for work
are adequate and are being properly used.

35
  To enable management to identify the cause of work deficiencies.
 To facilitate the recognition and reward for good work done and
recognise suitable staff.
 To identify mistakes before they become critical, bearing in mind that
prevention is better than cure
 Promotes coordination of activities
 Promotes efficiency of operations
 Facilitates decentralisation.

Elements of Control

The nurse manager must ensure that all staff members are conversant with
the elements of control. You will now cover each of these elements
individually.

Establishing the Standards

The first step involves formulating standards. Standards are yardsticks
against which nurse managers devise controls.
They are a way to measure and evaluate quality and quantity of
performance.
They are closely related to organisational goals but are more specific.
People must understand the results desired to avoid confusion. Standards
may be classified as:

Tangible and Objective

Tangible standards are physical standards, which pertain to actual operation
of the department. They can be quantitative or qualitative, for example, the
number of nurses to cover the duty per shift and quality of care expected, for
instance, every patient will have a nursing care plan twelve hours after
admission.

Intangible and Subjective

Intangible standards may include the reputation of the hospital based on good or
bad publicity.
They can also refer to the morale of employees, attitudes and relationships between
employees and complaints.
These are difficult to measure but can be assessed with a degree of confidence.
Actual Performance

After setting standards, they must be measured to identify their

achievement.
This can be done by direct observation and checking on employees.
Observations for control should attempt to identify:
 Inadequate output or improperly performed jobs.

36
  Deviations from expected standards. Assuming a questioning rather
than confrontational attitude.
 Comparisons between actual performances with the laid
down standards.

It is important to correctly interpret reasons for deviations from

standards.

Some deviations may be due to temporary circumstances, for

example, patients may not have had bed baths due to fewer nurses
on duty rather than due to poor performance

Corrective Action

If performance falls short of standards, then analysis indicates that

corrective action is required.
Supervisors must decide what remedial action is necessary to get improved
results in the near future.

These corrections may require:

 A revision of standards
 A simple discussion with those responsible for taking corrective action
 Verbal reprimand
 At times disciplinary action may be taken where rules and policies are
involved
 Better selection and training of staff that enables them to be more
effective and efficient
 Reinforcement of strengths by the manager so that the staff are
motivated
 Essential requirements for good control system

An effective and adequate control system must satisfy the following

characteristics:
 Suitability – must be tailor made to suit the nature and requirement
of activity controlled
Should be geared towards the objectives of the organization
 Promptness –should report deviations as soon as possible if not
before it occurs
 Control by exception – should focus on critical areas where urgent
attention is required
 Forward looking – should take into account of possibilities of
recurrence of deviations
 Flexibility – system of control should be flexible enough to be
adjusted according to changes in needs and circumstances

37
  Simplicity – should be simple to be administered , can work
effectively when understood
 Suggestive – a good system should suggest the necessary remedial
action
Should also disclose where occurring
 Economy – control must be worth their cost, the cost of installation
and maintenance of the control system should be justified by its
benefit

SUPERVISION
It is the art of overseeing, watching and directing with authority, the work
and behavuor of other people.

It is a process guiding, helping, training, and encouraging staff to improve

their performance in order to to provide high quality health care servises.

It means overseeing the employee at work.

Essentially it is an educative process in which the leader takes responsibility for
helping surbordinates to develope themselves and become more competent in their
jobs.
It is a continous process with atmosphere of cordiality, mutual trust, respect and
linking essential for posive work envinment and reletionship creation between the
supervisor and the supervisee.

Types of supervision.
Direct- face to face talk.

Dont loose temper or abuse,use democratic approach, repremand in private,

give workers a chance to reply, dont talk too much and too fast.

Indirect-supervision

38
It is the use of records and reports, written instruction, and analysis of
monthly reports.

Good supervision should be facilitative where the supervisor works a longside the
care giver with his or her permision or asking the personel to perform a procedure
and suggesting problems and how to overcome them.
Note that discussions on corrective or instructive measures should be held
privately.
Supervision methods should be adjusted to suit each employee’s
developmental needs.

The following approaches can be used;

 written case study assignment for presentation to the manager,or

 presentation in a conference of peers.

Incaes repeated correction and reminder fail there should be confrontation by

making face to face presentation of feelings to force employee acknowledge the full
weght of the performance failure and motivating him for immediate improvement.
Confrontation can be motivated by real concern for an employees longterm welfare.
Scheduling supervion in advance to avoid spending excessive time observing a few
excellent/poor workers but there should be enough time for all.

Factors of effective supervision

- Human relation skills –guiding workers toeards better

perfomance
- Technical and managerial knowledge – good supervisor must be
technically competent
- Leadership position– leadership style must be appropriate to the
nature os tasks /
Workers
- Favourable work climate – create a climate conducive to
effective supervision
- Improved upward relation -

Elements to consider during supervision.

Quantity of work output

Quality of work out put
Time use
Conservation of resources.
Assistance to co-workers
Suggestion ot adminisration.
Co-rdination

39
It involves synthesizing efforts of individuals.
It inludes all activities that enable work-group members to work
harmoniously. It reguires frequent information exchange between leaders
and surbodinates.
The information exchange can be done through face to face, conversations,
memoranda,posters and etc. Much co-rdination of employee efforts occur
during meetings among the work group

PRINCIPLES OF MANAGEMENT

The principles you are now going to cover were identified by Henri Fayol
He came up with fourteen principles, which might apply to nurses as they
perform their duties.
You will look at the most important ones that apply in your day to day work.
These include:
 The Division of Labour.
 Responsibility, Accountability and Authority.
 Unity of Command.
 Teamwork.
 Centralisation and Decentralisation.
 Discipline.
 Line of Authority.
 Esprit de Corps
 Stability of Tenure of Personnel
Division of Labour

This is one of the basic principles applied in nursing practice to a large

extent.
It is a way of determining who is responsible for what.
In an organization, no single person can do everything.
In order to achieve organizational goals, people must be assigned tasks
according to their skills.
The objective of division of work is to produce more and better work with the
same effort.
The tasks that individuals perform must be related to each other and
integrated.
This calls for an adequate definition of duties to be duly communicated to all
the people concerned.

The idea of division of labour in an organisation makes it possible for work to

proceed quickly and smoothly.
For example, in a hospital, there is a chief nurse, senior nursing officers and
nursing officers.

40
Each of these people have a specific job to perform in order to ensure the
success of the organisation.
Each person has the responsibility to perform their task in coordination with
other people's duties.

Responsibility, Accountability and Authority

Once the employees have been given different tasks to perform, the leader
is responsible for the work to be done.
Similarly, employees are responsible for the completion of their specific
tasks.
Both the leader and the employees are accountable for their tasks and
responsibilities.
Appropriate authority to perform certain functions is also necessary.
You will now examine the three terms and see how the nurse manager
applies them in nursing practice.

Responsibility

This is a duty or assignment related to a job. It also refers to each person's

obligation to perform at an acceptable level.

For example, one responsibility common to a nurse in charge is establishing

the patient care assignment for a specific area of work.

Nurse managers should always be assigned responsibilities with

accompanying authority because, if the latter is not given, role confusion
occurs for all individuals involved.

For example, a nurse manager may have the responsibility for maintaining
high professional standards, but if they are not given the authority to
discipline employees as needed, this responsibility may be difficult or
impossible to implement.

Accountability

This means that someone must be able to explain actions and results or
accept ownership for the results or lack thereof. For example, a qualified
registered nurse is accountable for nursing care given to a patient or client.

Authority

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Authority has its base in responsibility. Dictionaries define authority as ‘legal
or rightful power, a right to command or act, domination, jurisdiction’.

Authority defines which position will be superior and which will be

subordinate.

The various levels of divisional activities in health organisations are a direct

result of the size and complexity of modern institutions.

For example, in a hospital, at the top level is the operating authority, that is,
the chief nurse who takes the place of employer in the superior versus
subordinate relationship. Policy and decisions are made at this level.
They delegate responsibility to a group of nurse managers who exercise the
delegated authority in supervising the work of others. This is formal
authority.
On the other hand, responsibility can be delegated for performance of
specific functions.
This functional authority is based on technical knowledge and personal skills.
Both forms of authority are necessary for achieving goals and satisfying
individual needs.

Unity of Command

This is another important principle of management.

The concept of unity of command is described as ‘one person to one boss’ or
‘one person to one supervisor’.
Each individual has one manager to whom they report and to whom they are
responsible.
This concept is illustrated in the diagram next.

This makes the manager-employee relationship as simple as possible and

puts a limit to confusion, mistakes, excuses and delays in the daily
performance of duties.
For example, in a hospital, the nurses in various wards are responsible to
those in charge of the departments or wards, who in turn, are responsible to
the chief nurse.
All problems are channeled through this unity of command.

42
Teamwork

In many areas of your work, you are required to work with others in a smooth
and efficient manner in order to achieve your objectives.
Teamwork has been defined as ‘coordinated action by a group of individuals
in regular contact wherein members contribute toward task achievement’
(Sikula and McKenna 1994).
A health care team includes nurses, doctors, allied health professionals and
support staff who have to work together in order to deliver quality services to
the patients.
A team usually has a leader. Leadership is an important part of
efficient teams.
Group members support one another and their leader because they are all
mutually responsible for the objectives and
subsequent action. Openness and acceptance are the prime characteristics
of an ideal team situation.
The nurse manager is tasked with building an effective team in order to
accomplish their objectives.

Centralisation and Decentralisation

Centralisation and Decentralisation is frequently applied in health care

systems.
It refers to the extent to which decision making is concentrated or dispersed
within the health care unit

Centralisation

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This is the systematic retention of power and responsibility at higher levels
of the organisation.
Organisations vary greatly in their degree of centralisation.
The degree may differ for different tasks and responsibilities.
The Chief Nurse is responsible for centralised departments where major
decision making and responsibility for key functions is centralised at the top
level.
Thus, for example, the Chief Nurse would be responsible for budgeting,
staffing and quality assurance.

Decentralisation

Decentralisation is where decision making and responsibility for key

functions is delegated to the lowest possible managerial level in the
department.
Thus, a decentralised nursing department places most decision making at
the head nurse level with each individual head nurse running their unit
independently.

Centralisation and Decentralisation

Centralisation and Decentralisation has its advantages and disadvantages.

Advantages and Disadvantages

Advantages
Centralised Decentralised

No duplication of efforts, that is, Increased levels of decision making

44
special services grouped together. in organisation.

High cost effectiveness. Quicker and better decision making.

Managers are experts only in Increased freedom and flexibility of

concentrated range of skills. staff.

Disadvantages
Centralised Decentralised

Decisions can be made where action

Decisions take too long.
takes place.

Increased levels of organisation Risk of employees being treated

are cumbersome. unequally.

May shift responsibility and authority

to managers unprepared or it.

