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  • 1. PATIIIICurrentand ErnergingChallenges
  • 2. Developing l{urnanPoterrtial The purpose of this chapter is to examine the concept of human potential and to present methodologies for creating an organiza- iional climate in which that human potential can develop. On completion of this chapter, the reader will be able to: 1. Define human Potential. 2. Discuss the power of education in terms of human potential 3. Describe three motivational factors influencing human be- havior. 4. Differentiate between human beings and humans becoming 5. Describe behavioral change within the context of development 6. Differentiate between leaders and followers. t. Match management practices with growth needs as defined by Maslow.)rlowhere in the world of nursing is it more possible to influence thegrowth and development of other nurses than in nursing administrationihe nursing administrator creates an environment in which professionalpractice can flourish or deteriorate. This chapter focuses on human po-iential as an important concept in nursing administration. Inner-directedindividuals who are highly self-motivated will produce the answers tothe problems of productivity and dissatisfaction within nursing staff.HUMAN POTENTIAL AND THE POWER OF EDUCATIONNurses today want to be recognized as professionals. They want to berecognized for their contributions to patient care, and they want theright to control their professional practice within the limits of the law.Unquestionably, these rights always involve maximizing human poten-tial. Human potential means all of ones potentialities: knowledge, tal-ents, capacities, creativity, wisdom, character, and genetic makeup l07
  • 3. 108 cunnpxr nNl EMERGTNG cHALLEGES The acquisition of technical skill alone does not provide the necessary tasks so creativit5base for the independent thinkin-s and action essential in todays nursingpractice. Men and women har,e a great deal of unrealized potential, and siened tahelping staff discover that potentiai can be one of the most exhilarating ministratexperiences for the nursing administrator. torr,,ard tl The identification of needs for -ero.nvth, development, and utilization and thusof potential is an important part of Maslows self-actualization. This Pritcha :eacher irconcept was introduced in Chapter 4, "The Person in the Role of NursingAdministrator." The fully functioning administrator encourages the de- iundamer :nspires, rvelopment of human potential in self, peers, and subordinates. Optimal lrocess, abiopsychosocial functioning, so carefully nurtured in patients, needs also ls also toto be nurtured in oneself and ones fellow workers. Howard McClusky (1) had a passionate belief in the power of education :ential of same basito improve the condition of peoples lives and to liberate them from the and evalumeanness of intolerance and self-interest. Lifelong learning and the ful- Nursinfillment of growth needs are indeed powerful tools in enhancing humanpotential. Lifelong learning can hclp individuals become the persons nentors. roles, nurthey are best able to become. In most people, there is a large domain periencesof unexpressed and underexpressed talent that could be developed thc countthrough educative means. quently, c McClusky (l) further theorized that failure to internalize the learner administrrole as a central feature of the self is a major restraint in the adults directionachievement of his or her potential. Studying, learning, and intellectual rvill allor,radventure must become part of ones life in both work and social en-vironments. Striving to learn about employees and matching them with educa-tional and work experiences can be one of the nursing administrators MOTIVImost stimulating and rewarding challenges. Because the power of ed- !lotivatioucation lies both in learning and in teaching abilities, the administrator tivates orneeds to be a learner as well as a teacher. Satisfaction with work and Herzbergassumption of responsibility for professional behavior flourish in an en- gories: hyvironment that fosters maximizing human potential through continued The hygielearning. 1. Comp 2. SuperCHANGING BEHAVIOR 3. RelatThe role of the nursing administrator as a teacher has been largely un- 4. Workrecognized. In fact, in their efforts to stay away from educational roles, 5. Salarmany administrators may lose sight of the fact that most education oc- 6. Relatcurs in noncredit or nonformal learning environments. Achieving ones 7. Persomaximum potential involves learning new behaviors. Many adminis- 8. Relattrators spend a great deal of time teaching others how to perform as- 9. Statusigned tasks rather than delegating the responsibility for those tasks. 10. SecurHow much better it would be to teach individuals how to approach
  • 4. DEVELOPING HUMAN POTENTIAL 109 tasks so that they can grow and develop while unleashing their own.ecessary creativity in resolving problems that contribute to the need for the as-i nursing signed tasks. Understanding the logic and rationale behind various ad-Ltial, and ministrative strategies encourages the learner to have positive feelingsilarating toward the ongoing project; as a result, the learner is less likely to resent and thus negatively influence change..ilization Pritchard (2) suggests that the individual who has been a successfulion. This teacher in nursing can also be successful in administration. The same Nursing fundamental principles apply to both areas. Administrative leadershiprs the de- inspires, encourages innovations, assists the nurse in the self-actualizingOptimal process, and promotes and facilitates excellent nursing practice. To teacheeds also is also to inspire, to encourage creative effort, and to foster the full po- tential of the individual. Both teaching and administration require the:ducation same basic principles for implementation: planning, organizing, leading, from the and evaluating.d the ful- Nursing administrators may perceive themselves as preceptors org human mentors. These roles are in essence teaching-learning roles. Within these) persons roles, nursing administrators can open new doors to the intellectual ex-: domain periences that favor creativity and productivity. Staff nurses throughouteveloped the country have become increasingly critical of administration. Fre- quently, one criticizes and belittles what one does not understand. Onee learner administrative imperative is to plan to change behavior in the desiredre adults direction while recognizing the need to maximize staff potential thattellectual will allow everyone to move forward together.;ocial en-lh educa- MOTIVATIONistratorsuer of ed- Motivation is an internal force that incites a person to action; what mo-inistrator tivates one person will not necessarily excite another. According towork and Herzbergs (3) research, rewards can be listed under two broad cate- in an en- gories: hygienes, or extrinsic factors, and motivators, or intrinsic factors.:ontinued The hygienes include: 1. Company policy and administration. 2. Supervision. 3. Relationships with supervision. 4. Work conditions. rgely un-nal rclles, 5. Salary.:ation oc- 6. Relationship with peers.ing ones 7. Personal life. adminis- 8. Relationships with subordinates.rform as- 9. Status.rse tasks. 10. Security.epproach
  • 5. 110 CURRENT AND EMERGING CH-{L LErl9The motivators include: -n a cerl act willl. Achievement. formanr2. Recognition. ,, ariable3. Work itself. is deterr merit in4. Responsibility. iion tha5. Advancement. linkage6. Growth. rhe effor Expec If managers want to develop a highly motivated staff, says Herzberg, rors. Th,they should focus on the true initiators of action: the motivators, or can beintrinsic factors. These intrinsic factors are in keeping with the human :lersona need theory of Abraham Maslow (4), which postulates that humans have considerthe need to gror.v and develop beyond basic coping needs. A satisfied s]stemsneed does not motivate. If all basic and safety needs are met, one can one cho<move on to meeting belonging needs and so on up the ladder. Self-ac- administualization needs are never fully mct, and by definition, self-actualization Decisis a self-perpetuating, ongoing, and never finished process. tivator. The work of David McClelland (5) must also be recognized as an im- as inforrportant landmark in the field of motivation. He states that, to one degree people ror another, there are three basic human needs in all individuals: overstin compete Achievement: the need to excel, to achieve in relation to a set of stan- The skil dards, to strive, to succeed erstimu Power: the need to make others behave in a way they would not have Overs behaved othcrwise projects Affiliation: the desire for friendly and close relationship changcs same tir The nursing administrator needs to rccognize which needs are dom- guilty iIinant in employees. In order to determine which needs are present, sev- Undereral approaches may be used. One tool is a questionnaire that incor- or of ri1porates questions about employee bcnefits, clinical career ladders, and fortablepromotion opportunities. Anothcr approach could be part of the annual of heavobjective-setting process. Employees could be asked to write objectives Iation brelated to goals they wanl to achicve in the coming year. Some of these ample,lobjectives should be directed toward the employees professional growth, in orderfor example, completing a B.S.N. in order to be eligible for promotion. Havir While some individuals are motivaled by the need to excrcise power, at a balothers arc motivated by the need to achieve. The nursing administrators the amcchallenge is to find avenues for these needs to be met. There is also a accomp.strong need in slaff nurses for affiliation. Some observers suggest this tools asmotivation as the major reason why many more young women then Anotfmen enler nursing. classic r Expectancy theory suggests that the strength of a tendency to action classic <
  • 6. DEVELOPING HUMAN POTENTIAL 111 in a certain way is dependent on the strength of an expectation that an act will be followed by an attractive outcome (6,7). Attractiveness, per- formance-reward linkage, and effort-performing linkage are the key variables in this approach to developing human potential. Attractiveness is determined by what one would like to have, such as a promotion or merit increase. Performance-reward Iinkage is the individuals percep- tion that certain actions will lead to a desired reward. Effort-performing linkage is the perception that a desired reward, such as a raise, is worth the effort to achieve. Expectancy theory also presupposes the importance of intrinsic fac-{erzberg, tors. The theory holds that workers attempt to complete jobs they know/ators, or can be accomplished and expend energy on those that will result inre human personal benefit. However, in the world of nursing, employees may notrans have consider many activities, such as care plans and patient classification satisfied systems, to be meaningful activities; thus, the question arises as to how, one can one chooses meaningful activities that also meet the goals of the nursing. Self-ac- administrator to provide excellent nursing care.ralization Decis theory (S) highlights the concept of competence as a strong mo- tivator. Elaborating on Herzbergs work, Deci describes intrinsic motivesas an im- as informing those activities for which there is no apparent reward. Mostne degree people will actively look for stimulation in their work. When there isals: overstimulation, the individual withdraws and seeks another area of competence. Understimulation results in less than minimal competency.:t of stan- The skillful administrator seeks an environment balanced between ov- erstimulation and understimulation.not have Overstimulation can result from the occurrence of numerous clinical projects and changes at one time. Because staff need time to incorporate changes into their functioning, three or four changes attempted at the same time may result in very little lasting change. Also, staff may feel are dom- guilty if they neglect their usual tasks for innovative endeavors.senl, sev- Understimulation can be the result of an environment of no changesrat incor- or of rigidity. At times, staff require a period of time to become com-ders, and fortable with changes, but this must not continue idenfitely. A situationre annual of heavy work loads and understaffing can also result in understimu-rbjectives lation because staff are forced to give up the challenging tasks-for ex-e of these ample, patient teaching, patient care conferences, and committee work-rl growth, in order to meet minimal patient needs.omotion. Having staff involved in setting objectives can contribute to arrivingse power, at a balanced environment. However, staff may tend to overestimateristrators the amount of work and underestimate the amount of time required to is also a accomplish objectives. Trial and elTor are sometimes important learning;ges1 this tools as a group of staff struggle to put a new clinical concept into place.nen then Another useful concept in developing human potential is found in the classic work in operant conditioning conducted by B.F. Skinner (9). Theto action classic operant conditioning process is portrayed as:
  • 7. tt2 CURRENT AND EMERGING CHALLENGES Stimulus -------) response --------) consequences -------J future response human brto stimulation of Carl R, of these iSkinners theory focuses on four variables: positive reinforcement, ex- It is thattinction, punishment, and avoidance learning. This theory provides rather thiguidelines for rewarding desirable behavior and for punishment as a career planegative reinforcer designed to stop negative behavior. The principles not simplof reinforcement theory can be used to modify behavior in a desired Contintdirection. For example, consider the case of a nursing administrator recogniticwho wants to have the staff conduct group patient teaching sessions but is an impnone of the staff has enough confidence to volunteer. In such a situation, mains intstaff could be reinforced for learning and practicing skills that would rvas almolead to conducting group sessions. an enorrn Worker motivation appears to be a key factor influencing productivity studies hrand quality of employee performance. Gordon (10) takes issue with mo- rvith adv:tivation theorists who stress the responsibility of leaders and managers vision, mto motivate followers or subordinates. Gordon maintains that people timed teshave their own motives. The responsibility of the nursing administrator pation inis to provide a motivating environment in which people can carry on tinue to Ithe work of the organization. A motivating environment is one that pro- somethinvides opportunities for personnel to (1) express and satisfy their own Develoymotives and (2) contribute to the achievement of organizational goals. a perspe( A nonmotivating environment produces disillusionment, job dissat- developnisfaction, and role conflict. Role theory is structured on the observable hood, offfact that there are prescribed relationships and activities for specified for stagnroles; for example, a traffic police officer is expected to direct traffic, (17) has cand a secretary is expected to type the bosss letters. There is little scribingagreement in our society as to the expectations for the role of a nurse. scriptionAn ambiguous role, coupled with an abundance of diverse job descrip- opmentations, compounds the problem and interferes with the maximum de- McClusklvelopment of potential. Biology Todays mobile, intelligent, aggressive, and talented nurses need not repreleaders who can help them identify personai and professional goals. They out in eineed administrators with enthusiasm, sensitivity, and creativity in pa- time is pttient care and nursing administration; administrators who understand ciety, carthe difficulties involved in simultaneously pleasing patients, physicians, for both rand administrators. The nurse leader with such qualities seeks to create mendousan environment in which professional nurses are motivated to practice full use oat their highest level (11). Many r ministral part-tim<DEVELOPMENTAL PSYCHOLOGY AND HUMANS staff. A skBECOMING a compol rience. PDevelopmental stages occur over the life span. The concept of deveioping, create aras opposed to that of aging, implies a human becoming rather than a signmenl
  • 8. DEVELOPING HUMAN POTENTIAL 1 13response human being. The essence of this distinction is captured in the words of Carl Rogers (12): "I should like to point out one final characteristic of these individuals as they strive to discover and become themselves.ment, ex- It is that the individual seems to become more content to be a process provides rather than a product." Career development is a lifelong process, andnent as a career planning programs are based on the concept of humans becoming,principles not simply being. a desired Continued learning is the cornerstone of career development, and the,inistrator recognition of staff members learning abilities and educational interestsssions but is an important part of administration. The potential for learning re- situation, mains intact over the life span (13). Until the mid-1960s, however, itrat would was almost universally assumed that adults past their twenties suffered an enormous loss of intelligence and learning ability (14). More recentoductivity studies have shown that the basic ability to learn changes little, if any,: with mo- with advancing age. Changes in physical status, reaction time, hearing, managers vision, motivation, and speed of performance affect performance onrat people timed tests (15). Retention of the ability to learn favors active partici-rinistrator pation in a climate of positive motivation in which individuals can con-r carry on tinue to pursue the enchancement of their skills and to seek to become: that pro- something better than theY are.their own Developmental theories are useful in providing the administrator with,nal goals. a perspective on adult learning capabilities. Ericksons (16) theory ofob dissat- development, although predominantly confined to the years of child-rbservable hood, offers the potential for generativity and integrity, rather than" specified for stagnation and despair, in the last two stages of life. Robert Peck:ct traffic, (17) has developed a remarkable picture of the second half of life in de-:e is little scribing middle and old age as productive years. This now famous de-rf a nurse. scription has stood the test of time, as it has been utilized by other devel-b descrip- opmental psychologists, including Bernice Neugarten and Howardimum de- McClusky. Biology may influence the determination of societal roles, but it should rses need not repress the development of human potential. Work may be carried,oals. They out in either a meaningless or meaningful way. A meaningful use ofrzity in pa- time is possible only within the context of a meaningful life. In our so-nderstand ciety, career reentry for women may still occur after the age of 40 and,rhysicians, for both men and women, career change may occur at 50. This has tre-s to create mendous implications for the nursing administrator who seeks to makeo practice lull use of a nursing resource in a creative way. Many options are available in nursing, and the creative nursing ad- ministrator takes advantage of the various combinations of full-time, part-time, or intermittent employment patterns currentlv available for staff. A skills inventory completed at the time of employment can provide a composite picture of an employees educational life and rvork expe- rience. Periodic review of utilization of skills with the employee can,eveloping, create an environment for reward and creative planning for future as-rer than a signment (18).
  • 9. 114 CURRENT AND EMERGING CHALLENGESDEVELOPING LEADERS AND FOLLOWERS provide tl the nursiAn important part of leadership is the ability to identify potential leaders. strategiesThe willingness to nurture a potential leader at the risk of developing for coachcompetition for ones own role is the mark of outstanding leadership. develop nThe nurturance of followers of institutional goals is one of the major It mustchallenges in organizations, for it is easier to set up personal friendships highly perand loyalties. Identifying potential leaders based on personal friendships lies in theis a pitfall that nursing administrators should avoid. Since friendship to life an<tends to blind one to a friends faults, it is difficult for the nursing ad- career derministrator to objectively evaluate the performance of a friend. psycholop Nurses skilled in clinical practice or education are often moved into career intadministrative positions without the benefit of administrative prepa- cess theyration. Programs designed to develop administrators require integration Kleinkrwith institutional performance improvement. To improve organizational opment Pperformance, it is necessary to develop the institution or the institutional tunites founit. The development of individual administrators is an important part interestinof the overall schcma. cludes nu Nelson and Schaefer (19) argue that the development of individual responsihadministrators and institutional development are highly interdependent direct thttasks requiring an approach that integrates the needs of both the in- self-knoltstitution and the individual. Such an approach involves the setting ofinstitutional goals by top management, followed by the development ofparticipating administrators to move toward those goals. Translated tonursing, programs designed to improve the administrative capabilityof clinical directors and head nurses do not improve the performanceof the nursing department unless they are planned to integrate with UNDERSnursing dcpartment goals. Values The nursing administrator can encourage self-development efforts by Needs Skills andestablishing, with the employee, individual performance objectives and Previous cperiodic performance evaluation. The administrators attention to his lnterperso Decision-ror her own self-development further encourages such behavior in others.A positive climate for developing leadership can emerge from rcquiringadministrators to assume the responsibility for the growth and devel-opment of their stalf and assigning individuals to administrative re- UNDERSTANIsponsibilities appropriate for their experience and interests. Thc activeinvolvement of the supervisor is balanced with the encouragement of [;; Educatior I lFrnanctalself-evaluation and personal goal setting. I Proiected The concept of supervision as a professional growth-producing process I Employmis not new, but, except in public health nursing, it is not widely practiced Iin the nursing field. The supervisory process requires that each staff FIGUREmember receive one-to-one guidance much more often than once a year and J.O.for performance evaluation. The nursing administrator sets the cxample Septembfor this process through conferencing on a regular basis with each em- Americarployee who reports directly to him or her. The conferences, of coursc, with perr
  • 10. DEVELOPING HUMAN POTENTIAL 115 provide the opportunity for exchange of information, but they also give the nursing administrator timc to review objectives, perlormance,I leaders. strategies, and problcms with cach key person. This time is also used veloping for coaching the cmployee so that he or she can gain new skills and rdership. develop new approaches to old problems. re major It must bc recognized that each individuals capacity to dcvelop is aendships highly personalized process and that the best tool for self-development endships lies in the ability to accurately assess developmental necds in relationiendship to life and carcer goals. Thorne, Fee, and Carter (20) suggest that idealrsing ad- career dcvelopment should match job requircments with the individualsd. psychological makeup, educational background, experiential skills, andrved into career interests. Figure 9.1 portrays the individual career planning pro-/e prepa- cess they propose.tegration Kleinknecht and Hefferin (21) also propose a model for career devel-rizational opment programs that can help nursing administrators identify oppor-titutional tunites for restructuring nurses work experiences to make them moretant part interesting and challenging. Figure 9.2 portrays that model, which in- cludes nursing administrator, professional nurse, and career counselorrdividual responsibilities. The program focuses on assisting nurses to develop andependent direct their or,vn careers as well as on guiding them toward attainingh the in- self-knowledge of:;etting ofpment of LIFE MANAGEMENTrslated to Mid-life transitionsapability, Management style in organization.ormance Leisure, retirement-ate with Financial management UNDERSTANDING SELF Separation, divorce, death Marriage, family, parenting Values Alcohol and drug abuse:fforts b1 Needs Selfunderstanding, interpersonal communication, and intimacytives and Skills and abilities Health Previous career historyon to his lnterpersonal style Stress Decision-making style Sexualityin others. Handicaps-equirin-erd devel-ative re- - DERSTANDING ENVIRONMENT TAKING ACTIONhe active i Career job options Self-development lntegrated Work experienceement of Educational options knowledge of Education trinancial considerations self and Additional training )rojected skill needs environment for Job enrichmentg proccss Employment opportun ties decision making Job-keeping skillspracticed -Jobseeking skillsach stallce a |eat- FIGTRE 9.1 Indrriclu:il r:.rrcl nlanninS procL-ss. (From L-1. Thorn, F.X. Fee, erampl.- :- J.O. Carter dcr.lc,p:t.:: , ,-.;,lut a:ir e apprr-rach. .1c:a-gclrettl Rcllett, S::tJnbe-r l9Sl p -19 . 1-:l :. 1 1rn.ire:srin Publrcaiions Dir ision,:ach ei::- r:i--iirinD lana=:rnren: .:,- -:. -:: ;.,. ,-,ri. lr :-:ch:. r->r11 !d. Reprinredi C r)U].:- . . . a- :1. Il!-;-I]ll!:]1,
  • 11. 116__ CURRENTAND EMERGING CHALLENGES MEETI] POTEN Nothing ,4;N I career l as burno inson (22 action / / plan / ptan / expendit / ----/z;/ manasement I structure l oRGANlzATloN / I , Mutual aclion olannins, career / counseling I ___/ INDIVIDUAL situation much m< create a trator w. statrsrl"c stress an In this / ,"..onn", examplei I needs | /- by Masl< assessment / / losophy ,/ / Manage < | ,i"ll goals of also incl r mentor IFIGURE 9.2 A dynamic career development program. (From M.K Kleinknecht, view, guand E.A. Hefferin. Assisting nurses toward professional growth: a career de- nition arvefoprnenr mcrdel. Tlrc Joumal of Nursing Adntittistration. July/August 1982, 11,p. 32. Reprinted with permission.) for devel. Personal values, interests, and goals related to life and career planning.. Endeavors and accomplishments related to life and work history. SUMMI Life and work decision-making skills Personal and professional growth needs and potentials. By takin Career concerns and objectives. (p. 34) an envir, maximiz Nursing career development programs serve a dual purpose: to help account The wormeet specific needs of the organization and the individual nurse and toprovide the potential for expanding the reservoir of talent and motivation oreticalwithin the nursing division (21). and sub< The followers of today will be the leaders of tomorrow. Setting thepace for the growth and development of the staff involves presentingan image of excitement and enthusiasm for excellence in the nursing STUDYdepartment. Technology changes daily, but the need for nurses to developand grow within a physically exhausting environment presents a major 1. Definchallenge to the nursing administrator. The nursing administrator has 2. Discuthe responsibility to provide leadership in creating a climate in whichnurses can practice at their highest level of expertise while continuing 3. Discuto develop as individual professional practitioners. The nursing admin- new tistrator alone cannot create this climate but has the knowledge and skills 4. List tlto lead the nursing division to this end and d
  • 12. DEVELOPING HUMAN POTENTIAL II7 MEETING NEEDS AND MAXIMIZING HUMAN POTENTIAL Nothing mars the maximum development of human potential as much as burnout of either the nursing administrator or staff members. Lev- inson (22) describes the special kind of exhaustion that can follow the of intense energy with few visible results. People in such "*p.rrjit.r.e angry, helpless, trapped, and depleted The experience is situations feel much more intense and devastating than ordinary stress. In seeking to create a professional practice climate, the successful nursing adminis- trator will seek to prevent burnout in self and staff by alleviating job stress and dissatisfiction in the early stages whenever possible. In this regard, Stubbs and Parker (23) have developed work setting examples u.rd -u1ugement practices to meet human needs as developed by Maslow. Their methodology translates to nursing as a caring phi-) losophy on the part of administration. It includes caring about the career gouls of staff and about how those goals mesh with the organization. It also includes caring about professional development opportunities, mentor relationships, and a creative environment that provides for re-einknecht, view, guidance, reinforcement, and rewards for work as well as recog-career de-t 1982, 11, nition and advancement. This philosophy can well serve as the guide for developing a motivating nursing environmentlanning.Lstory. SUMMARY By taking a human approach, the nursing administrator can create an environment in which the development of human potential can be maximized. In order to do this, the administrator must take intoe: to help account the dilference between human beings and humans becoming.se and to The work of Abraham Maslow and Howard Mclusky provides a the-rotivation oretical basis for the development of human potential in self, peers, and subordinates.:tting theresentinge nursing STUDY QUESTIONSo developsa major 1. Deline human potential and discuss its relationship to education.rator has in which 2. Discuss the role of the nursing administrator as teacher and learner.rntinuing 3. Discuss how achieving ones maximum potential involves learningrg admin- new behaviors.and skills 4. List the hygienes (extrinsic factors) and motivators (intrinsic factors) and discuss how they are utilized in your operating environment.
  • 13. 118 CURRENT AND EMERGING CHALLENGES5. Discuss the importance of performance-reward linkage and effort- 21 Kleinl performing linkage in expectancy theory. Be sure to include the im- growtl July/A portance of staff opinion in the performance of individual operations. 22. Levinr Discuss how to identify and develop a potential leader, with attention 1981, to a career development plan. 23. stubbr EconoREFERENCES 1 McClusky, H.Y. Education for aging: the scope of the field and perspectives for the future, in Grabowski, S.W., and Mason, W.D., eds., Edttcation for the Aging. Syracuse, N.Y.: ERIC Clearinghouse, 1974. 2. Pritchard, R.E. A philosophy of teaching applied to administration. The Jountal of Nursing Administration, September 1975, 5(7),3840. 3. Herzberg, F., Mausner, 8., and Snyderman, B.The Motivation to Work. New York: Wiley, 1959. 4. Maslow, A.H.Toward aPsychology of Being. New York: Van Nostrand,1962. 5. McClelland David. The Achieving Society. New York: Van Nostrand, 196l . 6. Vroom, Y.H.Work and Motivatiort. New York: Wiley, 1964. 7. Robbins, S. P. The Administratire Process,2d ed., Englewood Cliffs, N.J.: Prentice-Hall, 1980. 8. Deci, E.L. Intrinsic Motivation New York: Plenum, 1975. 9. Skinner, B.F. Science and Human Behavior. New York: Macmillan, 1953.10. Gordon, G.K. Motivating staff: a look at assumptions . The Journal of Nursing Adminis tration, Novemb er 1982, I 2(l 1), 27 -28.1 1. Nyberg, J. The role of the nursing administrator in practice. Nursing Admin- istration Quarteily, Summer 1982, 6(4), 67*73.12. Rogers, C. Freedom to Leant. Columbus, Ohio: Charles E. Merrill, 1969.13. Arenberg, D.L. and Robertson, E.A. The older individual as a learner, in Grabowski, S.M., and Mason, W.D., eds., Education for the Agizg. Syracuse, N.Y.: ERIC Clearinghouse, 197 4.14. Thorndike, E.L., Bergman, E.O., Tilton, J.W., and Woodward, E. Aduh Learning. New York: Macmillan, 1928.15. Zahn, I.C. Differences between adults and youth affecting learning. Adult Education, Winter 1967 , 17, 67-77 .16. Erikson, E. Childhood and Society. New York: Norton, 1963.17. Peck, R.C. Psychological developments in the second half of life," in Newgarten, 8.L., ed., Middle Age and Aging. Chicago: University of Chicago Press,1968.18. Smith, M.M. Career development in nursing: an individual and professional responsibility. Nursing Outlook, February 1982, 30(2), 128-131.19. Nelson, G.M. and Schaefer, M.J. An integrated approach to developing ad- ministrators and organizations. Jounnl of Nursing Administratiorz, Febr"uary 1980, 1o(2),3742.20. Thorn, LM., Fee, F.X., and Carter, J.A. Career development: a collaborative approach. Management Review, September 1982, 7 1 (9), 27 -28 , 28-41 .
  • 14. DEVELOPING HUMAN POTENTIAL II9d effort- 21 Kleinknecht, M.K. and Hefferin, E.A. Assisting nurses toward professional growth: a career development model. The Joumal of Nursing Administratiort,: the im- July/August 1982, l2(7 and 8), 30 36.:ations. 22. Levinson, H. When executives burn out. HarvardBusiness Review, May/Junerttention r98t, s9(3),73-81. 23. Stubbs, I.R. and Parker, E.R. Motivating for management effectiveness.legal Economics, September/October 1979, 5(5), 38-40.spectiveson for the.tion. The/orft. Newnd,1962.rd,1961.iffs, N.J.:n,1953.f NursingqAdmin-,1969.:arner, inSyracuse,, E. Adulting. AdtltI life," inrf Chicag<rofessionaloping ad- February.aborative-41.
  • 15. budgetin10 understa mate. The pr fosteredManagtng Firscal demonst an essen involved Dollan nancial c to budgeAgnes M. Buback and Nancy V. Moran sional se nursing r charges. tivities o to quant The purpose of this chapter is to present fiscal management con- It is clr cepts in relationship to nursing administration. Emphasis is on and poli health care reimbursement issues, selected principles of managing into one fiscal resources, tools of fiscal management, and types of budget ment ski techniques. On completion of this chapter, the reader will be able delivery to: financial l. Describe selected reimbursement issues and relate them to isting rer nursing administration. tinued dr 2. Describe the concept of financial management 3. Identify the key concepts of accounting and budgeting. 4. Differentiate types of budgets and selected budgeting tech- REIMB niques. 5. Discuss the pervasiveness of the budget as a management tool The curr and its impact on clinical nursing practices. care envi 6. Relate the budgeting process to the nursing process. in manal health cr strategieWhy should nursing service administrators become involved in budg-eting and financial mangement? In the recent past, these functions werewillingly and gladly relegated to financial officers or hospital admin- Growthistrators who prepared, monitored, and evaluated the nursing budget In 1963,and assumed total responsibility for the broad area of financial man- tional pragement. increase< Fortunately, nursing service adminstrators saw the error of having economynonnursing personnel assume critical financial functions. Nursing itures wrbudgets usually make up the largest proportion of a hospitals operating creased lbudget. Thus, because money is power, it has become incumbent upon (1). Mostthe nurse adminstrator to acquire a fairly sophisticated level of skill in icaid-Me120
  • 16. ,1,ANAC]Nq-ET$Q4LSEEoIJB9ES UL budgeting and financial management, as well as an awareness and understanding of the evcr-changing health care reimbursement cli- mate. The precarious nature of the health care reimbursement climate has fostered increasing fiscal conservatism in most hospitals. As a result, demonstrating the value of nursing services in terms of cost has become an essential activity in which all nursing adminstrators must become involved. Dollars do influence clinical nursing practice. During the current fi- nancial crisis facing many hospitals, nursing budgets remain vulnerable to budget cuts. Nursing services commonly are not isolated as profes- sional services, and neither is reimbursement for them. Charges for nursing care remain relatively hidden in room rates or other grouped charges. In addition, costing out and justifying nursing services are ac- tivities only recently being undertaken by nursing leaders in an effort to quantify and qualify nursing.nt con- It is clear that through a variety of environmental, social, economic,sison and political changes, the role of the nurse administrator is evolvingnaging into one that requires a high level of budgeting and financial manage-budget ment skill. Such skill, if properly applied, may ultimately enhance thebe able delivery of nursing care through judicious maintenance of human and financial resources, vigilant monitoring to most effectively utilize ex-hem to isting resources, and aggressive pursuit of resources to ensure the con- tinued development of clinical nursing practice.F5g tech- REIMBURSEMENT ISSUES:nt tool The current reimbursement climate has a profound effect on the health care environment. Therefore, it is important for nursing adminstrators, in managing nursing services, to be knowledgeable about the history of health care expenditures and reimbursement trends and to develop strategies for coping with the financial uncertainties of the future. in budg-ions werell admin- Growth of Health Care Expendituresrg budget In 1963, health care expenditures made up 5.6 percent of the gross na-cial man- tional product (GNP). Between 1965 and 1973, health care expenditures increased at an annual rate of l0 percent, while the remainder of theof having economy grew at a rate of 6 to 7 percent. In1979, health care expend- Nursing itures were $212.2 billion, or 9 percent of the GNP. This proportion in-cperating creased to 10.5 percent of the GNP in 1982, or a total of $322.4 billion)ent upon (1). Most of this growth is attributable to the impact of the 1966 Med-of skill in icaid-Medicare legislation.