Discipline

One of the principle of management to be covered is discipline.

You should be familiar with the term because you may have been involved in
disciplining someone, for example, your child or a sibling. On the other hand,
you may have been disciplined or punished after violating rules and
regulations either at home or in the work place.

The word ‘discipline’ originates from the latin term ‘disciplina’, which
means teaching or learning.
As it was put forward by Fayol, discipline is ‘respect for agreements which
are directed at achieving obedience, application, energy and the outward
marks of respect.
The primary emphasis in discipline is in assisting employees to behave in a
manner that allows them to be self directed in meeting organisational goals.
Punishment may be applied for improper behaviour in constructive discipline.
This should be carried out in a supportive, corrective manner.

Management usually disciplines an employee for:

 Not meeting laid down standards of performance.
 Violating the rules and policies.

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  Insubordination, that is, lack of respect for authority.

The highest level and most effective form of discipline is self discipline
because the roles are internalised and become part of the individual's
personality (Curtin, 1996).
The manager plays a vital role in this.
There are several factors that must be present to foster a climate of self
discipline.
They include:
 Employee awareness and understanding of rules and regulations that
govern behaviour. These must be clearly written and communicated
to subordinates.
 An atmosphere of mutual trust should exist. The manager must believe
that employees are capable of actively seeking self discipline.
Conversely, the employees must perceive the manager as honest and
trustworthy.
 Employees should identify with the goals of the organisation. When
this happens, they are more likely to accept the standards of conduct
deemed acceptable by the organisation.
Discipline, therefore, is important for the smooth running of the organisation.
It should be used as a means of helping the employees grow but not as a
punitive measure.

Disciplinary Process

The following is a guideline on the steps in the disciplinary process that can be
applied to an employee who has violated rules or regulations:

 Preliminary investigation and caution to the employee about the

problem.
 A cordial discussion with the offender and a brief warning as to why
further violations will not be tolerated.
 A stronger verbal warning after a further violation of regulation.
 A formal written warning.
 A written warning accompanied by suspension from the job for a
prescribed number of days.
 Suspension from the job for a longer period of time.
 Discharge with opportunity to appeal.
This process provides an opportunity to make amends for violations of the
rules and regulations.
Administering discipline is one of the most difficult and resented tasks, but
as a manager, this is your final responsibility.
Your main concern should be to provide staff that can give safe care to
patients and to help employees grow as individual human beings.

Line Authority

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Authority is the formal and legitimate right of a manager to make decisions,
issue orders, and allocate resources to achieve organisational goals.
Line authority is a manager's right to direct the work of their employees and
make decisions without consulting others

Scalar Chain

Refers to the chain of superiors ranging from ultimate authority to the lowest
level in the organization
There should be clear line of authority from top to bottom
All upward and downward communications should flow through position of
authority along the chain

Esprit de Corps

Refers to harmony and mutual understanding among members of an

organization
The union is strengthened and unity in the staff is the foundation of success
Management should not follow the policy of divide and rule but should
maintain team spirit
Unity among personnel can be developed through proper communication
and coordination

Stability of Tenure of Personnel

Employees can’t work efficiently unless job security is assured to them

Time is required for the employees to get used to new work and succeed in
doing it

Leadership
The word leadership is an intriguing one and brings up images of all kinds of
people.
Some names that come to mind include former leaders like President Julius
Nyerere, President Jomo Kenyatta and Prime Minister Margaret Thatcher.
In nursing, Florence Nightingale may be considered an example of a
leader in the profession.
You may also think of a relative or a nurse who has had notable leadership
skills.

47
Leadership is a process of influencing the work and behavior of
subordinates in choosing and attaining specified objectives
A leader is anyone who uses interpersonal skills to influence others to
accomplish a specific goal.
A leader can also be defined as a person who exerts influence by using
certain personal behaviours and strategies or a person given authority by the
statutes of an organisation to lead a group of people.
Leadership can be defined as ‘the use of one's skills to influence others to
perform to the best of their ability towards the achievement of goals’
(Douglas, 1996).
Koontz – leadership is the ability of a manager to to induce the subordinates
to work with confidence
Chester Bernard – leadership is the ability of the superior to influence the
behavior of the subordinates and persuade them to follow a particular course
of action
It is the art of getting others to want to do what one deems as important.
It is a process which changes on a situational basis.
A manager leads by personally and actively working with subordinates for
two main reasons:
 To guide and motivate their behaviour to fit the plans that have been
established
 To understand the feelings of employees and the problems they face
as they translate plan into action

Managers and leaders are different in the following ways:

 Managers think incrementally while leaders think radically
 Managers do things right while leaders do the right things
 Leaders stand out by being different
 Leaders question assumptions and are suspicious of tradition

‘Manager’ is derived from the Latin term ’managere’, that is,

‘someone in control’. A manager uses authority, the legitimate
right to govern

Types of Leadership

There are two types of leadership.

These are:
Formal

This is when an appointed leader is chosen by the administration and given

official or legitimate authority.
This form of leadership has the greatest impact when followers accept the
leader.

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Informal

An informal leader does not have official authority to direct activities of

others.

They are usually chosen from within a specific group, for example, social
group, church organisation or work group.
An individual may become an informal leader as a result of a variety of
factors including age, seniority, special competencies or personality.

THEORIES OF LEADERSHIP

Various writers have attempted to explain the theoretical basis for leaders
and leadership.
You will look at the two following theories in detail:
 Trait Theory of Leadership
 Situational or Contingency Theory of Leadership
 Behavioral Theory

Trait Theory of Leadership

This was the first theory to emerge and was studied from approximately
1900 to 1950. This theory states that leaders possess a set of physical and
emotional characteristics that are important for inspiring others towards a
common goal.

Some theorists who subscribe to this theory believe that leaders are born
with certain qualities that determine leadership ability and success.
The leader is seen as gifted or develops certain characteristics including:
 Physique, that is, weight, height.
 Intellect, that is, knowledge, judgmental.
 Personality, that is, aggressiveness, dominance and authoritarianism.
According to this theory, the leader behaves according to the role
expectations of the group.

Situational or Contingency Theory of Leadership

This model of leadership was developed by Fred Fiedler

This theory states that the effectiveness of leadership depends on the
relationship among the leaders and the task at hand, interpersonal skills and
the favourability of the work situation.

However, there are critical factors that must be considered in the above
relationships, these include:

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  The degree of trust and respect between the leader and follower
 The clarity of goals to be accomplished
 The ability of the leader to reward followers and exert influence
As a result of all the above, leaders were viewed as able to adapt their style
according to the situation.
For example, if one is faced with a specific situation, they consider the
challenges and encourage an adaptive leadership style to understand the
issue being faced. The implication here is that you, as a nurse manager,
must assess each situation and determine appropriate action, based on the
people involved.

Behavioral Theory
Is based on the assumption that leadership effectiveness depends upon what
the leader does
Leadership is seen as a function of effective role behavior
The leadership behavior ie the product of the leader and followers
A leader uses his skills to exercise the influence and modify the behavior of
the subordinates
The behavioural approach is useful to the extent that it suggests favorable
leader behavior to inspire and guide subordinates

Leadership Styles

The styles of leadership used by managers vary from organisation to

organisation and are tailored to fit their needs and individual behaviour.

There are too many kinds of leaders, personnel, tasks, organisations and
environments for any one leadership style to apply.

There are three(3) main styles of leadership, namely:

 Authoritarian or Autocratic
 Democratic or Participative
 Laissez faire or Permissive
 Bureaucratic leadership

1. Authoritarian or Autocratic

In this leadership style, the leader assumes full responsibility for all decisions
and actions.
The characteristics of an autocratic leader include:

This style of leadership may be counter productive.

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It may cause employees to lose interest and initiative and stop thinking for
themselves because there is no need for independent thought. It may also
lead to loss of motivation, especially where employees find it necessary to
adopt an attitude of obedience to an autocratic leader.
Due to lack of motivation, the employee may perform dismally.
As a result, less than optimal goals are achieved because the resources
utilised are the manager's only.
Some forms of authoritarian leadership are applicable to nursing.
It is particularly suitable in crisis situations, when clear directions are of
highest priority.
It may also apply in situations where the people being led are
inexperienced.

2. Democratic or Participative Leadership

Democratic leadership refers to a situation where people are free to

express themselves.
In contrast to the autocratic style of leadership, the manager here is ‘people
oriented’ and focuses attention on human aspects as well as on building
effective work groups.
A collaborative spirit or joint effort exists which allows for group participation
in decision making.
The leader assumes that employees are eager to perform their jobs and are
capable of doing so.
The group is seen as having responsibility for goal determination and
achievement.
Democratic leadership encourages enthusiasm, high morale and increased
satisfaction.
Research has shown that this style of leadership leads to high productivity
and is the most desirable form in a wide variety of work situations.

3. Laissez-Faire or Permissive Leadership

Laissez-faire leadership is at the opposite end of the continuum from

authoritarian leadership. In this style, the leader lets people do what they
want.

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The leader plays down their role in the group's activity and exercises
minimum direction or control.
The leader wants everyone to feel good about what they are doing and often
avoids responsibility by relinquishing power to followers and permitting them
to engage in managerial activities, for example, decision making, planning,
setting goals, structuring and controlling the organization.
This style is often evident when a manager is too weak or feels too
threatened to exercise the function of leadership.

It is also visible where the manager has a great need for approval and does
not want to offend anybody. In this leadership style, the following can be
observed:
 Little or no visible leadership
 The manager’s tend to be preoccupied with their own work
 There is no communication and direction to the employee
 There is very little teamwork and employees do as they wish
It should be noted, however, that this style could be highly effective in
motivated professional groups, for example, in research projects in which
independent thinking is
rewarded

Bureaucratic Leadership
A bureaucratic leader depends upon rules and regulations developed by
him.
The rules specify the functions and duties of every member of the
organization the leadership is therefore reduced to routine job
There is little initiative from the subordinates
Such a rule centered leadership often results in inefficiency
The style of leadership differs from situation to situation and depends upon:
- Traits and value system of the leader
- Characteristics of the group
- Nature of the task

Autocratic Democratic Laissez - Faire

Amount of Little freedom Moderate Much freedom
freedom freedom
Amount of High control Moderate Little control
control
Decision making By the leader Leader and By group or no
group one
Leader activity High High minimal
level
Assumption of
responsibility Leader Shared Abdicated

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Output of the High quantity, Creative , high Variable, may be
group good quality poor quality
Good quality
Efficiency Very efficient Less efficient Inefficient

Servant Leadership

A leader focuses primarily on the growth and wellbeing of the people and the
community to which they belong.
Servant leadership shares power puts the needs of the others first and help
people develop and perform as highly as possible.

Characteristics include; Listening, Empathy, Healing, Awareness, Persuasion,

Conceptualization, Foresight, Stewardship
Advantages

Influence the society in a positive way.