  • 17. 122 CURRENT AND EMERGING CHALLENGES is the aclRetrospective Reimbursement up to wi1Retrospective, cost-based, reimbursement was the methodology em- Clearlyployed by most third-party payers prior to 1983. After services were experiencprovided, hospitals r.rere paid on the basis of expenses incurred. Clearly, unprofitithis system did little to provide inccntives for controlling unnecessary control scosts. Due to the significance of health care cost increases, governmental What zregulation became the strategy for cost control in the 1970s. enue los: Public Law 92-603 was enacte d in 197 3 in an attempt by the govern- ficiency,ment to impose regulations on Medicare providers. This legislation in- strategycluded institutional budget and financial planning requirements and insuranctmechanisms for accountability. desirable activitie:Prospective Reimbursement ImplicaThe current approach to reimbursement is the prospective approach.That is, hospitals are reimbursed a flat, illness-specific amount deter- Althougtmined before services are rendered. Clearly, this method offers incentives averageto avoid unnecessary services and extended hospital stays. this reas The concept of prospective reimbursement was introduced into the tificatiorMedicare program via the Tax Equity and Fiscal Responsibility Act of many nu1982 (TEFRA). This act may be the most significant piece of legislation ultimateaffecting health care to date. It was expected to generate a savings of quantify92.6 billion between 1984 and 1987 through a complex set of formulas One prbased on diagnosis-related groups, or DRGs (2). acuity, r.r care cal( nursingDiagnosis-Related Groups These nt identifyResearchers at Yale University have developed 467 DRGs, 356 of which This liare to be used to determine a hospitals case-mix adjustment. These as it is tlgroups are based on the assumption that patients can be homogeneously the reimgrouped into various clinical categories that require similar use of re- their kn<sources. Considerations in the classification process include principle order todiagnosis or procedure, presence or absence of surgical procedures, age Severeof the patient, and presence and complexity of complications or co- from themorbidities. maintair The DRG system works as follows. After assignment to DRG categories, Since hea case-weighted cost per Medicare discharge is calculated to determine continutthe maximum amount of Medicare reimbursement. Hospital target rates nurse w(are then calculated and increased by an inflation factor. If the hospitals advocaticost per case exceeds its designated target rate, Medicare pays the target be accorrate. Some percentage of the excess cost is reimbursed only if the case sional nris approved as an outlier, but the actual cost is not recovered. Nursir However, an incentive is built into this program if the hospitals actual pro[essi<cost per case is below its target rate. In this event, Medicare payment
  • 18. MANAGING FISCAL RESOURCES 123 is the actual cost per case plus 50 percent of the variance fiom the target, up to within 5 percent ol the target rate.ogy em- Clearly, the possibility exists undcr this system that hospitals may)es were cxperience substantial losses of revenue for a variety of reasons, includingClearly, unprolitable case mix, inefficiency of operations, and poor financialLQCQSSbIJ control systems.rnmental What are the strategies that hospitals may employ to minimize rev- enue losses? One is to offset thc losses through greater operational ef-3 govern- ficiency, for examplc, through staffing or supply reductions. Anotherlation in- strategy is to attcmpt to shift rcvenue losses to other payers, includingents and insurance carriers and private pay (self-responsible) patients. Other, less desirable approaches include obtaining revenue from nonpatient care activities and reducing the quality and accessibility of services (3). Implications for Nursing Servicespproach..nt deter- Although nursing services are included in the calculation of a hospitalsncentives average target cost, they do not receive separate reimbursement. For this reason, hospital administralors are beginning to pressure for jus- into the tification of nursing services. This is not enlirely unwelcome news toity Act of many nursing service administrators who believe it is important and:gislation ultimately politically helpful to be able to clearly and precisely identify,avings of quantify, and justify nursing activities.formulas One proposed method of justifying nursing services is based on patient acuity, which is related to DRG categories. Twenty-three major nursing care categories have been developed and subdivided into 356 general nursing care stralegies, which correlate with the DRG classifications. These nursing care strategies includc detailed nursing care plans thaiof which identify both the direct and indirect care needs of the patient (4).rt.These This linkage with the DRG process is an important one for nursing, as it is the first major rational eff<-rrt to correlate nursing services with3eneously:se of re- the reimbursement system. Nursing service adminstrators must increaseprinciple their knowledge and application of this new reimbursement system inures, age order to effectively plan and managc nursing services.ns or co- Several other important consequences for nursing services will result from the change in reimbursement systems. Hospitals will develop andategories, maintain a strong focus on efficiency of services and cost containment.etermine Since health care is a highly labor-intensive industry, nurse staffing will:get rates continue to be pressured through, demands for increased individualrospitals nurse work load and efficiency of performance, and perhaps a movementhe target advocating the use of less expcnsive labor. Such cost containment maythe case be accomplished at the expense of decreasing the proportion of profes- sional nurses (5).ls actual Nursing service administrators have a critical role in providing strongpayment professional leadership and increased professional cohesion in idcnti-
  • 19. r32 CURRENT AND EMERGING CHALLENGES Variable costs, on the other hand, fluctuate in some manner with ac- comple;tivity levels. For example, the number of disposable supplies used-and trators.therefore the expense related to those supplies-will probably rise or the futufall as surgical patient days increase or decrease. If they vary to the it difficrsame degrei as volume, variable costs may be referred to as proportional servicescosts. Some variable costs only partially vary with changes in activitylevels. Payroll expenses, for instance, may decrease when patient days Zero-Brfall but may not do so in the same proportion or percentage An obvious advantage of the flexible budgeting technique is that it is The zerrmore sensitive to how expenses vary with volume changes. More ap- Presiderparent opportunities may be provided for controlling costs as more is to budgtno*n utbttt how costs will fluctuate as activity levels change. amount The behavior of varying costs may, however, not be easy to identify charactrwithout committing considerable time for study. Managers need to have rebuildia somewhat deeper knowledge of finances in order to effectively par- Everyticipate in and benefit from a variable budgeting system. The time re- each buquiied for budget development may also be considerably longer than this goa that required by other budget techniques. at least develop, tional dtPlanned Programmed Budgeting System benefit rDuring the 1960s, Robert McNamara introduced the Planned Pro- Sincegrammed Budgeting System (PPBS) in the Department of Defense. This est operiystem consisis of three components: planning, programming, and to "buybudgeting. First, a plan that includes multiyear objectives and alter- processnatiie methods of achieving the objectives is defined. Substantive, or the flonrlong-range, objectives as well as fiscal objectives are included, giving to forcerise-to -,rttiy"ur fiscal projections. A program that includes methods developfor achievingthe objectives is outlined. Activities necessary to yield the The trattainment of tn" specific objectives or outputs and the costs associated extensivwith producing the desired results are then compiled Finally, financial developfo.ecasts and a process to facilitate administrative control of the entire plementprogram are applied. ing to p Resources are generally allocated on the basis of the defined programand the associated services, supplies, and so on that are required tomeet the objectives or output. Such requirements may cut across tra- RELATditional divisional lines but be assigned to a single administrator or PROCIdirector. An example of a hospital setting in which a PPBS might beutilized is the emeigency room service. Specific objectives might be de- Budgetiveloped, activities necessary to meet the objectives delineated, and re- it is inte,o,r..", assigned from multiple departments to accomplish the objec- framew<tives. Administrative responsibility would then be under the control of erally, athe emergency room service director. ducing t In geneial, FfeS -uy facilitate price establishment for services, out- that areput, Ir products. Moreover, it facilitates the organizational linking of examinzresources to outcomes, products, or services. However, PPBS involves the focu
  • 20. MANAGING FISCAL RESOURCES 131tivity belo insure o c o o Uthe cashnization.lhe least Volume (number of services) FIGURE 10.3 Fixed budget.the mostr balance amount are established and are not altered throughout the budget period) predict regardless of whether changes in volume (number of services rendered);ash bal- occur (see Figure 10.3).mine the From the brief description above, it is readily apparent that this ap-fore, this proach is fairly straightforward to prepare and manage. It is easilyensuring understood by most managers regardless of their level of financial so- phistication, and it is highly adaptable to accounting systems. Variancesy budget can be compared to a constant. Perhaps the greatest potential advantage budgets, of the fixed budget in our current reimbursement climate is that thethe other technique is in harmony with the intent of allocating a fixed amount of resources (dollars). The less desirable consequences of the fixed budget include the fact that it is not or cannot easily be adjusted for actual changes in activity levels. It is further difficult to analyze variances caused by changes in volume or price if actual activity levels vary.:chniquese become;, such as Flexible Budgetingny event, The flexible, or variable budget, was characteristic of the 1970s. It hasrinciples been described as a series of fixed budgets based on varying forecastsand cons or activity levels. Various cost expenses are identified according to how they behave in relation to volume. Mechanisms exist within the flexiblecribed in budget approach to adjust forecasts and actual budget during the fiscal:ide with period on the basis of changes or varying activity levels and the asso-,, a single ciated costs. Although most health care institutions do not fully imple-lescribed ment this technique, most are concerned with identifying how costs vary with volume changes. The first cost category usually identified during the flexible budgeting process is fixed costs, which are costs of time. These costs accumulate over the fiscal period irrespective of volume or output. Examples of suchand still costs include depreciation, insurance premiums, and the like. They occurbudgets. regardless of whether patient days, acuity, or other work load indices-time es- increase or decrease.:d) dollar
  • 21. t3a CURRENT AND EMERGING CHALLENGES It is important that the statistical forecasting of patient activity becarefully considered in development of the commodity budget to insureaccuracy of the planning function. o q oCash Budget o UThe final budget component, as illustrated in Figure 10.2, is the cashbudget, which delineates the cash flow in and out of the organization.It is important to the financial health of any business that the leastcostly method of financing cash needs be determined and that the mostadvantageous investment opportunities for any temporary cash balancesurplus be identified (6). amounl A properly prepared cash budget enables management to (1) predict regardlthe timing and amount of future cash flows, net cash flows, cash bal- occur (rances, and cash needs and surplus and (2) systematically examine the Fromcost implications of various cash management decisions. Therefore, this proachtool assists in both protecting a hospitals cash position and ensuring underslthat it invests its assets appropriately. phisticz It is important to note that the cash budget is not a primary budget can be ,in and of itself. It is derived from the operating and capital budgets, of the Inot from fundamental operating forecasts and decisions, as are the other techniqmaster budget components. resourc The I rhat ir iTYPES OF BUDGETING APPROACHES levels. l volumeIn developing a budget, an enterprise may utilize a variety of techniquesor approaches. Some of these, such as zero-based budgeting, have becomefamiliar through frequent use in the news media, while others, such as Flexiblvolume-adjusted budgeting, are not quite so widely known. In any event, The flerit is helpful for the nursing administrator to know the basic principles been drunderlying the major techniques as well as some of the pros and cons or acti,associated with each. they be In this section, several budgeting approaches are briefly described in budgetrather pure form. Thus, the descriptions may or may not coincide with periodthe realities of budgeting in any given institution. That is to say, a single ciated <corporate entity may use variations or combinations of the described ment tttechniques in order to meet its purposes. with vc The fFixed Budgeting process over thtFixed budgeting is often viewed as the traditional approach and still costs inseems to be the most common technique utilized for nursing budgets. regardlIn general, a fixed budget is developed based on a single, one-time es- increasrtimate of work load or activity. Expenditures for a specific (fixed) dollar
  • 22. MANAGING FISCAL RESOURCES t29udget, a Capital Budgetal struc-for a re- The capital budget identifies expenditures on assets whose returns areLzations expected to extend beyond one year (6). Definitions of capital equipmentoughout vary among institutions but may typically be defined as major movablepolicies, equipment items that have a unit cost greater than or equal to $500 andrt be ac- a life expectancy of two or more years. Nursing administrators typicallynization participate in the development of this budget by assessing and sub-ssful. Fi- mitting patient care unit equipment needs. Capital construction budget:dgeable items are costs related to the acquisition and maintenance of the physicalnitoring, plant. Although nursing administration involvement is seldom sought in development of the capital budget, the benefits of participation may be well worth the administrators efforts of seeking participation.umerous Operating Budgetnot have The operating budget is a plan of revenue and expenditures geared to the cash a certain level of services to be rendered for a particular period of time.y for the In most institutions, the operating budget consists of two distinct com-mponent ponents: the revenue budget and the expense budget. The revenue budgetre capital includes revenue and statistical projections, while the expense budgete admin- encompasses payroll and commodity elements.nent and The revenue budget defines the plan that quantifies future incomethe level based on statistical forecasts of activity. This linkage of dollars to patienthe devel- activity indicators is an important area for nursing involvement. Pre-istrators, dicted levels of patient activity directly influence the plans for nursea typical staffing reflected in the payroll budget. Expense budgets incorporate all institutional expenditures, most no- tably payroll and commodity components. The payroll budget identifies all anticipated payroll expenditures for the fiscal year by department or other specific grouping. It includes the following elements: (1) regular salaries, indicated by appointment hours as well as dollars; (2) special salary items (e.g., overtime pay, temporary and agency salaries, holiday pay, shift differential, on-call pay); (3) fringe benefits, (e.g., health in- surance premiums, retirement plans); and(4) miscellaneous payroll ex- penses such as prerequisites and tuition refund payments. The payroll budget tends to occupy more of the nursing administrators time in planning, developing, monitoring, and evaluating than do the other budgets. The commodity budget identifies all nonpayroll expenditures that do not meet the institutions definition of capital equipment. It may include the following items: postage, telephone and telegraph services, travel epenses, equipment depreciation charges, repairs and maintenance, general and office supplies. medical and surgical supplies, and phar- maceutical supplies.