It leads to excellent care of customers.
High employee identification with the enterprise
Leaders of a company define themselves by their significance to the people.
Leads to good performance

Disadvantages
It’s a long term application and needs a lot of time.

Charismatic Leader

Charisma-resting on devotion to exceptional sanctity, heroism, or exemplary

character of an individual
Certain quality of an of an individual personality, by virtue of which he is set
a part from ordinary men and treated as endowed with superhuman or at
least specifically exceptional powers or qualities.
These are not accessible to the ordinary person, but are regarded as of
divine origin or as exemplary, and on the basis of them the individual
concerned is treated as a leader.

Transformational leader

Enhances the motivation, moral, and performance of followers through a

variety of mechanisms..
These include connecting the followers sense of identity and self to the
project, and the collective identity of the organization, being a role model for
the followers that inspires them and makes them interested; challenging

53
followers to take greater ownership of their work, and understanding the
strength and weakness of followers so the leaders can align followers with
tasks that enhance their performance.

Situational style

Uses different styles in different situations

The leader changes his style according to the situation.

Qualities of Effective Leadership

For leaders to be effective in influencing others to perform, they should

possess the following qualities:

 Empathy, that is, an ability to look at things from another person's

point of view.
 Respect, that is, an effective leader should respect others as unique
individuals.
 Objectivity, that is, no bias or prejudice.
 Self awareness, that is, self knowledge, being aware of the impact you
have on others and being aware of your ability to make decisions or
involve yourself with specific problems.
 Courage to take responsibility
 Technical competence
 Healthy and physical fitness
 Steady, persistent, thoughtful determination, emotional stability

A nurse manager uses all the leadership styles separately or together

depending on their flexibility and the circumstances inherent in each
situation.
There are many similarities and differences in the behaviour, attitude and
conditions present in the various leadership styles.
Not all of the behaviours are evident at any one given time.

Levels of Leadership
Your success as a leader may also depend on your level of leadership.
John C. Maxwell lists the five levels of leadership as: 5 Ps

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Position
This is the lowest level of leadership and is based solely on title and position.

Permission
As relationships are developed with others, they give permission to the
leader to lead beyond the limits of their job description.

Production
As the group becomes more productive together, leadership is advanced.

People Development
This level of leadership involves developing people and assisting them to
reach their potential.

Personhood
This level of leadership involves a lifetime of developing others to their
highest potential

Human Resource Management

The shift in terminology from ‘personnel’ to ’human resources’ is symbolic of
a true change in the field.

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The term human resource reflects the position that people are a resource
that needs to be managed strategically in support of the organisation’s
mission.
The effective functioning of an organisation depends upon various resources.
Human resources or manpower is one of the most vital resources for the
labour intensive health institution.
Human resource management can be said to be an integral part of the role
of any person who is responsible for the work of others. In this module,
human resource management will refer to a group of specialists concerned
with increasing the effectiveness of staff performance in an organisation.

According to Basawanthappa (2002), the main objectives of human resource

management are:
 Effective utilisation of human resources to enable the achievement of
organisational goals.
 Establishment and maintenance of an adequate organisational
structure and desirable working relationship among staff.
 Securing integration of the individual and informal groups with the
organisation and thereby ensuring their commitment, involvement and
loyalty.
 Recognition and satisfaction of individual needs and group goals.
 Provision of maximum opportunities for individual development and
advancement.
 Maintenance of high morals in organisations.
Bearing in mind the objectives covered previously, you will now look at the
main aspects of human resource management. These include:

Forecasting Future Manpower Requirements

This involves estimating the institution’s demand for labour and matching
this with what is available.

Formulating and Proposing Policies

Formulation of human resource policies is done by the human resource

management department.
The policies have to be agreed upon by top management.
The key areas of personnel policy include recruitment and selection, terms
and conditions of employment, training and development as well as labour
union issues, for example, laid down procedures on how to handle strikes
and disputes.

These personnel policies are guidelines for behaviour and state how the
organisation will respond in relation to employee affairs.

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Recruitment of Staff

This involves preparing job descriptions and specifications, drafting job

advertisements, interviewing candidates and assessing appropriate salary
levels for new employees.
A job description states the principal duties, responsibilities and the scope of
authority. A job specification also spells out the vital qualities required in an
employee for them to be able to perform a job adequately, for example,
specific knowledge, skills, ability and behaviour.
These must be prepared before advertising for any job.

Staff Training and Development

Once the employees join the organisation, they require training.

This involves induction of new employees as well as training and
development.
This was covered in more detail in section two. Human resources are the
most dynamic of all the organisation's resources.
Training and development is important in order to maintain the key skills
within the organisation and motivate the staff.
This is to enable them to realise their full potential.
The human resources department has the responsibility of assessing the
training needs, designing training methodology and evaluating training
activities to determine their effectiveness.

Staff Retention

It is essential to retain employees within an organisation.

Promoting staff is one way of retaining employees.
This allows them to advance from one given grade to a higher one.
Promotions are based on whether an individual meets the requirements as
specified in the job description.
The career structure or recognised promotional path should provide an
opportunity for all workers to get promoted.

Health and Safety

The employees should be informed about their rights and duties,

occupational hazards should be identified and accident prevention measures
put in place.
First aid facilities should also be at hand.
Most of the effects may have hazardous effects which may comprise the
ability of the individual to perform various types of work.
Aims of safety and health according to the ILO international labour
organization are:

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Promotion and maintenance of higher degree of mental, physical, and social
wellbeing of all workers in different work places
Protection of workers from risks associated with adverse health effects.
Planning and maintaining workers in occupational environment free from
hazards or risks.
Prevention

 Enlighten the workers example on personal protection equipment.

 Early diagnosis and care
 Facilitative supervision
 Reporting of occupational diseases and injuries for further evaluation.
 Occupational health surveillance.

Compensation and Benefits

Workers who suffer occupational injuries and diseases have the right to
compensation. There is need of enlightenment as regards to compensation.
If it is demonstrated that the employee, injury or illness arose out of
employment, and that this was incurred within the scope of employment,
then employee will be eligible for compensation.
There should be pre-employment medical examination, there should be
periodic examination, and should be special medical examination,
All the examination should include;
 Detailed medical and occupational examination
 Comprehensive physical examination
 Laboratory examination
 Special examination to include; hearing and even visual should be
done.
If exposure is confirmed to have resulted into suffering compensation should
be claimed.

Welfare

Welfare services are provided for matters concerning employees which are
not immediately connected with their jobs although they may be connected
generally with their place of work.
These include counselling, problems of health or sickness, social and
sporting activities, restaurants, child care facilities and special services for
retired employees.

Consultation and Negotiation

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Opportunities should exist for collective bargaining and liasing with trade
unions.
Trade unions should be utilised by management as an avenue for
consultation and joint planning with employees.
Trade unions should not be viewed as antagonists but a partner in planning
and decision making.
If employees through their trade unions felt appreciated, they would be
motivated to perform better and improve the image of the organisation.

Labour Management Relations

Labour management relations has been defined as ‘the effort to develop

harmonious working relations between employees and management in order
for a firm to increase productivity, improve quality of work life and remain
competitive’.

Objectives of Labour Management Relations

 To enhance a healthy relationship between employers and employees,

that is, a sound, harmonious and mutually beneficial relationship.
 To safeguard the interests of employees and management by securing
mutual understanding and goodwill between them.
 To avoid industrial and workplace conflict that could affect production
and productivity.
 To preventing or reduce labour turnover and frequent absenteeism.
 To nurture and sustain workplace democracy in order to enhance
employee participation in decision making and problem solving.
 To eliminate strikes, lockouts and go slows.
 To allow the government some control over private means of
production, distribution and service provision in the public interest.
The management should never be caught up in a surprise strike if they have
been in good relations and communication with the employees.
Those in Management positions should not be members of trade unions.

Financial Resource Management

59
In the previous section, you covered the management of human resources.
In this part, you are going to examine financial resource management.
Managing finances is one of the most important roles of a nurse manager.
Arguments have been put forward that this function should be left to
accountants who are specialised in this area.
However, if nurses do not have the basic skills to enable them manage
finances, they will not succeed in providing nursing services.
Most of the resources you will be managing are acquired with money.
Financial planning requires that the manager identifies objectives, policies
and procedures. The budget is one of the main tools of financial
management.

Budgeting

In simple terms, budgeting involves managing money and how it is used to

maintain other resources.
A budget is a means of control, which reflects the plan against which actual
performance is measured.
It can also be defined as a means of checking the progress made in keeping
the expenses and costs in compliance with an organisation's financial plans.
Budgeting is the process of planning and controlling future operations by
comparing actual results with planned budgetary expectations.

The following are some of the purposes of a budget:

 To avoid spending more than an organisation can afford
 To aid in planning and controlling
 To assist in assessing the financial requirements of the institution
 To indicate the areas in which money raised or received will be spent
 To facilitate comparison of actual performance with budgeted targets

In order to draw up a meaningful budget, the hospital should have a clearly

defined organisational structure with responsibilities defined and assigned.
Personnel at all levels of management should participate in budget
development.
The personnel involved should have an understanding of the ideas and
financial goals of the hospital.
There must be an adequate system, which provides reliable financial and
statistical information to the responsible people.
The budget should allow enough freedom to accomplish departmental
objectives and must be flexible enough to allow for unpredictable
expenditures.

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There are two main types of budgets, which the nurse may be involved
in preparing:
 Operational or Annual Budget
 Capital Budget

Operational or Annual Budget

This is the organisation's statement of expected revenue or income and

expenses for the coming year. It coincides with the fiscal year.
The fiscal year is a specified twelve month period during which the
operational and financial performance of the organisation is measured.
It usually coincides with the calendar year, that is, it runs from January to
December or may follow another time frame, for example, the government
calendar, which runs from July to June.
The operational budget includes the accumulated estimates of operating
revenues and expenses. In nursing management, the revenue is derived
from patient fees.
Actual payment is generated by a given service or procedure.
The expenses consist of salary and non salary items, for example, personnel
emoluments and education, including in service training, on the job training,
educational leave and travel scholarships.
They may also include personnel uniforms, books, periodical subscriptions,
laundry, medical equipment and maintenance, drugs and pharmaceuticals,
non pharmaceutical supplies, legal and professional fees and stationery.
The expenses should be comprehensive and thorough.
Budgets are prepared by the heads of each ward or department in
consultation with staff.
Thereafter, the matron, chief nurse or director of nursing services compiles
the nursing division budget. In some cases, the director of nursing services
prepares a budget for the whole of the nursing division.

As you can see from the figure, the income and expenditure parts of the
budget have the same totals, that is, they balance. A budget that has a
higher income than expenditure is said to show a surplus while the one with
a higher expenditure shows a deficit. If there is a deficit in the budget, it
means you have spent more money than you have. This may require you to
borrow money or be indebted to your suppliers.

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Capital Budget

This is the second type of budget.

It outlines the need for major equipment or physical changes in the
organisation requiring large sums of money, for example, physical
renovations, new construction and new or replacement equipment.
Organisations define capital items based on certain criteria, for instance, the
item must have an expected performance of a minimum of one year or more
and exceed a certain shilling value, for example, fifty thousand.
The criteria vary from one hospital to another.
Requests for capital items are usually made on a special form or letter,
accompanied by a written justification for the item. If there are a large
number of items requested, a priority list should be set.
Where possible, the period within which items are needed should be
specified.
Capital costs should consider long term goals and must complement the
organisational objectives.

All nurse managers are involved in the budgeting process.

Preparation begins several months before the end of the fiscal year to allow
time for careful preparation.

In a decentralised system, budget preparation has several steps:

 Review of policies, standards and objectives.

 Top level management projections for the future and preparation of
guidelines.
 Middle level nurse managers prepare the annual budget.
 The administrator of nursing services, finance director or manager
reviews the budget.
 Budget is accepted or modified.
 Budget is implemented and regularly evaluated.
As you can see from the figure, the income and expenditure parts of the
budget have the same totals, that is, they balance.

A budget that has a higher income than expenditure is said to show a surplus
while the one with a higher expenditure shows a deficit.
If there is a deficit in the budget, it means you have spent more money than
you have.
This may require you to borrow money or be indebted to your suppliers.

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Managing Materials
So far you have managed human resources and money.
The other resource that a manager is concerned with in the organisation is
the materials. Materials refer to drugs, supplies and equipment needed by
the nurses and other health personnel to deliver services.
For quality and efficient services, the materials must be provided at the right
place, at the right time and in the right quantity.
Materials are essential if the health care institution is to achieve its
objectives.
The nurse manager should know the policies and procedures that relate to
materials management.

You should be familiar with the following activities:

Demand Estimation

Since a large quantity of materials is used in hospitals, you need to identify

your requirements or needs beforehand.

Procurement

Having developed your list of requirements, the next step is procurement or

ordering.
Some institutions have laid out specific rules and regulations regarding
procurement. This is aimed at reducing wastage and maximising the value of
money.
Remember the PUSH and PULL systems in medical ordering

Receipt and Inspection

The materials received should be subjected to either physical or chemical

inspection. This ensures that you received the right quality and quantity of
materials as requested by the organisation.

Inventory Control

Adequate quantities of materials should be available whenever required.

Close supervision of movement of materials or consumption rate is a good
tool for proper control.

Storage

The materials should be placed in a store within or near the institution.

The store should be of adequate size to accommodate all the different
materials required, for example, fridges, shelves and cupboards.

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FIFO or FEFO systems are used for medical supplies
The materials should also be stored in appropriate conditions, for
example, temperature, light as specified by the manufacturer and
the Security
It is, therefore, important that the nurse manager adopts the proper
procedures for materials management.

Disposal of stores
Not all the procured/receive goods are used. Some may have to be disposed
off after a period of storage.

Steps in disposal
 Identification of stores to be disposed off.
 Categorizing the stores by type or absolute irreparable
 Standard disposal committee which should be in place to consider the
suitability of the disposal of the identified store.
 The SDC should carry out inspection of the store before disposal
 The SDC determine the disposal methods
 Fixing of reserve prices
 Approval of the disposal by a competent authority too.

Types of store disposal

 Anything that has lasted over 5 years needs to be disposed.
 Absolute stores
 Unserviceable stores goods
 Scrapes
 Empty containers

Disposal options
 Donations
 Transfers to other institutions that are needy.
 Public auctioneering
 Dumping

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Managing Time
Time is an important resource although in many cases, it is not thought of as
such.
It is sometimes referred to as one of the M’s of management and stands for
moments.
The other M’s being money, manpower and materials.
For example, you may recall times when you have wished that a day had
more than twenty four hours or that a week had more than seven days so
that you can accomplish the tasks you had set out to do.
This often happens when you are not managing time well.

The demands on time as a manager and a health care provider fall into three
categories (Nduba 1999):
 Tasks that have to be performed. These relate to key responsibilities,
for example, clinical or administrative duties.
 Tasks that other people pressurise you into doing. Some of these are
important and must be done while others you do because you do not
want to say no.
 Tasks that you perform because you want to.
These are usually out of choice and include tasks that someone else
could do just as well, for example, attending a nurses' association
meeting.

Time Waster

This is something that prevents a person from accomplishing a job or

achieving a goal. Some of the common time wasters include:
 Interruptions such as telephone calls and drop in visitors.
 Lack of clear cut goals, objectives and priorities.
 Meetings both scheduled and unscheduled.
 Lack of daily or weekly plans.
 Lack of self discipline.
 Failure to delegate.
 socialisation
 Ineffective communication.
 Inability to say no.

Principles of Time Management

The following are techniques that you can use to deal with time management
constraints.

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Goal Setting

The nurse manager sets both organisational and personal goals.

The goals are either short or long term and provide direction and vision for
actions as well as time frames in which activities will be accomplished.

Time Analysis

The manager should conduct a survey of how they spend a day.

Reviewing the daily schedule and keeping it accurate may demonstrate how
time is used.

Priority Setting

The nurse manager identifies time frames for achievement of goals.

The ’to do’ list should be prioritised by classifying activities as ’one’ for
urgent, ’two’ for not urgent but important and ’three’ for less important.
Delegation

The nurse manager can delegate those activities that can be effectively
handled by juniors.

Controlling Interruptions

The nurse manager should identify causes of interruption and plan to reduce
them.
One way of doing this is incorporating some of these interruptions into
planned and scheduled activities.
Time management requires planning the use of time according to work to
done and this can be done by use of;
 Time-tables
 Schedules
 Rosters
 Program charts
Good time management requires reducing time on non important tasks and
allocating more time on important ones.

This be approached as follows;

 You should know what you ought to be doing and how much time you
need to do it.
 Know how best to use your time to produce maximum results.
 Take an inventory of your time and activities done. Write a conclusion
of the inventory.
 Plan your time according to the activities that need to be carried out
considering both professional and objectives.
Tools for planning your work

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  Note book
 Diary
 Yearly planner-record things to be done in a year
 Daily planner –things to be done during the day.

Steps in planning
Develop tasks for each day by listing all non-routine tasks
Assign a number by priority
Tick accomplished tasks
 Work schedule
Show who, when, and what time will be done. It is used for intermittent,
variable events including details of where the events are to take place.
Timetables
Is a time plan for daily, weekly, regularly events
 Duty roster
A time plan to show who is on duty and when used for different staff
members for different times in turn.. In duty roster periods of duty roster
should be of the length from one duty to another for all the staff.
 Project work plan
This is a legal frame work that depicts activities with the inputs outputs and
the overall goal. It is also known log frame or project planning matrix.

Advantages of work plans

 Plans are carried out in the right sequence
 Priority tasks are carried out first
 It helps the staff to use time efficiently.

CHANGE IN ORGANIZATIONS
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Change is the alteration in the order of the organization or the society.

It is the alteration in the order of a group, organization or a society in the

structure, characterized by cultural symbols, rules of behavior and value.

SOURCES OF ORGANIZATIONAL CHANGE

Change may originate from inside or outside the organization so change may
be caused by external or internal environments

EXTERNAL SOURCES OF CHANGE

The external triggers or factors of organizational change may include:

a. Technological factors
Development of new technology may be applicable in an organisation
May include new ways of transforming resources into products or services
Technological changes may include new machines, equipment, and new
techniques/methods of work
b. Competition factors
Changes in demand for products or services as a result of consumer
preferences will trigger some changes in an organization
c. Government action
Government policies and regulations can affect organization
d. Environmental factors
Prevailing economic conditions as inflation and interest rates are sources
of change
Cultural factors as modes of dressing, reasons for work, composition of
workforce can trigger changes in an organization

INTERNAL SOURCES OF CHANGE

These are assumed to be more predictable indicators of change

These forces constitute internal factors that for change as distribution of
responsibility, accountability for scarce resources
These factors may include:
a. Changes in organizational strategy
Review of mission or goals may trigger changes in an organization policies,
systems, and procedures
These will have effect on other systems of the organization
b. Introduction of cultural changes
Efforts to introduce organizational culture changes like management styles,
collaborative working etc can trigger changes in an organization

c. Changes in employee factors

Any changes in knowledge and skills requirement by the organization may
lead to changes within the organization

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 d. Changes in Job/roles culture
The roles of a job holder plays a significant part in the structure of an
organization
These can trigger changes

Types of change
Structure change

It involves setting goals for the organization.

Authority
Administration

Strategic changes.
It involves changing fundamental approach of doing things from routine
services
People
Alters the attitude, skills, of performance of employees and organization
Process
To improve productivity and work flow and efficiency
Process of introducing change
Implement change
Develop the plan for effective transformation.
Support the plan
Communicate that is relay information through a channel to the recipient
and getting feedback.

Factors that limit change

Fear of unknown

Ignorance

Attitude

Environment

Lack of motivation

There are two basic approaches to the management of change

(Bennett, 1997).

These are:

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  To predict all environmental changes relevant to the organisation that
might occur and then anticipate how the organisation will be affected
by them
 To list all the organisation's major functions and follow this by an
analysis of environmental factors that might affect the functions

Once the organisation identifies the need for change, it should assess the
possible implications of this change.
This may require:
 Definition of alterations in operational methods, staffing levels and the
employee's attitudes and perspectives necessary to implement
alterations.
 New equipment and systems.
 Redesigning of jobs.
 Restructuring of jobs.
 Restructuring the organisation.

Resistance to Change

Employees may fear change because of its potential for the disruption of the
existing status quo in the organisation.

The following are some of the reasons why people resist change:
 Insecurity, fear of unforeseen consequences and threats to individual
status.
 Skills and experience acquired may have no further value.
 Possible collapse of work groups and interpersonal relationships.
 Dislike of imposed change
 Group norms – established rules/procedures
 Awareness of weakness in the proposed change
 Balance of power – a change that threaten the autonomy of a division
or department within an organization may be resisted

To reduce or avoid resistance to change, we can help the employees go

through a change process.

Kurt Lewin suggested three steps to overcome resistance:

 Unfreeze, that is, getting rid of existing practices and ideas that stand
in the way of change. This requires a high level of communication with
employees to convince them that change is necessary.

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  Change or movementphase that is, teaching employees to think and
perform differently.
 Refreeze that is, establishing new norms and standard practices.
To implement the change process, the following approaches will be
necessary and helps reduce resistance to change:

Education and Communication

This is to make employees fully aware of all aspects of the situation and
convince them that change is essential.
Avoid coercive tactics as it increases resentment and tension

Participation and Involvement

The employees should actively participate and get involved from the
beginning so as to stimulate commitment.