  • 23. L23 CURRENT AND EMERGING CHALLENGES In order to develop and execute a meaningful and relevant budget, aset of organizational prerequisites must exist. The organizational struc- Capitalture of the institution must be effective and stable. Provisions for a re- The ca1sponsible accounting system must be operational. The organizations expectegoals and objectives should be well-defined and disseminated throughout vary anthe organization to maintain a constant focus on the mission, policies, equiprrplans, programs, anci priorities. Adequate statistical data must be ac- a life ercumulated and distributed to appropriate persons in the organization partici,for the financial control and evaluation functions to be successful. Fi- mittingnally, the organization must develop a cadre of fiscally knowledgeable items atmanagers who are able to contribute to the development, monitoring, plant. Iand evaluation of the financial plans. in deve be wellTypes of BudgetsThe master budget of an organization may be composed of numerous Operatitbudget subsets. Nursing service administrators typically do not havesignificant involvement in all budget components-for example, the cash The ope a certaibudget-but do have substantial responsibility and authority for thedevelopment and monitoring of others, such as the payroll component In most ponentsof the operating budget. Still other budget subsets, such as the capital includerbudget, may require the nursing administrators input, but the admin-istrator may have no authority or responsibility for development and encompcontrol. Institutional policies and practices normally dictate the level The r based orof nursing administration participation; however, in view of the devel-opment of substantive financial skills by many nursing administrators, activitythese practices are being challenged. Figure 10.2 illustrates a typical dicted I staffingschema of master budget components. Exper tably pa all anti< or other salaries salary il pay, shi CAPITAL BUDGET CASH BUDGET su.rance Capital equrpment Receipts penses s Capital construction Disbursements budget Net cash plannin budgets OPERATING BUDGET The cr Payroll not mee Commodity (supply) the follr Revenue Statistical expense general FIGURE 10.2 Master budget model. maceuti
  • 24. UANA_GM.G_II$E4! 3E!A!3cE_s- _- ) ?7 unit for which costs can be determined Cost center. organizationalfor the Variable cosl: expense that changes in relation to volume (output) changes (e.g., surgical supplies)rctivity- Fixed cost. expense that is a function of time and is not related to changes in volume (e.g., equipment depreciation)e entity Direct cosl: expense that can be traced specifically to a given cost ob- jective (e.g., salaries)an item Indirect cost: an expense that cannot be related to a cost objective (e.g., equipment depreciation)vo sides Full-time equfualent (FTE): unit of staffing measurement related to time worked by a full-time (40-hour-per-week) employee in a period of oneding of year: period Fiscal year: the 12-month budget year designated by an institution; may or may not coincide with the calendar year.income, Variance: difference, expressed in dollars or percentage, betweenIe same budgeted amount and actual expense Profit center: organizational unit for which costs can be determined and revenue producedounting Accounts receivable: funds owed to a provider, usually for patient care well as services renderede, of the Accounts payable: frnds owed to other institutions, usually for suppliesI frame-ill begintasks of THE CONCEPT OF BUDGETINGlso pro-rospital A budget may be viewed as a descriptive plan as well as a process. As:e in to- a plan, a budget may be (1) a numerical depiction of the activities of the institution derived from written objectives and the behaviors needed to achieve the objectives, (2) a financial description of department ob- jectives and activities, and (3) a financial plan serving an as estimate of and control over operations to occur in the future. As a process, aI have a budget may be (1) the process of allocating limited resources to unlimitedof fiscal demands and (2) the process of relating expenditures to revenues to ser-rent ac- vices rendered and then evaluated.ound or Viewing a budget as both a plan and a process suggests the followingms may set of objectives for a budget in an institution:r sectioninitions To provide a quantitative expression of policies, plans, programs, and prioritiesent and To provide a mechanism of evaluating financial performance withamiliar: policies, plans, and programs To provide a useful tool for the control of costsLs actual To create and reinforce cost awareness throughout the organization
  • 25. 126 CURRENT AND EMERGING CHALLENGES Cost t Six basic accounting principles comprise useful information for thenursing service adminstrator: Varia changes1. Entity concept: the hospital (or any business) is viewed as an activity- Fi-x.ed driven entity capable of taking economic actions. changes2. Transactions concept: all transactions that have an effect on the entity Direct must be reflected in accounting reports and records. jective (3. Cost valuation concept: the most useful basis of valuation of an item Indire is the price paid for the item. (e.g., eq4. Double entry concept: accounting records should reflect the two sides Full-ti of every transaction (i.e., changes in assets and liabilities). worked5. Accrual concept: the accounting system requires the recording of year revenue when realized and the recording of expenses in the period Fiscal in which they contribute to operations. may or6. Matching concept: to accurately present and determine net income, Variat revenue and expense items must be brought together in the same budgete accounting period. (6) Profit and revr This text provides only an introduction to the practice of accounting Accouto differentiate it from the concept of financial managment as well as servicesto illustrate what is probably the most notable tool, or technique, of the Accou;financial management process. Mastery of the basic conceptual frame-work and definitions of financial management and accounting will beginto prepare the nursing service adminstrator for the herculean tasks of THE C(forecasting and preparing the nursing service budgets. It will also pro-vide him or her with the necessary broad view of the world of hospital A budgefinances within which the effective nurse manager must practice in to- a plan, :days health care environment. the insti to achieFundamental Fiscal Concepts and Definitions jectives of and cAs previously indicated, contemporary nursing managers must have a budget nsolid foundation in the fundamental concepts and definitions of fiscal demandrterms in order to effectively participate in financial management ac- vices rertivities. For individuals who have no finance or business background or Viewirskills, it is important to note that the definitions of many terms may set of obvary according to the institutional setting. It is the intent of this sectionto provide an overview of the most common concepts and definitions To probefore proceeding to develop the concept of budgeting. priorit There are numerous terms related to financial management and . To probudgeting with which the nursing administrator must become familiar; policie To pro Annualize: to project yearly data based on less than 12 months actual To creiinformation
  • 26. )tive ap- l. Planningiccess or External environment Organizational environmentd future l4arketing f--C.rd-_l t cr,""t;-l t P*p*=_l f-t.rr-l A. Assessing the l-R"ilgi*-l tfip"ifti-l f-Filf.t-l [-uffil I labor of I environment |lect*"rrgi*i I l-undrng I I Pnlici.s ll I r *::;"-:;---1Fhfid] I Protessronar I r-*,*_l fP..;d,,"n I structure Irent, the t - R"il-l tlr.@ I--P"rrti;l,ial man-both the;, imple- R;;;J Goals and objectives IP"ttC---_l I I tlr.--;r lTasksandl l-l I;sociated B. Programming t fi"".---_l I I ll vateriats ll lffil activrtresLs chang-adminis- t Fr.r;"d;rbilty I L__.1possible.rncial of-rtive andhose em- f;,-,-;,1 r-tl [ffi:rl.-l t*-ll order to C. Budgetine I I l.".no,oe"tl lc,pitu,ouogetl lrristrators I fEp"t1] I I I I I I ll ll llaatancesneetll:ial man- llr"a;rl; various ll. lmplementingtems. Al- Working capital Noncurrentassets,liabilities Residualequitiesrethodol- --..l nec"i".bb.l f-c"-t-d, I tr*;t."tl fs.--rt"ro",,lunting to Fil;bl f- Bril"!"s.l I caeitat I financial [- "*a,",* iJSH::L I Liabilities I t-Gr-l fApp"phtill [-L.i-, I TEqrD."rt I l-c""6--l t c""t.*G--l I-otn*--_llhe art ofeting, in lll. Controllingystem, or General controls Report characteristicsrment the R"p*til e.*trok_l fragementand prac- reffitn."ntl T r.*r.t* I Type of reports F;*,__lt I h.f",".";;l svstem I External I Policiesancl ll-l I procedures lll Accountinc ll f;il.un."m"dtb;_l___--> l-o*"""rtb"-l ll t_l oPeationat ll T- op""d;l Kaluzny,.t Services. r-l ll t-l Other ll fotn",---l:mission.)
  • 27. 124 CURRENT AND EMERGING CHALLENGESfying, defining, and evaluating standards of nursing care. Effective ap- l. Planningplication of the leadership function will certainly affect the success orfailure of nursing services to thrive during both the current and futuretrends in reimbursement. A. Assessinl environmFINANCIAL MANAGEMENTArmed with fundamental knowledge of health care reimbursement, thenursing administrator is ready to consider the concept of financial man-agement. In a broad sense, financial management encompasses both theacquisition and the utilization of funds and includes planning, imple-menting, and controlling functions (see Figure 10.1). Historically, the arena of financial management has been associated B. Programrwith the complex world of accountants. This traditional view is chang-ing, however, as it has become necessary for nursing service adminis-trators to provide quality services in the most efficient ways possible.This is not to minimize or negate the roles of a hospitals financial of-ficers, but, rather, to highlight and advocate a strong consultative andcollegial relationship between nursing administrators and those em-ployed in financial administration within the organization. In order to C. Budgemaximize the effectiveness of these relationships, nursing administratorsmust be conversant with the basic concepts and tools of financial man-agement. A variety of financial management tools abound, including various ll. lmplemerquantitative methodologies and accounting and reporting systems. Al-though it is beyond the scope of this chapter to define these methodol-ogies, it is important to delineate a working definition of accounting tostimulate further study and to avoid confusing accounting with financial Obtairmanagement. and u resoutBasic Accounting PrinciplesBerman and Weeks (6) define the practice of accounting as "the art ofcollecting, summarizing, analyzing, reporting, and interpreting, in lll. Controllinmonetary terms, information about the enterprise." It is the system, ortool, that provides managers with the data necessary to implement thedecision process called financial management. Financial managementhas a broad operational scope, of which accounting principles and prac-tices are but one informational piece.FIGURE 10.1 Over-view of financial management functions. (From A.D. Kaluzny,D.M. Werner, D.G. Warren, and W.N. Zuman, Management of Health Services.Englewood Cliffs, N.J.:, Prentice-Hall,@ 1982,p.291. Reprinted with permission.)
  • 28. MANAGING FISCAL RESOURCES 133vith ac- complex calculations and requires sophisticated input from adminis-d-and trators. It may involve multiyear projections and extend further intorise or the future than is reasonable to predict. Such a system may also make to the it difficult to measure performance against outcomes of patient care orrrtional se rv i ces.activitynt days Zero-Based Budgetinghat it is The zero-based budgeting (ZBB) technique was popularized by formerlore ap- President Carter when he was governor of Georgia. The phrase appliesmore is to budgets in which amounts of services are identified for incremental amounts of money, in increments above zero. The technique is furtheridentify characterized by a periodic reevaluation of all programs and a required to have rebuilding from base.ely par- Every department is required to justify and defend its entire budgettime re- each budget period, as if its activities were entirely new. To accomplish;er than this goal, decision packages containing a description, evaluation, and at least two levels of activity effort to attain the proposed objectives are developed. The decision packages are then rank-ordered at organiza- tional decision points advancing up the hierarchy based either on a cost- benefit analysis or some alternative decision process.red Pro- Since decision packages should theoretically be developed at the low-rse. This est operational level capable of producing them, the ZBB process servesng, and to "buy" the decentralized manager into the planning and budgetingrd alter- process of the organization. It further tends to increase commitment ofetive, or the front line manager to outcomes of the approved packages. ZBB helpsl, giving to force a focus on planning and ensure close integration with budgetmethods development.gield the The technique requires that managers have appropriate and fairlysociated extensive information about the organization and its goals in order toinancial develop good decision packages. It frequently requires a long-term im-re entire plementation period, well-defined fiscal procedures, and in-depth train- ing to prepare effective first-level managers to participate.programluired toross tra- RELATIONSHIP OF BUDGETING TO THE NURSINGlrator or PROCESSnight beht be de- Budgeting may be viewed as both a plan and a process. As a process,, and re- it is interesting to integrate its components with a commonly recognizedre objec- framework: the nursing process. Both processes may be defined gen-ontrol of erally, according to Webster, as "a series of actions or operations con- ducing to an end." Both are composed of discrete and identifiable stepsices, out- that are repeated in a continuing cycle through a feedback loop. Uponinking of examination, many similarities exist between the processes, although involves the focus of the nursing process is the individual patient, and the focus
  • 29. I34 CURRENT AND EMERGING CHALLENGES TABLE I Internal Internal I Revenuer Expenset FIGURE 10.4 The nursing process. Capital Personneof the budgeting process is the aggregate plan of resources and programsdesigned ultimately to benefit all patients. In the Marriner (7) defines the nursing process simply as "the application requiresof scientific problem solving to nursing care." It is a continuing cycle an indivof the components of assessment, planning, implementation, and eval- gardinguation, as shown in Figure 10.4. Each of these components may also be futurserve to illustrate the budgeting process. The components are examined apparen Forecihere individually for comparative purposes. clearly, precise.Assessment prehensIn the nursing process, assessment is performed by various means of accurat( Assessdata collection in an effort to isolate and define an individual patientsproblems. Based on data collection, a statement of the patients problem is also c sets of e:is made; this statement is called a nursing diagnosis. Data collection techniques may include observation (e.g., physical as- budget beyondsessment), interviewing (e.g., health history), and review of current andpast medical and nursing documents (e.g., medical records, nursing amples providenotes, Kardex). The end step of the assessment phase yields a conciseand precise problem statement to bring to the planning phase environ portant Altho, sessingTABLE IO.I casts erExternal Considerations in Budget Forecasting curate IExtental Conditions Examples regardirPolitical Medicare legislation prepara Political party philosophies regarding health care marketSocial Population (birth rate, growth of elderly patient population) istratorEconomic Unemployment rates adminirTechnological Equipment innovations (CT scanner) Pharmaceutical product advancement (polio vaccine, antibiotics PlanniMarket conditions Demand for hospital beds, outpatient services Actions of health care competitors In the r ends w
  • 30. MANAGING FISCAL RESOURCES I35 TABLE IO.2 Internal Considerations in Budget Forecastingl Internal Conditions Revenues Examples Volume of services x income Charitable contributions Expenses Fixed (building overhead) Variable (disposable supplies) Capital Prices and interest rates Personnel Quantity and quality of human resourcesrograms In the budgeting process, assessment is known as forecasting. It toorlication requires collection of data from many sources in an effort, not to isolateng cycle an individual patients problem, but to isolate a set of assumptions re-nd eval- garding the future. How far into the future? Budget forecasting shouldray also be futuristic enough to visualize the attainment of the commitments(amined apparent in current budget decisions. Forecasting may seem to be an exercise in reading a crystal ball, and, clearly, many intermediate and long-term forecasts cannot be absolutely precise. However, if properly performed with consideration for a com- prehensive set of elements, short-term forecasting should be relativelyneans of accurate.ratients Assessment, or forecasting, is a crucial part of the budget process butproblem is also one of the most complex steps. Consideration must be given to sets of external as well as internal conditions. External conditions requiresical as- budget planners to examine and adapt to the changing environmentrent and beyond the hospitals walls. Table 10.1 illustrates some common ex-nursing amples to consider (8). Internal considerations in budget forecasting concise provide the organization with a means of reacting in concert with the environment. Table 10.2 displays a set of internal considerations im- portant to the budget forecasting phase of the process (9). Although the nursing administrator is not intimately involved in as- sessing all external and internal conditions, knowledge about such fore- casts enhances the relevance of the nursing budget. For example, ac- curate knowledge about technological conditions aids in predictions regarding patient acuity, which is a prerequisite piece of data for the preparation of the nursing payroll budget. Likewise, forecasts regardingIth care market conditions, economics, and revenue aid in the determination of patient census data, another key assessment area for nursing admin- istrators. At the end of the assessment, or forecasting, phase, the nursing administrator is prepared for the substantial task of planning.lio Planningices In the nursing process, planning begins with the nursing diagnosis and ends with identification and development of a nursing care plan. The
  • 31. 136 CURRENT AND EMERGING CHALLENGES expensesplan is highly individualized for each patient and reflects the prioriti- ities. It t zation of patient problems, along with mutually identified immediate, the begirintermediate, and long-term goals for problem resolution. the nurs In the budgeting process, planning begins with external and internal ation futfactor forecasting and ends with the development of the financial planor line-item budget. The budget plan, like the individualized nursingcare plan, is a highly specific one, reflecting the prioritization of nursing Evalualprograms and goals exhibited quantitatively in numbers and dollars. Appraisi In both processes, the planning function may be viewed as determining nursingin advance what is to be done, how it is to be done, when it is to be done, nurse in and who is to do it (1). The importance of planning cannot be over- comes aemphasized. The process itself constitutes a mechanism for sifting plan. Fethrough the data collected in the assessment, or forecasting, phase and for reassprovides the nursing administrator with a sense of direction and focus process.on the nursing departments objectives. It also enables the administrator In theto anticipate and compensate for changes that may occur throughout control.the fiscal year. If properly prepared, the budget plan serves to ensure and notcontinuity of plans from one fiscal year to the next. The assurance of in the ncontinuity is an important function, as planning and implementation performof major nursing program may be years in duration. Finally, the budget Feedbacplan facilitates the nursing administrators ability to quantitatively reports, monitor, control, and evaluate nursing programs, services, and activities While throughout the fiscal year. shift-to- These same benefits of the planning process-direction and focus, an- nursing ticipation of change, continuity, control, and evaluation-clearly apply should h to the nursing process as well. Planning, whether for individual patients financial or budgets, creates a blueprint for action, incorporates the dynamic na- at the lt ture of the environment, and utilizes a base (forecasting or assessment) sponsib for development. Both processes are also participative, the nursing care Schmie< plan with the patient and family, and the budget plan with all levels of It is ernurse managers. budgetir What constitutes a good nursing care or budget plan? The plan should process(reflect clearly stated objectives and be communicated effectively. It and evashould be economically feasible and professionally sound. Plans should modificiexhibit an integration of pieces into a whole and provide flexibility for adminirchanges and consideration of alternatives. Implementation should knowlecproperly proceed only after meeting this test of criteria. the budImplementation SUMMIn the nursing process, the implementation of the nursing care plan isthe actual provision of nursing care. Guided by the nursing care plan, An overthe nurse continues to assess, plan, and evaluate the nursing care while manageimplementing the plan. nents pr Implementation of the budget entails the realization of revenues and
  • 32. MANAGTNG FTSCAL RESOURCEQ _ 137 expenses that reflect the various nursing programs, services, and activ-prioriti- ities. It begins, pending appropriate institutional budget approval, withnediate, the beginning of the institutions fiscal year. As in the nursing process, the nursing administrator continues assessment, planning, and evalu-internal ation functions upon implementation of the budget. ial plan nursing nursing Evaluationlollars. Appraisal of the nursing care provided is the means of evaluation in thermining nursing process. The use of the nursing audit, for example, assists thele done, nurse in comparing the outcome of nursing care provided with the out-le over- comes and objectives indicated in the individual patients nursing care: sifting plan. Feedback mechanisms such as the audit assist in spotting pointsrase and for reassessment and replanning and complete the cycle of the nursingrd focus process.nistrator In the budgeting process, evaluation is usually known as financialoughout control. It is a function that should continue throughout the fiscal year) ensure and not be viewed as an end of the fiscal year exercise. Like evaluationrance of in the nursing process, budget control involves comparison of actualentation performance with a predetermined standard (i.e., the approved budget).: budget Feedback usually is processed from the institutions periodic financialtatively reports, such as revenue and expense statements and trend reports.rctivities While the nursing care plan is nearly continuously monitored on a shift-to-shift basis, the budget is most manageably evaluated by the)cus, an- nursing administrator on a monthly basis. Just as the nursing care planly apply should be evaluated by nursing staff who are providing the nursing care,patients financial control activities should involve those persons who are involvedlmic na- at the level at which costs are incurred. This concept is known as re-:ssment)ring care sponsibility accounting and is well developed in the literature by Schmied and others (1).levels of It is evident that there are many similarities between the nursing and budgeting processes, although the focus of each is quite different. Bothn should processes share the elements o[ assessment, planning, implementation,ively. It and evaluation, which are linked in a continuous cycle of feedback ands should modification. Such a comparative analysis maybe useful for the nursingrility for administrator in educating members of the nursing staff who are should knowledgeable about the nursing process but lack substantial skills in the budgeting process. SUMMARY: plan isrre plan, An overview of current health care reimbursement issues, financialre while management concepts, accounting principles, and budgeting compo- nents provides the nursing administrator with a framework for dealingLues and
  • 33. 138 CURRENT AND EMERGING CHALLENGESwith the complexities of a nursing service budget within a health careinstitution. Many, instructive correlations exist between the components 7. Marriof the budgeting process and the components of the nursing process. 8. Robbi The substantive and skilled involvement of nursing administrators in tice-Hthe fiscal process and subsequent allocation of institutional resources 9. Rowlz town,is essential. ultimately, the quality and quantity of nursing care availableis directly related to the effectiveness with which the nursing admin-istrator is able to influence the resource allocation process. BIBLI(STUDY QUESTIONS Connors, zations1. what does prospective reimbursement mean for a hospital? specif- LaMonic ically, for nursing services? Addiso2. Formulate a statement on the role of one nursing service adminis- Pyhrr, P. trator in the changing reimbursement climate. Riggs, H3. Describe the concept of financial management and its relationship Wildowsl to clinical nursing practice?4. Differentiate financial management, accounting, and budgeting.5. List one or more characteristic features of a fixed budget, a variable budget, a planned programmed budget system, and a zero-based budget technique.6. outline two or more factors the nursing administrator might consider in preparing to participate in each of the budgetary approaches.7. Describe the similarities between the budget process and the nursing process.8. Contrast the focus of the nursing process and the budget process.REFERENCESl. Schmied, E., ed. Maintaining Cost Effectiveness. Wakefield, Mass. Nursing Resources,1979.2. Grimaldi, P.L. Public law 97-248: the implication of prospective payment schedules. Nursing Management, February 1983, 14{2) 25*27.3. Coburn, R.W. and Harper, D.V. An alternative to cost-based hospital reim- bursement. Health Care Financial Management,May 1983, 37(5) 3644.4. Curtin, L. Determining costs of nursing services per DRG. Nursing Manage- ment, April 1983, 14 (4): 16-20.5. Levinstein, A. Art and science of management: tough times ahead? Nursing Management, December 1983, 14 (12): 65-66.6. Berman, H.J. and Weeks, L.E. The Financial Management of Hospitals, 5th ed. Ann Arbor, Mi.: Health Administration Press, 1982.