Minimise social change

Social relationships areimportant are importantand should not be

disruptedby the change
Maintain informal relationships as far as possible

Patience and Tolerance

Management should give support and assistance needed.

A nurse manager has an important role in initiating and managing change.
They should recognize the obstacles to change and assist employees to go
through the change process.

MANAGING NURSING CARE SERVICES

Introduction

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You will be able to apply various concepts already learned, which will enable
you manage the nursing care services in your organization more effectively
and efficiently.

Objectives

 Analyze the different types of health care organizations

 Describe the management of nursing care services
 Describe the different types of nursing care delivery systems
 Identify legal and ethical issues in nursing practice

Health Care Organizations

Ownership
Health care organizations have various designations. Private organizations
are directed and supported by private citizens.
They are usually owned by corporations, associations or religious groups, for
example, private or mission hospitals.
They can further be divided into two categories.
The non profit category ploughs back all profits to its operation or the
community while the commercial category distributes profits to investors or
shareholders.
Meanwhile, government health care organizations are government or state
owned.
The majority of our organizations in Kenya fall under this category.

Role or Services Offered

These range from specialty institutions, which provide for a specific disease
or section of the population, for example, psychiatric or children's needs, to
those referred to as general, which provide a full range of services for the
whole population.
These services may include acute care, ambulatory and rehabilitative
services.

Activity and Size

These mainly refer to teaching institutions, which have both a general

hospital and a teaching hospital, for example, the Kenyatta National Hospital.

Nurses practice in many different types of health care organisations where

they provide direct and indirect care services to patients.

Health care organisations make up the health care system, which provides
all the services offered by all health disciplines.

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Today, many types of health care organisations exist. These differ in terms
of:

Types of Health Care Organisations

There are four main types of health care organisations.
These are:

Hospitals

These are institutions whose purpose is to serve the whole community, sick
or well. Hospitals play a significant role and provide preventive, curative,
rehabilitative and health promotion services as well as education and
research.

Hospitals are classified into acute care facilities, where the average length of
stay is less than thirty days and chronic or long term hospitals, which are
designated to care for patients whose average length of stay is longer than
thirty days.

The services provided by hospitals include:

 Medical care, that is, the care given by doctors to meet the needs of
patients, for example, surgical.
 Nursing services, that is, the care given by the nurses in coordination
with other health care team members.
 Emergency care, that is, care given at any time of need for people
requiring emergency measures, for instance, acute trauma accident
cases, intoxication or poisoning.
 Diagnostic services, which include radiological and pathological
services.
 Drug therapy, that is, most hospitals should have a good pharmacy
with the drugs required for the care of patients.
 Dietary services, which are important for the nutrition of patients.
 Rehabilitative and recreational services, which contribute to the well
being of patients and are therefore, therapeutic.

Ambulatory Based Organisations

This is the second type of health care organisation.

Many health services are provided on an ambulatory basis.
This refers to the care given by private physicians or in hospitals as
outpatient care.
The goal is to focus on out patient preventive care and patient follow up
care.
This serves to reduce the cost of expensive acute hospital care.

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Health Managed Organisation (HMO)

The other type of health care organisation is the HMO.

This is a new concept in Kenya, which is catching up quickly.
This is where an organisation gets people to enrol and pay a fixed periodic
fee to the organisation, which determines the kind of services used.
The HMO offers hospital and out patient services.
Examples of these include insurance companies who cover medical
expenses.

Home Health Care Organisation

The last type of health care organisation is home based.

The services in this case are offered at home. Professional nurses provide
care.
They assess the patients’ ability to take care of themselves and identify the
resources needed to overcome problems and meet patients’ needs.
These include patients' requiring palliative care, chronically ill patients, the
disabled or the elderly.
The nurse manager plays a significant role in all the above health care
organisations particularly in managing nursing services.

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Managing Nursing Services
The nurse as a leader and manager must ensure that the nursing services
are run effectively and efficiently.

This refers to the coordinating responsibility of the nurse, who, in addition to

giving care, also works with members of the health care team in providing a
comprehensive programme of nursing care (Basavanthappa 2000).

The nurse’s main task is to link the team or a nursing department to the
larger organisation and to the resources necessary to achieve the objectives.

The following are the main responsibilities as regards to managing nursing

services:

 The nursing service must be operational twenty four hours a day,

seven days a week all year round.
 High quality nursing care must be provided to patients taking into
consideration their physical, social, psychological and spiritual needs.
 Resolution of health care delivery problems.
 Policy development.
 Planning, organising, directing and controlling materials and human
resources in order to provide effective care. This was covered in
sections two and three.
 Utilising the appropriate methods of patient assignment in order to
deliver care
to patients.
 Research for knowledge generation, better understanding of issues
and engineering new methods of management, that is, innovation.

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Nursing Care Delivery Systems
The practice of nursing has emerged as an aggregate of complicated duties
and responsibilities.
There is, therefore, a need to develop certain systems, methods or
modalities to ensure delivery of quality care.

There are four methods of assignment of patient care in a hospital.

These are:
 Case Assignment
 Functional Nursing
 Team Nursing
 Primary Nursing
The changes in these modalities or systems are a response to ever changing
needs. These methods may be used separately or to complement one
another.

Case Assignment Method

This was the first method to be identified in nursing care delivery.

It was popular in the 1920's.
Each patient is assigned to a nurse for total patient care while the nurse is
on duty.
If they go off duty, the work is handed over promptly to another nurse.
This means that the patient has a different nurse each shift.
Assignment is made according to the severity of illness and tends to be
mostly for acutely ill patients, for example, in the intensive care unit (ICU).

Functional Nursing

The second method is known as the functional nursing method.

It was the first major deviation from case method.
It began in the early 1950's when there were few registered nurses and more
practical nurses available.
Nurse aides provided most of the patient care.
This method emphasises the division of labour according to specific tasks.
It is ‘task or thing oriented’ and is determined by the technical aspects of the
job to be done.
Each nurse has a clearly defined set of tasks determined by complexity,
including skills, knowledge and experience in certain nursing techniques, for
example, drug administration, wound dressing, bed baths and so on.
In this approach, the nurse in charge must have experience and exceptional
knowledge in nursing.

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The nurse must know the skill level of their workers in order to make
accurate assignments.
The nurse in charge establishes rigid routines, structures and time
schedules.
This method has several advantages:
 It emphasises the efficient delivery of care
 There is little likelihood of confusion over who will do what
 Minimal time is spent coordinating activities
 It is economical in that it allows for the use of less skilled personnel
 Each member can become highly skilled if they do the same tasks
repetitively
It proves particularly useful when workers have limited knowledge and
experience, facilities and equipment and there is a shortage of staff.
However, there are some disadvantages.
These include:
 The nurse tends to lose close contact with patients.
 Fragmentation of care rather than total care. This means that the
patient's needs may be overlooked because of failure to fit in
compartments or task categories, for example, there may be a nurse
skilled in administering medication but none skilled in dealing with
anxiety.
 Continuity of care is difficult if not impossible since no single staff
member has a complete picture of the client's needs and responses to
nursing or medical interventions.
 There is little avenue for development.

Team Nursing

Team nursing was introduced in the late 1950's to improve nursing

services by utilising the knowledge and skills of professional nurses
and to supervise the increasing number of auxiliary staff.
The philosophy support achieving goals through group action or team
spirit.

Team nursing can be organised in the following manner:

 A group or team of nurses with different levels of skills are assigned to
a group
of patients. The size and composition of the team is dependent upon
the setting.
 The team works together to accomplish a goal.
 They focus on patient centred as opposed to task oriented
assignments. These are based on patient needs and the knowledge,
skills and experiences of
team members.

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  A member of the work group is assigned as a leader. In the original
concept, the team was led by a registered nurse.
 The leadership role may be permanent or rotated.
 The team works together with each member performing the tasks for
which they are best prepared.
 Team members report to the team leader who reports to the head
nurse.
 Success is dependent upon effective communication.

This approach has several strengths.

These include:
 It allows individual members to make personal and useful suggestions.
 It combines the best thinking of all team members about patients'
problems and improves the quality of decision making.
 It cultivates team spirit, which affects the climate and continuity of
care.
 There is fragmentation of care and better utilisation of personnel in the
performance of quality care.
 There is also the potential for leadership development and it
encourages greater staff satisfaction due to increased guidance and
better matching of assignments to skills.

As an individualised care approach, it is often more satisfying to patients.

The patients are cared for by a limited number of nurses who know them
better.
This provides an opportunity for more therapeutic and enhanced nurse
patient relationships.
However, there are also weaknesses associated with this approach.
These include:
 It may be difficult to find the time needed for team planning and
conferences. This would mean that at times, care plans are not
comprehensive enough.
 The time spent in coordinating delegated work and supervision can
prove expensive.
 Logistics may hamper team nursing, for example, four or five nurses
converging at a medicine cupboard designed to support one nurse

Primary Nursing

This is a newer approach to the delivery of nursing services.

The concept was developed in the early 1970s and is used by many
institutions in the developed world.
People are becoming more aware of it in this country and some institutions
have begun to incorporate it.
The following is the basis for assignment:

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  A professional nurse, usually a registered nurse, is assigned to a
patient for their total hospital stay or to a small group of patients, not
more than four or five.
 This nurse assumes responsibility for twenty four hours a day for the
duration of the patient’s stay in hospital.
 The primary nurse assesses plans and executes the plan or may
delegate to a secondary or associate nurse to execute the plan during
her absence.
 Every nurse serves as the primary nurse for a few patients and as an
associate nurse for other patients on other shifts.
 The primary nurse communicates with the physician and coordinates
care with other health workers.
 The chief nurse functions as a coordinator of the unit and is a resource
person for the primary nurses.

Advantages:

 It encourages a one to one relationship and in so doing promotes total

patient care by virtue of the quality of interaction.
 The nurse coordinates all aspects of care, including the physical, social
and psychological, which ensures the continuity of care.
 This method promotes increased autonomy and responsibility leading
to job satisfaction due to involvement.
 Clients are satisfied as a result of their increased interaction with one
nurse who
is knowledgeable.

Disadvantages
 It limits professional mobility. An associate nurse may find it difficult to
follow plans made by another nurse.
 It requires high levels of expertise and commitment from all nurses,
that is, patient care may suffer if the nurse is not competent enough to
perform all the
tasks assigned.
 Primary nursing requires competent practitioners who can function
independently when utilising the nursing process. However, not all
nurses are comfortable in accepting this responsibility.
 It may be less economical than the other methods since it may require
a larger percentage of registered nurses.

Legal and Ethical Issues In Nursing (management tools)

You have examined the different types of health care organisations and the
responsibilities of the nurse manager in the management of nursing services
within these organisations.

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As the manager works and supervises the work of employees, they must be
knowledgeable and conversant with the laws and ethics that govern nursing
practice.
The manager has a responsibility to apply legal and ethical principles in their
work and monitor the practice of employees under their supervision.
Legal Issues

The legal responsibility refers to the obligation upon nurses to obey the law
in professional activities.
The professional nurse should understand their legal responsibility when
taking care of patients and be aware of their limitations.

Patients have a right to expect professionals to live up to certain safety

standards and to demonstrate responsibility and accountability.
The scope of nursing practice is defined and guided by the nursing practice
act and the common law.

The nursing practice act provides legal regulation for licensure, while
common law is derived from legal doctrine and consists of both broad and
comprehensive principles based on justice, reason and common sense.
The two are responsible for educational and examination requirements,
providing licensing for those who meet professional requirements and
defining the functions of each category, for example, registered nurse or
enrolled nurse.
Nursing practice should not leave room for negligence or malpractice
because this can lead to litigation.
Litigation is being taken to a court of law by a patient who makes a claim for
damages or compensation.

Good Samaritan laws

Fear of being sued has prevented a trained professionals from assisting

during an emergency
When administering emergency care nurses and physicians are protected
from civil liability so long as they behave in the same manner as any
ordinary professional would.
However if payment is received for the care then the good Samaritan law
doesn’t hold

Confidentiality

It is possible for nurses to be involved in lawsuits other than those of

negligence
The client/patient has a right to confidentiality and it is the responsibility of
the professional nurse to ensure this right

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This assures the client that any information obtained during the care will not
be communicated to those that don’t need it.

Slander and Libel

Slander refers to spoken words while libel refers to written word

Making a false statement about a client condition that may result in an injury
to the client is considered a slander. Making a written false stamen is libel
May also be considered about co workers (credibility damage- personally or
professionally)
Think before you speak and write
False imprisonment
Is confining an individual against his or her will by either physical or verbal
means
Examples:
- Using restraints on individual without appropriate consent
- Restraining a mentally handicapped individual who donot
represent a threat to themselves or others
- Detaining unwilling client in an institution when they desire to go
home
- Threatening client with some form of physical emotional, or legal
action if they insist of leaving
Nurses should try obtain co operation of the patients before applying any
form of restrain

Assault and Battery

Assault is threatening to do harm

Battery is touching another person without his/her consent
Significant of assault is in the threat
If you don’t stop pushing that bell I will give you an injection with a bigger
needle- is considered assaultive statement
Battery would be when the injection were given when it was refused even if
the staff deemed it was necessary – the right of the patient.

Ethical Issues

Ethics have always been an integral part of nursing.

Throughout your nursing practice you have applied the nursing code of
ethics.
The ethics provide the standards for professional behaviour in terms of what
is expected of nurses.
They are based on the principles of what is right or wrong.

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The nurses’ code of ethics serves as a self regulatory mechanism and a
source of guidelines for individual behavior and responsibility.

Policy

It is a set of plans and actions a greed upon by a group /government as

related to service provision.
It is a set of values and objectives that enhance ethics and human values
and objectives that guides action.
Policies act as guidelines that enhance ethics and human rights since they
regulate the conduct of workers in service provision.

Organizational philosophy

Philosophy is a system of motivating beliefs /values and principles that direct

action of a particular group of people.
As regards to nursing it includes individualism respect for life that is
(enhancement of health, promote, health).
Philosophy of care to those who deserve it

Organizational chart

It is a diagram that shows structure of a group or organization from the top

to the lowest level. It depicts chain of communication.
A chart indicates not only individual managers and subordinates but also the
entire hierarchy in the establishment.
All people who report to the same individual are on the same management
level regardless of where they may appear in the chart.

Advantages
 Employees and others have a picture of how the organization is
structured.
 The chart indicates where to find who to handle a specific problem.
 It enables managers to pinpoint organizational defects eg potential
source of conflicts or areas of unnecessary duplication.

Disadvantages

 They obscure may things eg they do not show who has greater
responsibility and authority at each level.

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  It does not indicate the organization informal relationship and
channel of communication without which the organization could not
function efficiently.
 Misinterpretation is common in charts eg employees may interpret
status and power on the basis of the distance from C.E.O’S box.

Health Information Systems
The use of computers in health care is a rapidly growing area.
As nursing care becomes more computerised and geared towards telehealth,
nurses must be well prepared to be at the cutting edge of information
technology (IT).
The health care system in Kenya is rapidly changing for the better and the
nurse in Kenya needs to be well prepared in meeting the information
technology challenges.
One of the nurses’ new roles will be agents of change in health care
revolution (Ball 2005).
Studies have shown that nurses spend as little as 15% of their time on direct
patient care. As much as half their time goes into documentation. Clinical
documentation is an area where IT has had a major influence.
As they help coordinate all the multifaceted activities related to patients,
nurses must ensure that every aspect of diagnosis and care is carefully
documented.
Documentation poses a tremendous, often unmanageable, challenge and
has become the root cause of many patients’ safety and related legal
problems (Ball 2005).
The key to embracing IT is computer literacy among the nurse care
providers.

Information Technology

This is the acquisition, processing and dissemination of information using

computers.
Whereas in the past and even today in some institutions, information
handling involved dependence on paper, the emphasis is now shifting to
creation, storage and transmission of information through tiny electrical
impulses.

Paper no doubt will continue to be important as a tangible product of the

interchange of information.
Nevertheless, computers are likely to dominate the scene.

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Most healthcare institutions collect comprehensive information about their
patients. They also have information on administrative matters related to
staff, equipment, supplies and so on.
All this information is kept in records, which are either in written documents,
tapes or computers.
Records are an important tool in controlling and assessing the workplace.
Records should be accurate, accessible and useful.
To achieve goals and maintain efficiency and effectiveness, the organisation
uses a variety of tools to collect information, analyse data and make
predictions about outcomes.
The facts used to produce information, for example, admissions, invoices,
receipts, stock issues are termed as ’data’ while the process that transforms
raw data into information, useful items or summaries of data, is called data
processing.
The raw data is input into the system whereas information is output, that is,
processed data.
The process that converts input into output involves sorting, storing,
amending, calculating, deleting or retrieving data.
Information must be relevant, easily understood, up to date and easily
available to the users.
This can only be achieved if nurses are computer literate.
Computer Literacy

Computer literacy is ‘the minimum knowledge, know how, familiarity,

capabilities and abilities in regard to computers’ (Burk 1985, 33).
According to the western Illinois university senate’s committee on computer
literacy, the basic competencies considered for academic success are:
 Use of word processing programs effectively
 Use of library databases and catalogues to locate print materials
 Ability to find information on the Internet and evaluate its reliability
and usefulness
 Ability to write email effectively and appreciate the ethical issues of
computing
Information literacy is a fundamental skill. It is, in fact, the first component
on the continuum of critical thinking skills.

It includes the ability to identify a lack of information, and decide what

information is needed as well as the ability to evaluate and organise the
available information (Brevet 1991).

Nursing Informatics

Nursing Informatics is a specialty that integrates nursing science,

computer science, and information science to manage and communicate
data, information, and knowledge in nursing practice.

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Nursing informatics facilitates the integration of data, information and
knowledge to support patients, nurses and other providers in their decision
making in all roles and settings.
This support is accomplished through the use of information structures,
information processes, and information technology (ANA 2001, vii).
Ball and Hannah (1988), provide a comprehensive description of nursing
informatics as the use of any information technology by nurses in relation to
the care of patients, the administration of health care facilities, or the
educational preparation of individuals to practice the discipline of nursing.
They suggest that nursing informatics includes, but is not limited to:
 The use of artificial intelligence or decision making systems to support
the nursing process.
 The use of a computer based scheduling package to allocate staff in a
hospital or health care organization.
 The use of computers for patient education.
 The use of computer assisted learning in nursing education.
 The use of hospital information systems.
 The use of data and information generated from research to form a
basis for evidence based practice.
Advantages of Computers to Nurses and Nursing Services

 Time saving is often the most sought after benefit since nurses are
keener on doing than on recording (Strachen, 1994).
Speedier recording is possible using core care plans, and with the use
of technology such as bar coders, light pens, or voice recognition.
All that is required is a structured language or terminology that can
be coded.
 Computers can process information far quicker than the human
brain .The vast amount of data nurses collect and record is put to very
little use because it takes too long to analyse. All the nurse needs to do
is to decide what information they need, what data to collect, how it
should be analysed and the computer will do the rest.
 Printed care plans are easier to read than manual records with
numerous changes by unknown nurses. The computer can
automatically track any changes made to a care plan.
 Computers improve accuracy. A person repeating the same complex
calculation one hundred times is likely to get a dozen different
answers.
A rigorously tested computer repeating the same calculation one
hundred times will get the same answer each time.
 Computer software can be designed to undertake validity checks on
data, rules can be added, comparisons made and reminders given.
These help reduce human error and improve the accuracy of nursing
records.

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  Improved communication can offer patients considerable benefits.
If a network is in place, a computer terminal can be used to access
nursing records, day or night, by those who have been granted access
to the system through use of passwords.
The possibility of better access increases the risk of unauthorized entry
into
the system. These concerns must be compared with the present
reality, for example, how secure are the current records and does the
computer offer better security. All that is required is good design, user
education and a well managed computer system.
 Computers can offer easier retrieval of information simply through the
touch of a button. Nurses can ask questions and get answers from their
own data, for example, how many patients developed pressure sores
or how many patients with a sore had a high risk on the Norton scale.

Advantages of Computers to Nurses and Nursing Services

Other benefits include:

 Preventing the duplication of collection and recording of demographic

details.
 Linking treatments and procedures with orders to suppliers, pharmacy
or catering services.
 Linking nursing cases to research references, producing discharge
plans for patients or summaries of care and treatment for other health
care professionals and so on.
A Health information system is an integrated system used in health care
settings to manage patient information.

It is primarily a centralized patient record of demographics, health and

financial information (Yoderwise 1999).

The information is entered, stored, retrieved, displayed and communicated.

A major function is to communicate and integrate patient care data and
information, and provide management support.
Health data is entered into the system from computer stations located in the
various departments in the organization and stored in a central computer to
be accessed by all patient care services.
The systems contain a central database that is written to and accessed by all
departments, for example, nursing, laboratory, pharmacy, radiology,
physiotherapy and so on.
The programs that link the individual departments must be able to ‘talk’ to
one another in order to exchange patient data.

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For example, the wards need access to laboratory results or the pharmacy
may need access to the ward for information like patient height, weight or
allergies as entered by the nurse in the patient’s clinical chart.

The nurse managers and staff must understand the patient care process
from a data information knowledge perspective.
They must be aware of the data collected, reasons why it is collected and
decisions made based on the data.
The type of information that can be tracked in this system includes:
 Appointments, admissions, discharges and transfers.
 Medication profiles, for instance, prescriptions and allergy reports.
 Care planning.
 Patient acuities.
 Human resources, including staff pay roll, performance, incident
reports and staff scheduling.
 Plans, for example, budgeting information.