  • 34. MANAGING FISCAL RESOURCES I39Ith careponents 7. Marriner, A.The Nursing Process, St. Louis: Mosby, 1975.ocess. 8. Robbins, S.P.TheAdministrativeProcess,2d ed. Englewood Cliffs, N.J.: Pren- tice-Hall, 1980.ators in 9. Rowland, H. and Rowland, B. Nursing Administration Handboo,ft. German-sources town, Mo.: Aspen Systems Corporation, 1980.vailableadmin- BIBLIOGRAPHY Connors, T.D. and Callaghan, C. Financial Management for Nonprofit Organi- zations. New York: American Management Association , 1982. Specif- LaMonica, E.L.TheNursingProcess: AHumanistic Approach. Menlo Park, Calif.: Addison-Wesley, 1979.dminis- Pyhrr, P. Zero-Base Budgeting. New York: Wiley, 1973. Riggs, H.E. Accounting: A Suruey. New York: McGraw-Hill, 1981.-ionship Wildowskey, A. The Politics of the Budgetary Process. Boston: Little, Brown , 1964.ting.,uariableo-based:onsider:hes.nursing)cess.Nursing)aymental reim-44.Manage-Nursingtals, 5th
  • 35. Leinir 11 and pro ing beer group fr emphasManaging Conflict or more their "fz somethiGladys Ancrum PHILO oF co The purpose of this chapter is to present conflict and conflict res- Early cl olution within the framework of professional nursing practice. conflict Nursing administrators must cope with the competing pressures to elimi and demands of hospital administrators for cost effectiveness, of the liter medical staff for competent nursing assistance, and of nursing per- created sonnel for improved wages, benefits, and working conditions. Al- or cowo though such continued conflict can and does produce feelings of Since tl stress in nurse administrators, it can also provide an opportunity courage for the individual and organization to change and grow. On com- In cor pletion of this chapter, the reader will be able to: althoug ophy, c< 1. Define conflict and describe three pertinent theories of conflict. was ma 2. Discuss functional and dysfunctional aspects of conflict. ures to . 3. Identify examples of types and sources of conflict. entirely 4. Discuss strategies of conflict resolution. soning r 5. Describe five power bases. eficial t 6. Relate collective bargaining to conflict resolution. needed propos€ InterrConflict is an inherent part of all organizations. Within a health careorganization, it may result from divergence of opinion, incompatibility, sition a Indeed,transmission of erroneous information, or competition for scarce re-sources. Although often viewed as a negative manifestation of human in needinteraction, conflict can have positive as well as negative aspects. The that doconcepts, theories, and processes related to conflict and conflict reso- tivationlution have been the subject of extensive and intensive study. out tha decisior Conflict has a variety of definitions. Robbins (1) depicts conflict as"all kinds of opposition or antagonistic interaction. It is based on scarcity quate d, group. lof power, resources or social position, and different value structures"(p. 231). This definition is based on the premise of awareness. Admin- ministr and doistrators must first perceive a conflict situation before they can study actionitit. Such awareness is especially pertinent for the practitioner, for whom Sociaconflict implies interpersonal, intergroup, and intragroup interactions.140
  • 36. MANAGING CONFLICT 141 Leininger (2) views conflict as "opposing viewpoints, forces, issues, and problems which confront individuals, groups, and institutions, hav- ing been generated from a variety of internal and external personal and group forces" (p. 18). On the other hand, Archer (3), in her definition, emphasizes resource allocation because when a situation involves "two or more competing individuals or groups wanting more resources than their "fair share" or than is available, or have different ideas about how something ought to be done, the stage is set for conflict" (p.85). PHILOSOPHICAL AND HISTORICAL BACKGROUND OF CONFLICT MANAGEMENT:t res- Early classical writers on management, the traditionalists, consideredctice. conflict a destructive force and believed it was the role of the managerisures to eliminate conflict from the organization. This philosophy dominated the literature until the 1940s. Traditionalists felt that if a staff member)ss, ofg per- created a conflict situation by disagreeing with the views of management or coworkers, then that person must be discharged from the organization.rs. Al-lgs of Since the reason for dismissal was rarely discussed, others were en- couraged to abide by rules and regulations:unity com- In contrast to the traditionalists, the behavioralists held the view that, although harmful, conflict was inevitable. In the behavioralist philos- ophy, conflict in complex organizations was accepted, and an attemptflict. was made to rationalize its existence. This was done by devising meas-t. ures to reduce, rather than to eliminate, conflict. Such measures focused entirely on the development of conflict resolution techniques. This rea- soning eventually led to the view that conflict could be turned to ben- eficial use. Thus, Robbins (1) espoused that a positive approach was needed if conflict was to be of value to an organization, To this end, he proposed the current interactionist philosophy. Interactionists recognize the need for conflict and encourage oppo-lth care sition as a creative force that must be stimulated as well as resolved.Itibility, Indeed, they are concerned when conflict is inadequate or absent and)arce re- in need of greater intensity. The interactionists believe that organizations:human that do not encourage conflict increase the probability of or lack of mo-:cts. The tir,ation, creative thinking, and effective decision making. They pointict reso- out that companies have failed because few staff members questioned decisions made by management; in such cases, apathy allowed inade-nflict as quate decisions to remain in effect because of a conflict-free management scarcitl. group. In the field of health care, Stevens (4) notes that most nurse ad-lctures ministrators do not consider the stimulation of conflict to be beneficial .dmin- and do not bf intent engage in this practice as it is promoted bf inter-rn studr actionists.lr rvhomactions. Social scientists and hun-ranisis har e studied conflict and conflict be-
  • 37. MANAGING CONFLICT I43)ur major is a challenge to administrators (p. 20)." A conflict that may be dys- functional at one time, in a given setting, or as perceived by individuals at a certain level in the organizational hierarchy may be considered:hiatrists, functional at another time, in a different setting, or by individuals at are of con- higher status level in the organization For example, a conflict may arise:e as well over an administrative decision to use computers for recording patientr evident. data, especially if the staff nurses were not involved in the decision andi. they perceive this change as an increased burden. However, management behavior rationale for the change was that data on the population served by the group. organization would be more readily available and accessible and facil-ulture ac- itate planning for needed services.:elated toted to po- CHARACTERISTICS OF CONFLICTeconomic Baldridge (6) noted that the situations that provoke conflict can be de- scribed by four general characteristics. The first is known as the iceberg phenomenon, in which an apparent problem serves to draw attentiono conflict to other critical issues under the surface. The superficial problem isransdisci- raised as a pretense for bringing more fundamental issues to light. For this area example, an initial problem related to staffing, such as nurse assignmenting, man- patterns, may actually be merely the externalization of a much moreonflict ef- basic issue: the wish to gain participation in decision making at the if none is staff nurse level.rum, with The second characteristic situation is related to issues that cause large-lme point scale conflict that tends to have a unifying effect on diverse interestI and val- groups. This had occurred in almost all campus resistance movements,recessarily in which individuals usually have no common interest other than being bound by the current conflict situation. Third, conflict is often the result of rising expectations, rather than the presence of intolerable conditions. Nurse administrators need to be cognizant that major concessions and improved conditions can induce a high level of expectation and thus actually provoke new conflict withnents, are the repetition of a similar pattern.nd highly Fourth, the issue in conflict often has moral overtones that justify andrpropriate legitimize radical action. Individuals use issues such as sex discrimi-rps within nation and nurse power as ultimate goals to justify almost any short-trators to range excesses. However, at the other end of the organizational spectrum,.he energy the same tactic is used by nurse administrators when they demand au- tonomy in their negotiations with the governing boards of health care:.It is the agencies.ive value.listinctionor precise. TYPES OF CONFLICTional con- Although, as we havc seen, conflict situations have similar characler-,f conflict) istics, the lorms of conflict arc highly diverse. Thev mav be categorized
  • 38. 144 CURRENT AND EMERGING CHALLENGESas intrapersonal, interpersonal, intergroup, or interorganizational in The ernature. Intrapersonal conflict, which was mentioned earlier as a psy- makinchiatric phenomenon, is incongruous to an individuals role; there is tulfillilack of conformity between a persons goals and what is expected within to thethe framework of his or her role. "Intrapersonal conflict exists in the Intercognitive and affective realms of an individuals mind. Thus, an indi- such a,vidual may perceive that he or she is conflicting with the organization transnor other employees, but the conflict, in fact, exists only in that persons betweemind, not at a behavioral level" (7, p.299). flict. S: However, intrapersonal conflict can be the underlying cause of inter- (12) pcpersonal conflict. For example, emotionally distressed persons bring to as badtheir jobs feelings that relate to their private lives. Preoccupation with the corpersonal problems can produce less concentration on work-related re- emphasponsibilities and decision making. The behavior due to mental pro-cesses, especially for the nurse administrator, can be the source of in-terpersonal conflict among peers, subordinates, and coworkers of other SOURdisciplines. Interpersonal conflict arises between two or more individuals or within Power,a group. For example, withholding information may create a conflict of confbetween a nurse administrator and her assistant. Conflicts among di- interpevision heads, staff nurse and physician, and committee members may "givenoccur for the same reason. power Interpersonal conflict may be inherent in a persons role when there of oneis disagreement between the values and beliefs of the occupant of the valuesrole and the expectations set forth by others. In many health care in- groupsstitutions in the 1980s, the nursing administrator is charged with the trol ofoverall responsibility for the practice of nursing. However, disagreement Frenrcan occur if one professional challenges the practice decisions of a mem- has pober of another profession. Kalisch and Kalisch (8) refer to a common power,source of conflict in the traditional behavior pattern between physicians power.and nurses as "physicians dominance and nurses deference." This an indihierarchical attitude and expectation is found not only at the practice anothelevel but extends through executive-administrative levels. reward In the capacity of executive-level administrator, the nurse adminis- that antrator is expected to perform an array of activities with an unusually is basediverse professional group. Kelly (9) maintains that the role of nurse vidualadministrator is extremely difficult to enact because "that role is often based <stereotyped and contradictory, with multiple split opinions on its power emulat,and authority. A top-level nurse administrator . . . lisl surrounded by to havrdifferent sets of behavioral expectations to satisfy from groups higher Becaup, lower down, and on the same level in the structure" (p. 157). Studies the nurconducted by Arndt and Laeger (10) and Halsey (ll) both concluded descritthat conflict and role strain existed for the nurse administrator resulting use of 1from pressure to respond to role prescription from a variety of sources. are aw It is vital that the nurse executive examine his or her role conception. uses ot
  • 39. MANAGING CONFLICT 145ional in The executive should take an activists position in regard to that role,s a psy- making it the sort of role he or she perceives it to be, rather than merelythere is fulfilling the role others expect or anticipate. An attempt to subscribed within to the latter philosophy can be a source of intrapersonal conflict.ts in the Intergroup, or interorganizational, conflict arises between two groups, an indi- such as in the form of interdepartmental issues. Disagreements and thenization transmission of erroneous information between departments, such aspersons between medicine and nursing, are common sources of this type of con- flict. Such conflicts are depicted as harmful by management, but Argyris (12) points out that "instead of trying to stamp out intergroup conflictof inter- as bad and disloyal, the executives must learn how to manage it so thatbring toion with the constructive aspects are emphasized and the destructive aspects de-lated re- emphasized" (p.23).rtal pro-ce of in-r of other SOURCES OF CONFLICTcr within Power, defined as the ability to influence others, may be a major sourceL conflict of conflict. Frost and Wilmot (13) emphasize that, because it is alwaysmong di- interpersonal, power exists only in a human context and is, in a sense, "given from one party to another in conflict" (p. 52).Within this context,)ers may power is not an actual show of force, but it is the perceived potentialren there of one party to exert influence on another party, depending upon thent of the values and nature of the relationship of those involved. Individuals andr care in- groups have power when they have access to information and have con- with the trol of resources and support services to carry out tasks.greement French and Raven (14) describe five situations in which one personrf a mem- has power over another. These five bases of social power are reward common power, coercive power, legitimate power, referent power, and expert,hysicians power. The basis of reward power is the ability to offer rewards. Thus,ce." This an individual is made to perceive that compliance with the wishes of: practice another will lead to positive rewards. Coercive power, the opposite of reward power, is exercised in such a way that one individual perceives adminis- that another can mediate punishment for him or her. Legitimate powerrnusually is based on agreement and values held in common, enabling one indi- of nurse vidual to exercise power over the other by consent. Referent power is.e is often based on identification with the ideals of an individual and the wish to its power emulate that person. Expert power is present when a person is perceivedunded by to have superior knowledge or skill in a particular field.ps higher Because of position, knowledge, profession, and organizational context, the nurse administrator may acquire and use all of the kinds of power). Studies:oncluded described. The nurse executive should neither avoid nor overplay theresulting use of power, nor fail to use it for ethical and legitimate purposes. Othersf sources. are aware of potential resources of power, and the administrator whoInception. uses overkill in a power conflict risks loss of effectiveness. Thus, the
  • 40. - 146 cURRENT AND EMERGING IHALLE_NqES administrative nurse must frequently come to terms with conflicts be- inform tween personality, professional ideals, and the needs of the institution. to com By position and title, the nurse administrators legitimate power and Mart authority is generally recognized throughout the organization. However, situati the precise scope of this power and authority may be an area of conflict. have tl An issue in many health care facilities is who controls the practice of differe nursing. The director of nursing has the authority, but the extent of his and au or her power may be limited to resolving problems that occur within the ph the department. Unless the director has other powers to augument his conflic or her legitimate power, legitimate power may not be sufficient for the the nut administrator to decide a nursing practice issue related to the overall special organization or to other disciplines. and an The nursing administrator also has substantial reward and coercive status. power based on the right to hire, evaluate, promote, and discharge in- sourcel dividuals. The nursing director needs to be sensitive to the fact that As nt power is only a part of the continuing relationship between the super- conflic visor and the supervised and that power is not an acceptable substitute manag for skillful leadership and motivation. The nurse administrator has expert power derived from two sources: professional knowledge and administrative skills. The fact that these two types of expertise are not always compatible can become a source STRA of intrapersonal conflict. It is generally accepted that ones clinical ex- pertise diminishes with the immediacy of administrative burdens. This Negoti ionflict is pointed out by Aydelotte (15), who notes: "The director of Negotie nursing is in a unique place in the organizational structure of a hospital. Howev, She is not an executive in the full sense, nor is she solely a practicing limitec professional. She provides professional expression for the particular Nevert. group she represents by initiating and encouraging innovations in its service practice. . . . Concomitantly she exercises influence in determining goals admini ind policy, and in directing the movement of her professional group plishinl toward departmental and institutional goals" (p62). with a Referent power, based on personal characteristics, may or may not a majo be strong enough to induce others to emulate the nursing administrator. and re However, referent power can be diminished when the nursing admin- Neg< istrator develops hostile, defensive personality patterns. (18) vir Nurse administrators who are knowledgeable about the various types lyzed t of power and power bases and how they are used are better able to such s1 function in a enlightened position and provide a climate for more ef- towart fective leadership. Nurse administrators need to make informed and structl high-risk decisions that may be potential sources of conflict. As members negoti of the executive team in health care delivery settings, nurse adminis- and tt trators must take risks and move into positions of power. Much of the negoti power that administrators gain is derived from their access to infor- compl mation. The nurse executive who is aware of the information network negoti of the organization realizes there are formal channels that transport negoti
  • 41. 148 CURRENT AND EMERGING qFTALL!Ngqs_ cohen (19) presents another perspective on negotiation. He views it ership as a process of information, timing, power, and pressure to secure a the sar commitment to change behavior. power, the ability to use resources to coordir achieve worthwhile goals, may include risk taking, competition and goals. I persistence. cohen stresses that successful negotiatlon is tased on ac- must u curate and sufficient information gathered by critical listening, ques- They n tioning, and reading cues. It is important to note that, in order to achieve and wlagreement in negotiations, group tension must be reduced. Stress relief acquiremay be achieved by the following steps: (1) the maintenance of time In thlimitations by both parties and (2) the application of pressure on the structulnegotiator to take or avoid risks. are ofte General guidelines to effective negotiations include belief in oneself goal ofas an able negotiator; willingness to seek assistance in problem solving, ization,in the recognition that the objective is collaborative seitlement as com- patientrmitments made to individuals, not necessarily organizations; encour- authoriagement of an exchange of information; and the ability to assess and power.validate changing circumstances in the negotiating protess. power ( One rCollaboration depend exampl I-win-you-win collaboration as a strategy or technique is closely related for new to negotiation, and the terms are sometimes used interchangeably when nursing conflict resolution is discussed by different authors. However, collab- number orative theory supports the belief that people should bring their differ- tient ca ences to the surface and delve into the issues to identify underlying patient causes and to find an alternative mutually satisfactory to both parties. ment tc The approach is based on the assumption that people will be motivated opportr to invest time and energy in such problem-solving-activity. The conflict of the c is viewed as a creative, positive force that will lead to an improved state Furtherof affairs to which both sides are fully committed. when progress can sources.no longer be made, a mediator (third-party consultant) may be employed attainrrto assist the parties to arrive at a win-win position. erarchy collaborationists further argue that theirs is the preferable strategy subgror"for the good of an organization because (l) open and honest interaction cians, npromotes authentic interpersonal relations; (2) conflict is used as a cre- be mortative force for innovation and improvement; (3) the process enhancesfeedback and information flow; and (4) the solution of disputes in itselfseryes to improve the climate of the organization by enhancing openness, Collectitrust, risk taking, and feelings of integrity (20). Collecti, collaboration has been found to be most effective in situations in which their errthere is (1) a high degree of required interdependence; (2) power parity, staff. Tlallowing the parties to interact openly, utilizing all of their resources whetherto further their beliefs and concerns regardless of their superior-sub- workingordinate status; (3) potential for mutual benefits; and (4) the expectation issues arof organizational support. be a bar Nursing administrators are frequently encouraged to develop lead- In 194
  • 42. MA NAGTNG C_ONFLTCT__149: views it ership skills that emphasize the resolution or suppression of conflict. At secure a the same time, they often find that power is necessary to direct andiources to coordinate day-to-day activities, compete for scarce resources, and attainition and goals. However, to perform these tasks effectively, nurse administrators,ed on ac- must understand and be able to plan strategies for dealing with conflict.ing, ques- They need to know how power is distributed within the organizationto achieve and where they stand within the power structure to determine how toress relief acquire the leverage needed to fulfill their role.:e of time In the organizational hierarchy of a hospital, the two major powerrre on the structures are the administration and the medical staff. These two groups are often inherently in conflict because of differences in their goals: thein oneself goal of the administrators is to realize an efficient, cost-effective organ-n solving, ization, and that of the physicians to obtain optimum resources for theirrt as com- patients. In most hospitals, physicians do not have formal organizationals; encour- authority over hospital employees, including nurses; yet, they do haverssess and power. Thus, an important task of the nurse executive is to increase the power of nursing without aggravating organizational conflict. One route by which this objective can be attained is to emphasize the dependence of other organizational units of the hospital on nursing. For example, if the chief of pediatrics wants to open an intensive care unit:ly related for newborns, he or she must rely on the nursing director to staff it. Therbly when nursing director in turn must provide personnel not only in sufficient:r, collab- numbers but also with the necessary critical-care skills for quality pa-reir differ- tient care, ready and fully trained on the day the unit accepts its firstnderlying patient. Rather than treating this accomplishment as a routine assign-;h parties. ment to be expected of a nursing director, the director should use themotivated opportunity to make the hospital community aware of the importancere conflict of the director and of nursing in general to the realization of a goal.oved state Further, the director should convey the idea that he or she has re-)gress can sources-that is, power-and is ready to use them to help or hinder theemployed attainment of an objective of a member from another area in the hi- erarchy. Moreover, power may be augmented by gaining support frome strategy subgroups within a high-power group. Thus, by supporting the physi-rteraction cians, nurses can gain leverage in dealing with administrators who mayI as a cre- be more interested in satisfying physicians than nurses. enhances:s in itself Collective Bargainingopenness, Collective bargaining produces conflict not only between nurses ands in which their employers, but also between nursing administration and nursinger parity, staff. The principle questions related to collective bargaining are (1) resources whether it should serve primarily for economic gains and improvederior-sub- working conditions or whether negotiations should include patient carerpectation issues and (2) whether the American NursesAssociation (ANA) should be a bargaining agent.:lop lead- In 1946, the American Nurses Association adopted a program of eco-
  • 43. 150* cunRpNr nNn EMERGING CHALLENGESnomic security. However, because the ANA program included a no-strike SUMNpolicy, collective bargaining activities remained relatively conservative.Indeed, the idea of group action to improve salary and working con- Conflicditions precipitated a conflict concerning the question of professional can harethics . In 1966 , this position changed (2 I ). Finally , the 197 4 Health Care conflictAmendments of the National Labor Relations Act gave employees of There anonprofit health care organizations the right of collective bargaining. rvhich rToday, the majority of the members of the nursing profession at the from orstaff level seem to accept the validity and necessity of collective action itable cto attain economic goals and improve working conditions. actionis The issues that remain in conflict are in the area of professional goals: as wellwho shall control nursing, nursing practice, and nursing quality. Legally, Fourthe authority, responsibility, and accountability for hospital operations psycholand patient care are in the hands of hospital administrators (22). Nurses the antlare individually and legally accountable for their nursing practice, but Each apbecause they are employees of a hospital, management in the person of Situathe director of nursing is in fact responsible for institutional quality. problerr Many leaders of the nursing profession have published their views on that tenthe impact of collective bargaining on nursing. The thrust of arguments (4) moriof those opposed to the principle is that the concept of collective bar- The tgaining is counterproductive to professionalism, while those in favor includirsuggest that ir is "an opportunity to develop a new model of labor re- organizilations which will benefit not only employees and management, but is espechealth care delivery as a whole." Cleland (23) describes a professional and "hacollective bargaining model that emphasizes benefits for professional Frenchnursing practice. Her model provides for the joint devclopment power.o[ professional policy decisions by nursing staff and administrators. ManyThe policies would give nurses control of their practice and would resolutiallow thcm to determine standards of practice and to definc quality three ofof care. disadva A study cited by Erickson (24) indicates that "staff nurses are not al-ways supportive of professional or patient care issues, and indeed thatrank-and-file nurses seem to be primarily motivated by economics." Further, she raises the question of whether staff nurses are really in- STUDl terested in using collective bargaining to improve patient care or onlytheir own economic status. Herzog (25) deals in further detail with the 1. Fornschism existing in nursing and concluded that "until nurses agree upon 2. Coman accepted set of standards of practice, the issues of quality and practice acticwill remain controversial." 3. Citc Sargis (26), in a study in which 216 directors of nursing responded toa questionnaire, concluded that directors of nursing service show no 4. Wha Expltendency to support the professional organization as a collective bar-gaining agent and that a great deal of ambivalence exists about collective 5. Of tlbargaining activities, which may finally alienate the directors of nursing asnfrom ANA. 6. Wha
  • 44. MANAGING CONFLICT 1s1 no-strike SUMMARYservative.<ing con- Conflict, often viewed as a negative manifestation of human interaction,rfessional can have positive as well as negative aspects. How a person perceivesalth Care conflict may be influenced by the definition and theory he or she accepts.loyees of There are three major philosophical views of conflict: (1) traditionalist,rgaining. which views conflict as a destructive force that should be eliminated:n at the from organizations; (2) behavioralist, which views conflict as an inev-ve action itable occurrence that should be reduced or controlled; and (3) inter- actionist, which views conflict as a creative force that must be stimulatedral goals: as well as resolved.. Legally, Four approaches to understanding conflict are (/) the interpersonal-perations psychological approach , (2) the interactional-sociological approach, (3)l). Nurses the anthropological approach and (4) the economic-political approach.ctice, but Each approach assumes a different source of conflict.person of Situations that can provoke conflict include (1) the use of an apparentquality. problem to bring a more critical issue to the surface, (2) large-scale issues views on that tend to unify a diverse interest group, (3) rising expectations, andnguments (4) moral overtones that justify radical action.:tive bar- The types of conflict that mav be encountered are (1) intrapcrsonal,: in favor including role conflict; (2) intcrpcrsonal; and (3) intergroup, or inter- labor re- organizational. Power is onc of thc primary sources of conflict. Thisnent, but is especially true whcn the disposition of power is seen as a "have"rfessional and "have-not" situation. There are five kinds of power, as delined byrfessional Frcnch and Raven: reward, coercive, legirimate, referent and cxpertelopmcnt powcr.istrators. Many techniques or approaches may bc used effectively for conflictrd would resolution. Ncgotiation, collaboration, and collective bargaining arec quality three of the most common strategies. Each has its own advantages and disadvantages.re not al-leed thatnomics."really in- STUDY QUESTIONSe or onlywith the 1. Formulate a definition of conflict.,ree upon 2. Compare and contrast thc rraditionalists, behavioralists, and intcr-I practice actionists approach to conlict. 3. Cite at least two cxamples and sourccs of conflict.onded toshow no 4. What strategics of conflict rcsolution would you bc likely to utilizc?tive bar- Explain?:ollective 5. Of the five bases of powcr, which ones are the most applicable to youf nursing as nursing administrator? Why? 6. What is the relationship of collective bargaining to conflict resolution?
  • 45. t52 CURRENT AND EMERGING CHALLENGES 22. JacorREFERENCES Nich< ton: I1. Robbins,S.P.ManagingOrganizationalConflict:ANontraditionalApproach. 23. Clelar Englewood Cliffs, N.J.: Prentice-HalI, 1974. 1974,2. Leininger, M.M. Conflict and conflict resolution: theories and processes rel- 24. Erick evant to the health professions. The American Nurse, December 1974,6(12), siona t7-22. 25. Herz<3. Archer, S.E. and Goehner, P.A. Nurse: A Political Force.Monterey, Calif.: profe Wadsworth, 1982. 34-3t4. Stevens, B. J. The Nurse as Executive,2d ed. Wakefield, Mass.: Contemporarv 26. Sargi Publishing, 1980. gaini 5. Lewis, J.H. Conflict management. Journal of Nursing Administration, De 26. cember 197 6, 6(10),, 18-22. 6. Baldridge , J.Y. New Approaches to Managemenf. San Francisco: Jossey Bass Publishers, 1979. 7. Zey-Ferrell, M. Dimensions of Organizations. Santa Monica, Calif.: Goodyear Publishing Co.,1979. 8. Kalisch, B. J. and Kalisch, P.A. An analysis of the sources of physician-nurse conflict. Journal of Nursing Administration, January 1977 ,7(l),50-57. 9. Kelly, J. The role of the top level nurse administrator, in University of Min- nesota, Proceedings, Nursing Administration: Issues for the 80s-Solutions for the 70s. Battle Creek, W.K. Kellogg Foundation, 1977.10. Arndt, C. and Laeger, E. Role strain in a diversifed role set: the director of nursing service. Nursing Research, March l97O , 1 9(3), 253-259 .11. Halsey, S. The queen bee syndrome: one solution to role conflict for nurse managers, in Hardy, M.E. and Conway, ME., Role Theory: Perspectives for H ealth Professionals. New York: Appleton-Century-Crofts, 197 8.12. Argyris, C. How tomorrows executives will make decisions. Think, June 1967, 33(6),22-2s.13. Frost, J.H. and Wilmot, W .W. Interpersonal Conflicf. Dubuque Iowa: William C. Brown Co., 1978.14. French, J.R.P. and Raven, B. The bases of social power, in Cartwright, D. and Zander, A., eds., Group Dynamics: Research andTheory. New York: Har- per & Row, 1968.15. Aydelotte, M.K. Administration and directors of nursing. Hospitals, Novem- ber 197 4, 48(23), 6 1-63.16. Marriner, A. Conflict theory. Superisor Nurse, April 1979, 10(4) 12-16.17. Kelly, J.A. Negotiating skills lor the nursing service administrator. NtLrsing Clinics of-North America, September 1983, 18(3), 427-438.18. Strauss, A. Negotiations: Varities, Contexts, Processes and Social Orders. San Francisco: Jossey Bass Publishers, 1979.19. Cohen, H.YouCan Negotiate Anything. Secaucus, N.J.: Lyle Stuart Publishers, 1980.20. Likert, R. and Likert, J.G.Ways of Manttgittg Conflict.. New York: McGraw- Hill, 1976.21. McClelland, J"Q. Professional and collective bargaining: a new reality for nurses and manage menl. The J oumal of N ursing Administration, November 1983, 8(l r), 36-38.