An information system must provide the following (Yoder-Wise, 1999):

 Information confidentiality and security

 Uniform data definitions
 Standard format for transmitting data
 Sharing of information between departments
 Linking of clinical and financial information
 Patient specific data
An effective health information system is important in order to get the health
information required for appropriate planning and decision making.
It also assists in monitoring and evaluating the various activities within the
organization.

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DISASTER NURSING

INTRODUCTION
Disasters have been integral parts of the human experience since the
beginning of time, causing premature death, impaired quality of life, and
altered health status.
The risk of a disaster is ubiquitous. On average, one disaster per week that
requires international assistance occurs somewhere in the world.
The recent dramatic increase in natural disasters, their intensity, the number
of people affected by them, and the human and economic losses associated
with these events have placed an imperative on disaster planning for
emergency preparedness.
Global warming, shifts in climates, sea-level rise, and societal factors may
coalesce to create future calamities.

Finally, war, acts of aggression, and the incidence of terrorist attacks are
reminder of the potentially deadly consequences of man’s inhumanity
toward man.
The word derives from French “désastre” and that from Old Italian
“disastro”, which in turn comes from the Greek pejorative prefix dus = “bad”
+ aster = “star”.
The root of the word disaster (“bad star” in Greek) comes from an
astrological theme in which the ancients used to refer to the destruction or
deconstruction of a star as a disaster.
The ancient people believed that the disaster is occurred due to the
unfavourable position of the “planets” or “Act of God”.
Gradually they understand the mysteries of nature.

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India has been traditionally vulnerable to natural disasters on account of its
unique geo-climatic conditions.
Floods, droughts, cyclones, earthquakes and landslides have been recurrent
phenomena. About 60% of the landmass is prone to earthquakes of various
intensities; over 40 million hectares is prone to floods; about 8% of the total
area is prone to cyclones and 68% of the area is susceptible to drought.
We do not expect disaster, but they happen with living, come natural
calamities, the individual and technological advances, come from expedient,
socio-economic and political stagnation and war etc. disaster either man-
made or natural, may be inevitable, but there are methods to prevent or
manage the way, people and their communities respond to disaster.
So, nurses have an important role to play during a disaster to save the lives
and to provide healthcare to the victims.

DEFINITIONS
Disaster is a result of vast ecological breakdown in the relation between
humans and their environment, as serious or sudden event on such scale
that the stricken community needs extraordinary efforts to cope with outside
help or international aid.

WHO defines Disaster as “any occurrence that causes damage, ecological

disruption, loss of human life, deterioration of health and health services, on
a scale sufficient to warrant an extraordinary response from outside the
affected community or area.”

Red Cross (1975) defines Disaster as “An occurrence such as hurricane,

tornado, storm, flood, high water, wind-driven water, tidal wave,
earthquake, drought, blizzard, pestilence, famine, fire, explosion, building
collapse, transportation wreck, or other situation that causes human
suffering or creates human that the victims cannot alleviate without
assistance.”

UNDP (2004) defines “Disaster is a serious disruption triggered by a hazard,

causing human, material, economic or (and) environmental losses, which
exceed the ability of those affected to cope.”

Disaster can be defined as “Any catastrophic situation in which the normal

patterns of life (or ecosystems) have been disrupted and extraordinary,

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emergency interventions are required to save and preserve human lives
and/or the environment.”

Disaster may also be termed as “a serious disruption of the functioning of

society, causing widespread human, material or environmental losses which
exceed the ability of the affected society to cope using its own resources.”

Thus, a disaster may have the following main features:-

 Unpredictability
 Unfamiliarity
 Speed
 Urgency
 Uncertainty
 Threat
TYPES OF DISASTER
Disasters are classified in various ways, on the basis of its origin/cause.
1. Natural disasters
2. Man-made disasters
And On the basis of speed of onset-
1. Sudden onset disasters
2. Slow onset disasters

NATURAL DISASTERS
A serious disruption triggered by a natural hazard (hydro-metrological,
geological or biological in origin) causing human, material, economic or
environmental losses, which exceed the ability of those affected to cope.
Natural hazards can be classified according to their
- (1) Hydro meteorological,
- (2) Geological or
- (3) Biological origins.
 Hydrometer logical disaster– Natural processes or phenomena of
atmospheric hydrological or oceanographic nature. Phenomena /
Examples – Cyclones, typhoons, hurricanes, tornados, Storms, hailstorms,
snowstorms, cold spells, heat waves and droughts.
 Geological disaster – Natural earth processes or phenomena that
include processes of endogenous origin or tectonic or exogenous origin
such as mass movements, Permafrost, snow avalanches. Phenomena /

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 Examples – Earthquake, tsunami, volcanic activity, Mass movements
landslides, Surface collapse, geographical fault activities etc.
 Biological Disaster – Processes of organic organs or those conveyed
by biological vectors, including exposure to pathogenic, microorganism,
toxins and bioactive substances. Phenomena / Examples – Outbreaks of
epidemics Diseases, plant or animal contagion and extensive infestation
etc.

HUMAN-INDUCED DISASTERS
A serious disruption triggered by a human-induced hazard causing human,
material, economic or environmental losses, which exceed the ability of
those affected to cope.
These can be classified into –
- (1) Technological Disaster
- (2) Environmental Degradation.
 Technological disaster –
Danger associated with technological or industrial accidents, infrastructure
failures or certain human activities which may cause the loss of life or
injury, property damage, social or economic disruption or environmental
degradation, sometimes referred to as anthropological hazards.
Examples include industrial pollution, nuclear release and radioactivity, toxic
waste, dam failure,transport industrial or technological accidents
(explosions fires spills

 Environmental Degradation –
Processes induced by human behaviors and activities that damage the
natural resources base on adversely alter nature processes or
ecosystems.
Potentials effects are varied and may contribute to the increase in
vulnerability, frequency and the intensity of natural hazards.
Examples include land degradation, deforestation, desertification, wild land
fire, loss of biodiversity, land, waterand air pollution climate change, sea
level rise and ozone depletion.

LEVELS OF DISASTER
Goolsby and Kulkarni (2006) further classify disasters according to the
magnitude of the disaster in relation to the ability of the agency or
community to respond.

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Disasters are classified by the following levels:
1) Level I: If the organization, agency, or community is able to contain the
event and respond effectively utilizing its own resources.
2) Level II: If the disaster requires assistance from external sources, but
these can be obtained from nearby agencies.
3) Level III: If the disaster is of a magnitude that exceeds the capacity of
the local community or region and requires assistance from state-level or
even federal assets.

KEY ELEMENTS OF DISASTERS

Disasters result from the combination of hazards, conditions of
vulnerability and insufficient capacity or measures to reduce the potential
negative consequences of risk.

Hazards
Hazards are defined as “Phenomena that pose a threat to people, structures,
or economic assets and which may cause a disaster.
They could be either manmade or naturally occurring in our environment.”
Hazard is a potentially damaging physical event, phenomenon or human
activity that may cause the loss of life or injury, property damage, social and
economic disruption or environmental degradation. (UN ISDR 2002)

Vulnerability
Vulnerability is the condition determined by physical, social, economic and
environmental factors or processes, which increase the susceptibility of a
community to the impact of hazards. (UN ISDR 2002)

Capacity
Capacity is the combination of all the strengths and resources available
within a community, society or organization that can reduce the level of risk,
or the effects of a disaster. Capacity may include physical, institutional,
social or economic means as well as skilled personal or collective attributes
such as ‘leadership’ and ‘management.’ Capacity may also be described as
capability. (UN ISDR 2002)

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Risk
Risk is the probability of harmful consequences, or expected losses (deaths,
injuries, property, livelihoods, economic activity disrupted or environment
damaged) resulting from interactions between natural or human-induced
hazards and vulnerable conditions. (UNDP 2004)
Risk is conventionally expressed by the equation:
Risk = Hazard x Vulnerability
Some professionals use the notation:
Risk = (Hazards x Vulnerability) – Capacity
They identify capacity as an element that can drastically reduce the effects
of hazards, and vulnerabilities and thus reduce risk.
For example, an earthquake hazard of the same magnitude in a sparsely
populated village of Rajasthan and in the densely populated city of Delhi will
cause different levels of damage to human lives, property and economic
activities.

DISASTER NURSING- DEFINITION

Disaster nursing can be defined as “the adaptation of professional nursing
knowledge, skills and attitude in recognizing and meeting the nursing, health
and emotional needs of disaster victims.”

GOALS OF THE DISASTER NURSING

The overall goal of disaster nursing is to achieve the best possible level of
health for the people and the community involved in the disaster.
Other goals of disaster nursing are the following:
1. To meet the immediate basic survival needs of populations affected by
disasters (water, food, shelter, and security).
2. To identify the potential for a secondary disaster.
3. To appraise both risks and resources in the environment.
4. To correct inequalities in access to health care or appropriate
resources.
5. To empower survivors to participate in and advocate for their own
health and well-being.
6. To respect cultural, lingual, and religious diversity in individuals and
families and to apply this principle in all health promotion activities.
7. To promote the highest achievable quality of life for survivors.

PRINCIPLES OF DISASTER NURSING

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The basic principles of nursing during special (events) circumstances and
disaster conditions include:
1. Rapid assessment of the situation and of nursing care needs.
2. Triage and initiation of life-saving measures first.
3. The selected use of essential nursing interventions and the elimination
of nonessential nursing activities.
4. Adaptation of necessary nursing skills to disaster and other emergency
situations. The nurse must use imagination and resourcefulness in dealing
with a lack of supplies, equipment, and personnel.
5. Evaluation of the environment and the mitigation or removal of any
health hazards.
6. Prevention of further injury or illness.
7. Leadership in coordinating patient triage, care, and transport during
times of crisis.
8. The teaching, supervision, and utilization of auxiliary medical personnel
and volunteers.
9. Provision of understanding, compassion, and emotional support to all
victims and their families

HEALTH EFFECTS OF DISASTERS

The health effects of disasters may be extensive and broad in their

distribution across populations. In addition to causing illness and injury,
disasters disrupt access to primary care and preventive services.
Depending on the nature and location of the disaster, its effects on the short-
and long-term health of a population may be difficult to measure.

Disasters affect the health status of a community in the following ways: –

 Disasters may cause premature deaths, illnesses, and injuries in the
affected community, generally exceeding the capacity of the local health
care system.
 Disasters may destroy the local health care infrastructure, which will
therefore be unable to respond to the emergency. Disruption of routine
health care services and prevention initiatives may lead to long-term
consequences in health outcomes in terms of increased morbidity and
mortality.
 Disasters may create environmental imbalances, increasing the risk of
communicable diseases and environmental hazards.