  • 46. l{2- cunnerur nNo EMERGTNG cHALLENGEShavior particularly since World War II. They have identified four majorapproaches to understanding confl ict : is a cha function at a cerl1. The study of interpersonal conflict is spearheaded by psychiatrists, function psychiatric social workers, and psychiatric nurses. This type of con- higher st flict can and does occur within the individual. Ambivalence as well over an i as disordered perception, feeling, and behavior are usually evident. data, es; These symptoms are associated with psychiatric problems. they per<2. The interactional sociological approach focuses on group behavior rationalr and interactional phenomena in decision making within a group. organiza3. The anthropological approach emphasizes the stresses of culture ac- itate pla climatization, value and cultural conflicts, and conflicts related to personality and the social environment.4. The economic-political approach emphasizes conflicts related to po- CHARA litical concerns, power games, coalitions, and political and economic Baldridg processes. scribed t phenomt Leininger (2) predicts the evolution of another approach to conflict to othertheory in the health care professions, one concerned with transdisci- raised asplinary and intradisciplinary conflicts and problems. It is in this area example,that nurse administrators must be knowledgeable in identifying, man- patternsaging, and resolving conflict. They must not only deal with conflict ef- basic issfectively and use it constructively, but must also stimulate it if none is staff nurapparent. Lewis (5) notes that "we should visualize a continuum, with The se,too much conflict at one end and too little at the other. At some point scale corbetween these extremes, the quantity of conflict is functional and val- groups.uable. This point is determined by management and will not necessarily in whichbe the same for any two organizations" (p. 18). bound b Third, the prestFUNCTIONAL AND DYSFUNCTIONAL CONFLICT cognizar a high leHealth care institutions, such as hospitals and health departments, are the repefrequently classified as complex organizations. In complex and highly Fourtldiversified organizational settings, conflict is inevitable. Inappropriate Iegitimi:responses to conflict can be unhealthy for individuals and groups within nation athe organization. It is a frequent concern of nursing administrators to range exreduce conflict and tension to a tolerable level and to channel the energy the samrgenerated by conflict situations toward constructive goals. tonomy Conflict in and of itself can be a positive or negative force. It is the agenciesuse or misuse of this force that determines its effect and relative value.Thus, conflict may be seen as functional or dysfunctional. The distinctionbetween functional and dysfunctional conflict is neither clear nor precise. TYPESLewis (5) emphasizes that "determining the point when functional con- Althougflict is reached (as opposed to dysfunctional conflict or lack of conflict) istics, tl
  • 47. MANAGING CONFLICT 153 22. Jacox, A. Collective action: the basis for professionalism, in Hein, E.C. and Nicholson, M.J ., C ontemporary Leadership B ehavior : S elected Readings. Bos- ton: Little, Brown, 1982. i Approach. 23. Cleland, V.S. The professional model. Ameican Journal of Nursing, February t974, 7s(2), 288-292. :ocesses rel- 24. Erickson, E. Collective bargaining: an inappropriate technique for profes- t974,6(t2), sionals. N ursing F orum, March 197 l, I 0(3), 300-3 I 0. 25. Herzog, T. The National Labor Relations Act and the ANA: a dilemma of erey, Calif.: professionali sm. The Joumal of Nursing Administration, October 197 6,6(10), 34-36. Intemporary 26. Sargis, N.M. Will nursing directors attitudes affect future collective bar- gaining? The Journal of Nursing Administration, December 1978, 8(12), 21-;tration, De- 26. Jossey Bass[.: Goodyearsician-nurse 50-57.:sity of Min-Solutions for: director ofLct for nursespectives forThink, Junewa: Williamrtwright, D.r York: Har-a/s, Novem-), t2-16.tor. NtusingOrders. San. Publishers,k: McGraw- reality for, November
  • 48. Leadership in Careof the Elderly The purpose of this chapter is to introduce care of the elderly as a challenge for nursing administrators to provide leadership in health care delivery settings. On completion of this chapter, the reader will be able to: l. Describe trends in demography that contribute to the growth of the age group over 65. 2. Contrast the standards of health care for the aged and younger patients in health care settings. 3. Identify the characteristics of the frail and not so frail elderly. FIGURE 4. Clarify the difference between age-related changes and dis- to 2050 ( eases that affect psychological and physical functioning in old Health S age. 5. Present a systematic plan for assuming leadership in stimu- crease t( lating better care for the elderly. over hal 6. Describe obstacles to implementing a geriatric focus in a Figure 1 health care delivery setting. The fe 7. Discuss the factors that influence the nursing care of elderly nursing women. older ad health-r,The greatest challenge for nursing administrators in the 1980s is pro- educaticviding leadership in the care of older people. Not only is the population Life e:in the United States aged 55 and older growing at a rapid rate in num- significabers, but is is also steadily growing in proportion to the rest of the pop- ancy ofulation. Speaking to the American Public Health Association in Montreal, 6e.s). wiNovember 1982, Robert Butler past Director, Institute on Aging de- nonwhitscribed the threat of nuclear war and the growing number of aging SinceAmericans as the two most critical challenges facing American society celerate<(1). One out of every five Americans is currently 55 or older, and one in expectarnine is 65 or older (2). In other word s, ll .2 percent of the population is ages: gr(65 or older. The proportion of people in the 65-plus age group will in- mortalit154
  • 49. LEADERSIIIP IN CARE OF THE ELDE_BII J55 I I Age 53-b4 lltilliili:i.i:iiilli1l Age o5+ @-lyasahealthreader;rowthounger 0 1900 1950 1960 1910 1980 1990 2000 2010 2020 2030lderly. FIGURE 12.1 Numberofpersons aged 55 andoverby age group, 1900 and 1950rd dis- to 2050 (data for 1980-2050 are projections). (From the National Center for in old Health Statistics.)stimu- crease to approximately one out of eight by the year 2000. By that year, over half the population of the United States will be older than 35 (seersina Figure 12.1). The fastest-growing group is the old old, those over 75 years. If theelderly nursing profession is to respond adequately to the growing numbers of older adults, it must intensify its commitment to the special health and health-related problems of older people at every level of administration,0s is pro- education, practice, and research (3).:pulation Life expectancy at birth reached at record 73.3 years in 1978, with: in num- significant gains made by both sexes during the 1970s. The life expect-I the pop- ancy of women continues to be longer than that of men (77.2 versusMontreal, 69.5). White women have the highest life expectancy (77.8), followed byging de- nonwhite women (73.6), white men (70.2) and other men (65.0) (2). of aging Since 1950, life expectancy in the older ages has increased at an ac-rn society celerated pace (see Figures 12.2 and 12.3). Most of the increase in lifend one in expectancy before 1950 was due to decreasing mortality at the youngerulation is ages: growing numbers of people reached old age because of decreasedp will in- mortality rates in the younger age groups. Since World War II, life ex-
  • 50. 156 _cURRENTAND EMERGING CHALLENGES Under 18 18-54 55-64 65+19101920193019401950196019701980r9902000 G2010 o2020203020402050 o 20 40 50% bu 6u ruuFIGURE 12.2 Distribution of the total population by age group, 1910 to 2050(data for 1980-2050 are projections). (From National Center for Health Statistics.) FIGUR age 65, pectancy at the older ages has increased at a faster rate than at birth. Life expectancy at age 65 increased 2.4 years between 1950 and 1978 (2). Significant declines in the number of deaths from heart disease and stroke have been a major factor. It is anticipated that the number of older people will increase even more in the decades ahead. This is not an unreasonable or unwanted speculation when one considers the fact that, for humans to travel to and live on other planets, a much longer life span will be required. As
  • 51. White male Other male Whitefemale Otherfemale 30 U 1900- 1909- 1919- 1929- 1939- 1949- 1959- 1969- 1977 1978 1902 1911 r92r 1931 1941 195i 1961 r97r 0 1900- 1909- 19i9- 1929- 1939- 1949 1959- i969- 1977 1978 7902 1911 7927 1931 1947 1951 1961 I91l 100 (b)l0 to 2050;tatistics.) FIGURE 12,3 (a) Life expectancy at birth, 1900 to 1978. (b) Life expectancy at age 65, 1900 to 1978. (From National Center for Health Statistics.)Lat birth.and 1978sease and3ase evenrnwanted travel toluired. As 157
  • 52. I _5-8 cunner,rr ANrD EMERGTNG cHALLENGES 1960 1980 (projection) 2000 (projection) Diat Hyp€ (hish press Visue 75-84 lmpa Hearr impa 100 120 r40 160 180 200 220 240 260 100FIGURE 12.4 Sex ratios (women per 100 men) aged 55 and over by age group,1960, 1980, and 2000. (From Bureau of the Census.) 90 80women disproportionately outnumber men in the older age group, one 70wonders what new social patterns will develop by the year 2000 (see 60Fie. n.q. @ For health care professionals, including nurses, the impact of the in- 950 o Lcreased aging population is one of major importance. The utilization of 40all health care services increases dramatically with age. Most older peo- 30ple have one chronic condition, and old people with multiple chronicdiseases are common. The most common chronic conditions in old age 20requiring health care services are arthritis (44 percent), hypertension 10(39 percent), hearing impairment (28 percent), heart conditions (27 per-cent), visual impairments (12 percent), and diabetes (8 percent) (2). 0Therefore, chronic conditions have serious impact on care needs for thosewho require services ranging from daily personal care to hospitalizationin acute or long-term care facilities. Figure 12.5 describes the impactof chronic conditions on daily living. The utilization of hospitals and nursing homes increases significantlyin old age. The hospitalization rate for people 65 and older is tr.vo-and-a-half times greater than for younger people (2). While most people 65 FIGUREand older are not hospitalized in any given year, older people will con- of chronitinue to account for an increasing share of total hospital usage. (From N
  • 53. Rate per 1,000 persons by age Arth ritis Heart disease Dia betes Hypertension (high blood pressure) Visua I lmpairment Hearing impairment i00 150 250 300 - 350 400 450 500 (a) 260 lVobility Self-care 100 100e group, 90 90 80 80up, one 70 70)00 (see 60 60 c o c oi the in- 950 o o d cation of 40 40ler peo- 30 30chronicold age 20 20rtension [0 i0(27 per-rnt) (2). 65 74 75-84 85+ 65-7 4 75 84br thoserlization Confined to bed Needs help bathing Needs help in house Needs help dressing impact Needs help in neighborhood Needs help eating Needs help outside neighborhood Needs help with toilet No disabilityificantly No disabilityrvo-and- (b):ople 65 FIGURE 12.5 (a) Prevalence of chronic conditions by age group, 1979. (b) Impactvill con- of chronic conditions on daily living for the older population by age group,1977 . (From National Center for Health Statistics.) 159
  • 54. !60 CURRENT AND EMERGING CHALLENGES The nursing home population has also increased remarkably in the plete Ilast 20 years. In 1963, there u,ere 505,000 people living in nursing homes (6). rhin the United States. The latest data show that the number has grownto 1.3 million, a 150-percent increase (2). Less than 5 percent of all people Accerover 65 are in nursing homes, but this figure increases significantly in Com1the middle old and old old groups. Seven out of 100 people in the 75- Carir84 age group and one out of five in the 85-plus group are in nursing Afforhomes. Women are likely to be present in larger numbers than menbecause there are more women in this age bracket. Tran The causes of death, and therefore the nature of health care, for old centerrpeople are markedly different than for young people. Heart disease, servicestroke, and cancer account for three-fourths of all deaths in the group care thaged 65 and older. federal Thus, the demographic changes in our population project an increasing betweenumber of older people as well as increased need for health care services crease(The significance of long-term care-long considered less important than the totshort-term care-will become fully recognized in the next decade. Long- need arterm care encompasses a continuum of interrelated health and social Muclservices. It includes both institutional and noninstitutional services and servicerequires coordination of public policies, funding, and case management Libowto provide appropriate services for individuals with changing needs (4). Long Is The concern for the elderly in todays health care world is not solely for treathe result of the greatly increased number of older people. Changes in in the rfederal legislation since the 1930s have contributed much to the eco- sciencenomic status of the 65 and over group. As a result of the Great Depression, medicithe Social Security Act was passed, establishing a retirement income volve esystem and a system of federal grants to states to provide financial as- In prsistance to the aged (4). people, Nurses can expect to deliver care to increasing numbers of old people iatricswho can pay for health care either through private insurance or Med- not allicare-Medicaid reimbursement. All facets of care are available, ranging fruitiorfrom highly complex technological procedures to wellness-based, self- place icare, teaching-learning approaches. For most of the old age group who mainta are not incapacitated by disease, intellectual functioning and the ca- outagpacity for learning neither cease nor diminish because of chronological nursinS age (5). This fact allows nurses to creatively develop those options for High nursing care that uniquely meet the nursing care needs of older people. contint tologici relocatSTANDARDS OF HEALTH CARE in the g no morThere is a rapidly growing opinion on the part of all health professionals postrel,that older people should not be treated as separate systems, organs, and changediseases. Rather, they should be treated by a single practitioner as com- Then
  • 55. LE4rpEBqHIp rN!43E q rHE!!DEB_LY _169,ed for 2. Why are population trends considered important aspects of society? 3. People are living longer in the United States today than at any other time in history. Explain how this affects the health care delivery system. Include the effects of Social Security and Medicare-Medi- caid.lderly, 4. Describe holistic care. Give reasons why such care could be beneficial/omen. to the care of the elderly.ed, so- 5. Explain Libows position on nursing homes, and contrast it withr takes your own concept of nursing homes. edical 6. Discuss the concepts of primary and secondary aging.rilizers 7. Explain the importance of distinguishing the aging process from a sword. disease process and give the major reasons why aging is sometimesrlly as- considered a disease.des to- 8. Define frail elderly.: older 9. List the steps essential for nursing administrators to provide lead-g task, ership in stimulating better care for older people.:ses do 10. Give reasons why it is vitally important that nursing personnel un- derstand the concepts of geriatrics.rey be-ions. It 11. What is the most frequently cited reason for disinterest in workingry men with the elderly? What are some of the others?n older 12. What is geriatric burnout?stmen- 13. List some of the special needs of elderly women.ical di- REFERENCESrursrng l. Friedman, E. Medicare called unfit for the elderly. Hospitals, January 1, 1e83,57(l), t7,20.s. Most 2. Allan, C. and Brotman, H. Chartbook on Aging in America. Washington, D.C.:tial for Government Printing Office, 1981.ocietys 3. Abdellah, F.G. Nursing care of the aged in the United States of America.atients Journal of Gerontological Nursing, November 1981 , 7(ll), 657-663 .lminis- 4. Koff, T.H. Long-Term Care: An Approach to Sewing the Elderly. Boston: Little,g from Brown, 1982.rt meet 5. Pierce, P.M. Intelligence and learning in the aged. Journal of Gerontological Nursing, May 1980, 6(5),268-270. 6. Warfel, B.L. Information on Aging. Newsletter from the Institute of Ger- ontolo6;y, Wayne State University and the University of Michigan, no. 27 . October 1982. 7. Libow, L.S. Geriatric medicine and the nursing home: a mechanism for mutual excellence. The Gerontologlst, April 1982, 22(2), 134-l4l .ursrng 8. Coffman, T.L. Relocation and survival of institutionalized aged: a reex- amination of the eviden ce. The Gerontologisf, October l98 l, 2 1 (5), 483-500.