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  Disasters may affect the psychological, emotional, and social well-
being of the population in the affected community. Depending on the
specific nature of the disaster, responses may range from fear, anxiety,
and depression to widespread panic and terror.
 Disasters may cause shortages of food and cause severe nutritional
deficiencies.
 Disasters may cause large population movements (refugees) creating
a burden on other health care systems and communities. Displaced
populations and their host communities are at increased risk for
communicable diseases and the health consequences of crowded living
conditions.
PHASES OF A DISASTER
There are three phases of disaster.
1. Pre-Impact Phase
2. Impact Phase
3. Post – Impact Phase
PRE-IMPACT PHASE
It is the initial phase of disaster, prior to the actual occurrence. A warning
is given at the sign of the first possible danger to a community with the aid of
weather networks and satellite many meteorological disasters can be predicted.
The earliest possible warning is crucial in preventing toss of life and
minimizing damage. This is the period when the emergency preparedness plan
is put into effect emergency centers are opened by the local civil, detention
authority. Communication is a very important factor during this phase; disaster
personnel will call on amateur radio operators, radio and television stations.
The role of the nurse during this warning phase is to assist in preparing
shelters and emergency aid stations and establishing contact with other
emergency service group.

IMPACT PHASE
The impact phase occurs when the disaster actually happens. It is a time of
enduring hardship or injury end of trying to survive.

The impact phase may last for several minutes (e.g. after an earthquake,
plane crash or explosion.) or for days or weeks (eg in a flood, famine or
epidemic).

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The impact phase continues until the threat of further destruction has passed
and emergency plan is in effect.
This is the time when the emergency operation center is established and put
in operation.
It serves as the center for communication and other government agencies of
health tears care healthcare providers to staff shelters.
Every shelter has a nurse as a member of disaster action team.
The nurse is responsible for psychological support to victims in the shelter.

POST – IMPACT PHASE

Recovery begins during the emergency phase and ends with the return of
normal community order and functioning. For persons in the impact area this
phase may last a lifetime (e.g. – victims of the atomic bomb of Hiroshima).
The victims of disaster in go through four stages of emotional response.
1. Denial – during the stage the victims may deny the magnitude of the
problem or have not fully registered. The victims may appear usually
unconcerned.
2. Strong Emotional Response – in the second stage, the person is
aware of the problem but regards it as overwhelming and unbearable.
Common reaction during this stage is trembling, tightening of muscles,
speaking with the difficulty, weeping heightened, sensitivity, restlessness
sadness, anger and passivity. The victim may want to retell or relieve the
disaster experience over and over.
3. Acceptance – During the third stage, the victim begins to accept the
problems caused by the disaster and makes a concentrated effect to
solve them. It is important for victims to take specific action to help
themselves and their families.
4. Recovery – The fourth stage represent a recovery from the crisis
reaction. Victims feel that they are back to normal. A sense of well-being
is restored. Victims develop the realistic memory of the experience.

DISASTER MANAGEMENT CYCLE

THE DISASTER EVENT
This refers to the real-time event of a hazard occurring and affecting the ‘elements
at risk’.
The duration of the event will depend on the type of threat, for example, ground
shaking may only occur for a few seconds during an earthquake while flooding may
take place over a longer period of time.

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There are five basic phases to a disaster management cycle (Kim &
Proctor, 2002), and each phase has specific activities associated with it.
RESPONSE
The response phase is the actual implementation of the disaster plan. The
best response plans use an incident command system, are relatively simple,
are routinely practiced, and are modified when improvements are needed.
Response activities need to be continually monitored and adjusted to the
changing situation.
Activities a hospital, healthcare system, or public health agency take
immediately during, and after a disaster or emergency occurs.
RECOVERY
Once the incident is over, the organization and staff needs to recover.
Invariably, services have been disrupted and it takes time to return to
routines. Recovery is usually easier if, during the response, some of the staff
have been assigned to maintain essential services while others were
assigned to the disaster response.
Activities undertaken by a community and its components after an
emergency or disaster to restore minimum services and move towards long-
term restoration.
 Debris Removal
 Care and Shelter
 Damage Assessments
 Funding Assistance

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EVALUATION/DEVELOPMENT
Often this phase of disaster planning and response receives the least
attention. After a disaster, employees and the community are anxious to
return to usual operations. It is essential that a formal evaluation be done to
determine what went well (what really worked) and what problems were
identified. A specific individual should be charged with the evaluation and
follow-through activities.
MITIGATION
These are steps that are taken to lessen the impact of a disaster should one
occur and can be considered as prevention and risk reduction measures.
Examples of mitigation activities include installing and maintaining backup
generator power to mitigate the effects of a power failure or cross training
staff to perform other tasks to maintain services during a staffing crisis that
is due to a weather emergency.

PREPAREDNESS/RISK ASSESSMENT
Evaluate the facility’s vulnerabilities or propensity for disasters. Issues to
consider include: weather patterns; geographic location; expectations

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related to public events and gatherings; age, condition, and location of the
facility; and industries in close proximity to the hospital (e.g., nuclear power
plant or chemical factory).

MANAGEMENT OF MASS CASUALTIES

Mass Casualty Management is a multi-sectorial coordination system based

on daily utilized procedures, managed by skilled personnel in order to
maximize the use of existing resources; provide prompt and adapted care to
the victims; ensure emergency services and hospital return to routine
operations as soon as possible.

OBJECTIVES

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 The application of triage and tagging procedures in the management
of mass casualties
 Understand the priorities in triage and tagging, and orders of
evacuation

DISASTER TRIAGE
The word triage is derived from the French word trier, which means, “to sort
out or choose.”
The Baron Dominique Jean Larrey, who was the Chief Surgeon for
Napoleon, is credited with organizing the first triage system.
“Triage is a process which places the right patient in the right place at the
right time to receive the right level of care” (Rice & Abel, 1992).
Triage is the process of prioritizing which patients are to be treated first and
is the cornerstone of good disaster management in terms of judicious use of
resources (Auf der Heide, 2000).

NEED OF THE DISASTER TRIAGE

1. Inadequate resource to meet immediate needs
2. Infrastructure limitations
3. Inadequate hazard preparation
4. Limited transport capabilities
5. Multiple agencies responding
6. Hospital Resources Overwhelmed

AIMS OF TRIAGE
1. To sort patients based on needs for immediate care
2. To recognize futility
3. Medical needs will outstrip the immediately available resources
4. Additional resources will become available given enough time.

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PRINCIPLES OF TRIAGE

The main principles of triage are as follows: –

1. Every patient should receive and triaged by appropriate skilled health-
care professionals.
2. Triage is a clinic-managerial decision and must involve collaborative
planning.
3. The triage process should not cause a delay in the delivery of effective
clinical care.

ADVANTAGES OF TRIAGE

1. Helps to bring order and organization to a chaotic scene.

2. It identifies and provides care to those who are in greatest need
3. Helps make the difficult decisions easier
4. Assure that resources are used in the most effective manner
5. May take some of the emotional burden away from those doing triage

TYPES OF TRIAGE
There are two types of triage:
1. Simple triage
2. Advanced triage

SIMPLE TRIAGE

Simple triage is used in a scene of mass casualty, in order to sort patients

into those who need critical attention and immediate transport to the
hospital and those with less serious injuries.
This step can be started before transportation becomes available.
The categorization of patients based on the severity of their injuries can be
aided with the use of printed triage tags or colored flagging.
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system
that can be performed by lightly trained lay and emergency personnel in
emergencies.

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Triage separates the injured into four groups:
 0 – The deceased who are beyond help
 1 – The injured who can be helped by immediate transportation
 2 – The injured whose transport can be delayed
 3 – Those with minor injuries, who need help less urgently

ADVANCED TRIAGE
In advanced triage, doctors may decide that some seriously injured people
should not receive advanced care because they are unlikely to survive.
Advanced care will be used on patients with less severe injuries.
Because treatment is intentionally withheld from patients with certain
injuries, advanced triage has an ethical implication.
It is used to divert scarce resources away from patients with little chance of
survival in order to increase the chances of survival of others who are more
likely to survive.

Principles of advanced triage is

 “Do the greatest good for the greatest number”
 Preservation of life takes precedence over preservation of limbs.
 Immediate threats to life: HEMORRHAGE.

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 ADVANCED TRIAGE CATEGORIES
CLASS I (EMERGENT) RED
IMMEDIATE
– Victims with serious injuries that are life threatening but has a high
probability of survival if they received immediate care.
– They require immediate surgery or other life-saving intervention, and have
first priority for surgical teams or transport to advanced facilities; they
“cannot wait” but are likely to survive with immediate treatment.
“Critical; life threatening—compromised airway, shock,
hemorrhage”
CLASS II (URGENT) YELLOW
DELAYED
– Victims who are seriously injured and whose life is not immediately
threatened; and can delay transport and treatment for 2 hours.
– Their condition is stable for the moment but requires watching by trained
persons and frequent re-triage, will need hospital care (and would receive
immediate priority care under “normal” circumstances).
“Major illness or injury;—open fracture, chest wound”
CLASS III (NON-URGENT) GREEN
MINIMAL
– “Walking wounded,” the casualty requires medical attention when all
higher priority patients have been evacuated, and may not require
monitoring.
– Patients/victims whose care and transport may be delayed 2 hours or
more.
“minor injuries; walking wounded—closed fracture, sprain, strain”
CLASS IV (EXPECTANT) BLACK EXPECTANT
They are so severely injured that they will die of their injuries, possibly in
hours or days (large-body burns, severe trauma, lethal radiation dose), or in
life-threatening medical crisis that they are unlikely to survive given the care
available (cardiac arrest, septic shock, severe head or chest wounds);
They should be taken to a holding area and given painkillers as required to
reduce suffering.
“Dead or expected to die—massive head injury, extensive full-
thickness burns”
USING RPM TO CLASSIFY PATIENTS

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 CATEGORY (COLOR) RPM INDICATORS
Critical (RED) R = Respiratory rate >30;
P = Capillary refill >2 seconds;
M = Doesn’t obey commands
Urgent (YELLOW) R <30
P <2 seconds
M = Obeys commands
Expectant: dead or dying R = not breathing
(BLACK)

ROLE OF NURSING IN DISASTERS

“Disaster preparedness, including risk assessment and multi-disciplinary

management strategies at all system levels, is critical to the delivery of
effective responses to the short, medium, and long-term health needs of a
disaster-stricken population.” (International Council of Nurses, 2006)

MAJOR ROLES OF NURSE IN DISASTERS

1. Determine magnitude of the event
2. Define health needs of the affected groups
3. Establish priorities and objectives
4. Identify actual and potential public health problems
5. Determine resources needed to respond to the needs identified
6. Collaborate with other professional disciplines, governmental and non-
governmental agencies
7. Maintain a unified chain of command
8. Communication

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DISASTER TIMELINE AND NURSING ACTION/ RSPONSIBILITIES

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