  • 56. 168 cu_BIrBNr eNo EMERGTNG cHALLENGESmay simply be the failure of the organization to recognize the need for 2. tvla geriatric emphasis. 3. P ti slELDERLY WOMEN: A SPECIAL NEED c:Nursing care programs often ignore the special health needs of elderly, 4. D tCand, in particular, they may not even recognize the needs of older women.Lillard (24) describes older women as economically disadvantaged, so- 5. Ecially isolated, and negatively stereotyped. The medical profession takes yra different view of men and women experiencing the same medical 6. Dproblems, and it is not uncommon for women to receive tranquilizers 7. Ethat are not appropriate. Ageism and sexism form a double-edged sword. dPostmenopausal women have frequently outlived their culturally as- c(cribed usefulness and frequently face additional negative attitudes to- 8. Dward feminine aging. The vast majority of elderly people are older 9. Lwomen, and since the care of the elderly is primarily a nursing task, elthe opportunities for negative behavior are compounded if nurses do 10. Gnot have a geriatric interest. d, Women are less apt to have supportive family groups (25). They be-come widowed before men, and they have fewer remarriage options. It 11. is not socially acceptable for older women in our culture to marry men tvsubstantially younger than themselves. Health problems abound in older 12.women, and few doctors seem interested in these problems. "Postmen- 13. Lopausal syndrome" and "senility" frequently cover up a medical di-agnosis or lack of it.SUMMARY REFlResponsibility for care of the elderly as a significant part of the nursing 1. Fr l9adminstrators role has not been addressed in most organizations. Most 2. Alstaffing studies focus on high turnover rather than on the potential for Grnursing leadership in providing quality care for old people. Our societys 3. Atconcept of aging and the attitudes of health professionals and patients Joinfluence the development of optimal care programs. Nurse adminis- 4. K(trators should encourage creative approaches to care, ranging from Brchanging attitudes toward old people to designing programs that meet 5. Pitheir special needs. Ni 6.W or OrSTUDY QUESTIONS 7. Li m l. How does the increasing elderly population relate to nursing 8. C( administration and practice? AI
  • 57. LEADERSHIP IN CARE OF THE ELDERLY 167ective of Most deaths occur in old age. In environments where most attentionrl health, is given to lifesaving measures, older people are not given high priority.(18) sug- The United States is a youth-oriented society, and negative attitudesnd, indi- toward aging are well ingrained in health professionals long before their- encour- professional education. Because of their knowledge, health care providersing with have potentially the most negative attitudes toward old people. utilized According to Benson (21), negative attitudes toward old people pervaderdepend- all levels of nursing personnel. Various reasons for this include:nication l. Preference for working with younger people.:d by en- 2. Nurses age and experience with the aged. nursing 3. Type of agency where the nurse is employed.rest, and 4. Stereotypic view of old people.d out byeriences 5. Lack of gerontological content in the nurses educational program.nctional Miller (22) describes a "geriatric burnout" that occurs with nursesral com- who work with chronically ill elderly patients who eventually deterioraterple and and die. Society does not reward working with the elderly, and nursing[ound to homes have a poor image. The most difficult staffing problem in acuterportant care settings occur on adult medical-surgical units. Increasingly, theseresident units contain a large number of older adult patientsleasures Overcoming negative attitudes is difficult, for they are usually stronglyual, and held. In defining programs and goals with a geriatric emphasis, thenctional nursing administrator will have to support behaviors that will produccnce self- positive attitudes. Adclson and colleagues (23) havc identified behavioralre apply calegories dcemcd positive intcraction. Bccause it is usually easier to identiiy negative behaviors, it is a creative challenge to identifl,positive bchaviors. The categories includc: 1. Banter. 2. Asking for feedback.Le major 3. Giving procedural information.: setting. 4. Compensating for disabilities.regative 5. Social touching.nifestedlaborate 6. Attending to patient comforts.:, in the 7. Smiling.:serving 8. Speech pace..erlife isLl in the These behaviors seem to reflect common sense, but they are not uni- cost. In formly demonstrated across age groups.e all the Other obstacles besides negative attitudes stem from institutionalns seem goals that do not permit creative care planning. Such obstacles may being. financial or related to inadequate nursing resources. Or the problem
  • 58. fl A variety of educational programs can be designed, irrespective of N/. health care setting, that can improve the physical health, mental health, is g; self-esteem, and independence of the aged person. Gershowitz (18) sug- The gests that the best mode for restoring psychological health and, indi- tow, rectly, physical health is through remotivation techniques that encour- prof age patients to use their own past experiences and skills in coping with hav, At the present. Prior life experiences, values, and interests can be utilized by a knowledgeable staff in assisting older adults to greater independ- all I ence and improved quality of life. Feier and Leight (19) suggest that the intellectual and communication 1. P declines common in nursing home residents can be counteracted by en- 2.N gaging residents in meaningful activities. For old-timers in nursing 3.7 homes, regularly provided experiences may no longer be of interest, and 4.s cognitive performance may decline as a result. Studies carried out by 5.L Feier and Leight (19) demonstrated that when learning experiences meaningful to residents were provided on a regular basis, functional M capacity improved. who Sperbeck and Whitebourne (20) support attention to functional com- and petence and the need to teach staff how to work with older people and hom change behavior. Because institutional dependency has been found to care be related to poor self-concept and low life satisfaction, it is important unit: to investigate altering both behavior and setting to enhance resident Or autonomy. Nurses have a major role to play in identifying measures held that will offset the effects of cognitive, elimination, audiovisual, and nurs mobility problems. Regardless of disease processes, these functional posit disabilties commonly interfere with activities that could enhance self- catc esteem and encourage independence. The same principles of care apply idcn in acute, long-term and home care settings. behr 1.I OBSTACLES TO A GERIATRIC EMPHASIS )l A negative attitude toward the elderly is frequently cited as the major 3.( cause of disinterest in working with old people in any health care setting. 4. 1 Aging may be equated with disease or even death, both having negative 5. connotations in our society. All societies deny death. This is manifested 6. in various ways of ignoring the dying person or carrying on elaborate 7. rituals to keep the dead with the living, as seen, for example, in the 8. practices of keeping cremated ashes in the living room or preserving departed family members in cryogenic vaults. Belief in an afterlife is TT one of many societal supports, and the clear if unwritten goal in the fo institutions where most of us will die is to preserve life at any cost. In fact, modern medicine has added more to immortality than have all the g( theologians and church people in history combined. Physicians seem fi: determined to do almost anything to keep a human system going.
  • 59. LEADERSHIP IN CARE OF THE ELDERLY 165 .ce, and Stryker-Gordon (11) has described essential steps for nursing admin- ged pa- istrators in providing leadership in stimulating better care for olderlmands people. These include:fluence: single 1 Read in the field and divest oneself of false beliefs.Nursing 2. Examine ones personal experience with the elderly.. nurses 3. Pursue continuing education.r which 4. Take on the challenge of making quality care for the elderly com- parable to quality care for other individuals.w some; death. 5. Develop a cadre of interested nursing staff who are able to make ob-rn of re- servations and obtain information from the elderly.ral mis-he phy- The authors would add:ysicians 6. Create geriatric clinician or clinical specialist roles that give insti-rly. The tutional necognition to the importance of older adult care.rwerless. elderly The lag between nursing knowledge and practice is greater for thero have, elderly than for any other age group. Few nurses are prepared for ger-onic ill- iatric care, and few nurses know that the aging process alone is not algy, Put cause of a patients psychological condition; other causes might be drugs,rments. nutrition, disease, or depression due to grief. The nursing administrator without has wide influence in an institution and is in a better position than anyrance of other person to affect the care of large numbers of patients. For everyeal and organization that becomes a center of geriatric expertise, higher expec-ce a tre- tations of care will be sought in other organizations.ires rec- The nursing administration role in nursing homes is at a significant crossroad. National efforts are under way to improve the expertise of nurse leaders through increased opportunities for education for lead- ership in long-term care (15). Nonnursing leaders are losing power asTLY their competencies and motives are challenged. Nurses are learning that they hold the expertise to meet regulatory agencies demands and that.on, and it is the nursing profession that keeps the doors of the nursing home:ility to open (16).ho lived The 1981 White House Conference on Aging (17) provided an additional stimulus for the nursing profession to offer leadership in the care of the elderly. Major emphasis was given to the importance of such nursing80s, and leadership in health care services. Nurses have already demonstratedge per se leadership in establishing preventive health care services in nontradi-ted, who tional settings with a focus on wellness. Nurses have served as healthI or oth- care givers, counselors, and client advocates, and it is important now:r peopleo late to to direct such efforts to promoting health for older adults. Health was recognized at the conference as the chief determinant in improving quality of life for our senior citizens.
  • 60. t64 CURRENT AND EMERGING CHALLENGESfor health care workers to prevent confusion, minimize dependence, and Strlprovide physical care for older patients Skill in caring for the aged pa- istratrtient can be improved only if someone in a leadership position demands peopltnew standards of care. The nursing administrator has wide influencethroughout the institution and, aside from the physician, is the single 1. Reiperson most likely to affect the care of large numbers of patients. Nursing 2. Exiadministrators can establish the goal of having better-prepared nurses 3. Purby sharing gerontological knowledge and providing resources with which 4. Talstaff nurses may enhance their skills. par Aging is not the same as disease. The aging process may slow somemental and physical functions, but it is the disease that causes death. 5. De. serStryker-Gordon (11) notes two major obstacles to the assumption of re-sponsibility for improving the care of older patients: (1) a general mis- The arunderstanding by nurses of aging and (2) the fact that, due to the phy-sicians attitudes toward geriatric care, nurses cannot rely on physicians 6. Creas the traditional source of expertise. tut. Nurses are in a unique position to influence care of the elderly. Thefrail, disabled, and dysfunctional elderly are a particularly powerless Theand voiceless constituency (12). Burnside (13) describes the frail elderly elderlas those people who have reached a great age, over 75, and who have, iatricduring their long lives, accumulated multiple disabilities, chronic ill- CaUSenesses, or both. These changes, combined with an aging physiology put r nutrit. such people at increased risk of physical and psychosocial impairments. has wi The fraililderly person is under constant stress from within and without other and has difficulty maintaining daily living activities. Maintenance of organi wellness is difficult and illness is frequent. Recognizing the real and tation potential physical changes in old age, nursing administrators face a tre- The mendous challenge in planning patient-centered care that requires rec- crossr ognition of environmental and learning needs. nurse ership their cASSUMING LEADERSHIP FOR CARE OF THE ELDERLY they h it is tlThe basic assumption underlying all rehabilitation, remotivation, and open (reality-orientation care models is that older adults have the ability to Thelearn new behaviors. In the words of Howard Mcclusky (14), who lived stimdand functioned as a professor until the age of 82: elderl.In general, then, we are justified in sayin^g that even into the 70s and 80s, and leaderfor"all ue L.ro* ut long as we live on the functioning side of senility, age per-se leaderis no barrier to learniig. There is no one at any age, even the most gifted, who tionalis without limitation ii learning. Thus limitation per se-age related or oth- care gerwise-should not be our criterion for appraising the capacity of older people to dir<for education. We can teach an old dog new tricks, for it is never too late to recogrlearn. (pp.l2*13) qualit
  • 61. LEADERSHIP IN CARE OF THE ELDERLY T63 the aging process. A number of investigators are conducting experiments on cultured cells. Leonard Hayflick (9), in California, has shown that cultured human fibroblasts double only a limited number of times before they deteriorate, lose their capacity to divide, and die. However, he does not think that people age because some of their cells lose the capacity to divide. Rather, he attributes aging to the loss of cell function that occurs before cells reach their limit for division. As cells malfunction, body organs and whole systems are affected and eventually die (10). Other investigators attribute senescence to errors in cell operations regulated by DNA. The aging bodys increasing susceptibility to disease may be directly related to declining levels of thymosin. The increase in disease in the elderly occurs during the same period that the thymosin- producing thymus gland shrinks with age. Other biological theorists espouse the wear-and-tear theory, the lipofuscin theory, the cross-linkage theory, and the immunological theory (9). One cannot help but think that theories of aging that focus on changes in individual cells are not comprehensive enough. Yet the nature of this kind of research and the interest in prolonging life at any cost necessarily affects physicians, nurses and the decisions they make in caring for peo- ple. Many doctors and nurses still speak of finding a cure for old age,ieriatric as if it is a disease rather than part of the life cycle. There always seemsftologist, to be hope that some medication will be found to block the aging process. In a sense, then, aging presents a negative picure to health profes- sionals. In care settings, the loss of physical functions tends to blur therts own image of older people as lively, unique individuals. Students in nursingr. Older and medical schools must understand the function of all body systems; people. failure of these systems is viewed as an indication of the decline of the: health whole person.I oppor- Loss of function in primary aging occurs at varying levels in all organs.gewith and systems. Diseases, however, contribute a secondary aging effect and: health are the chief barrier to extended longevity. In primary aging, aging without disease, changes occur in audiovisual, neurological, cardiovas- cular, metabolic, renal, and respiratory function (10). When disease is present, more function is lost and at a faster pace. Nursing service administrators are responsible for nursing practice, research, and education as they relate to professional nursing withinrminant, the institution. Yet little if any attention is directed toward the care ofological old people, who now account for 25 percent of all health care costs.ical and According to Stryker-Gordon (11), the health care system in the Uniteding. The States has two standards of care: one for the aged and one for youngerdiseases patients. These problems of double standard are primarily due to failureitation. of the nursing and medical professions to incorporate gerontologicalmay not and geriatric knowledge into their educational curricula, research, andhe phys- clinical practice.r explain In hospitals, nursing homes, and home care settings, there is a need
  • 62. 162_ CURRENT AND IUEBGING CJIALLENGES the a1 on cu cultur they < Skilled nursing facility Health-related facility not tl "Nursing home" Long-term care facility "lntermediary care" to dir occur body Geriatric diagnostic Oth and regul: comprehensive care clinic may t diseas produ espour theorl One n il in ind kind o Yl.:lio"[:iil":ffi n"nt affects Pharmaceutical supplies ple. MFIGURE 12.6 The geriatric health care system. (From L.S. Libow, Geriatric as if itmedicine and the nursing home. Reprinted by permission of The Gerontologist,April 1982, 22(2), 139.) tobeh Ina sionalrthat involves provision of services across settings from the patients own imagehome to a skilled nursing home to an acute hospital, and so on. Older and mpeople are no more limited to place of care than are younger people. failureFrequently, the acute care hospital is the point of entrance to the health wholecare system, and it is at this point that nursing has the greatest oppor- Losstunity to influence decisions about continuity of care and linkage with and syaftercare. Figure 12.6 presents a model of the type of geriatric health are th,care system outlined by Libow. withot cular, presenTHE FRAIL ELDERLY AND SECONDARY AGING Nun resear(In the medical world, where a disease-illness orientation is predominant, the inssocial-psychological theories of aging are less important than biological old petheories. The identification of the causes of the numerous physical and Accorcmental afflications is the goal of research in the biology of aging. The Statesaverage human life has increased mainly because infectious diseases patienrhave succumbed to antibiotics, immunization, and improved sanitation. of the Various biological studies indicate that the cause of aging may not and gebe outside us but within us. Simple descriptions of changes in the phys- clinicaical and mental characteristics of the aged are not sufficient to explain In h,
  • 63. LEADERSHIP IN CARE OF THE ELDERLY 161, in the plete people with individual medical, emotional, and social histories (6). This single practitioner could provide:;homesi grown . Accessibility to care.ipeoplerntly in Competence of the practitioner.the 75- Caring focus.nursing Affordable care.an men Translated into reality, this mode of treatment would provide patient-for old centered care, with an emphasis on maintaining cost-effective, humanelisease, services. The elderly today pay more out-of-pocket expenses for healthe group care than when Medicare programs were first established. Even though federal expenditures for health programs increased by 35 to 40 percent:reasing between 1970 and 1980, out-of-pocket expenses paid by the elderly in- services creased 295 percent during the same period (6). Although 45 percent ofnt than the total health care bill is currently paid by Medicare, many items ofe. Long- need are excluded.d social Much of the inefficiency in care delivery is related to the lack of optimalices and services geared toward the special needs of older people. Dr. Leslie S.rgement Libow (7), the medical director at the Jewish Institute for Geriatric Care,eeds (4). Long Island, New York, envisions the nursing home as a respected place:t solely for treating people. He sees the nursing home as a major center of activityanges in in the nations health care scene and an extension of the university healththe eco- sciences.campus. Training of undergraduate and graduate students inpression, medicine, nursing, social services and allied health sciences would in- income volve exposure to geriatrics and nursing home patients.ncial as- In proposing a framework for improving the standards of care for aged people, Libow suggests that aging is the celebration of survival and ger-d people iatrics the fruition of the clinician. Increasingly, the nursing home-ifor Med- not all long-term care facilities-is the place for that celebration andranging fruition to occur. Libow sees the nursing home image changing from ased, self- place in which to die to a respected place for treating people. Libowoup who maintains that there is no respectable science and art of medicine with-I the ca- out a geriatric medicine and no true geriatric medicine without therological nursing home.tions for High standards of care for the elderly are based on the belief that ar people. continuum of care is affordable, available, and desired. Recent geron- tological research has come to grips with the inconsistent findings of relocation research. Increased mortality is not a typical or usual finding in the geriatric relocation literature (8). Increased mortality has occurred no more often than increased survival. Neither mortality effects norFessionals postrelocation decline have been observed as often as has no significant change in postmove mortality rates.3ans, andr as com- Therefore, it is conceivable to imagine a full-service geriatric program
  • 64. t70 CURRENT AND EMERGING CHALLENGES 9. Forbes, J.F. and Fitzsimons, Y .M. The Older Aduh. St. Louis: Mosby, 1981.10. Steinberg, F.V., ed. The aging of organs and the organ systems, in Care of the Geriatric Patient,6th ed. St.Louis: Mosby, 1983.I 1 . Stryker-Gordon, R. Leadership in care of the elderly: assessing needs and Part challenges. Joutaal of Nursing Administration, October 1982, I2(10), 4144.12. Moses, D. Nursing advocacy for the frail elderly. Jourutal of Gerontological N ursing, March 1982, 8(3), 144-145.13. Burnside,I.M. Nursing and the Aged. New York: McGraw-Hill, 1981.14. McClusky, H.Y. Education. Background paper for 1971 White House Con- ference on Aging. Washington, D.C.: Government Printing Office, 1971.15. Lodge,M.P.ProfessionalPracticeforNurseAdministratorsinLong-TennCare Fh Facilities. Unpublished report of the American Nurses Foundation and the Foundation of the American College of Nursing Home Administrators. Battle Creek, Mich. W.K. Kellogg Foundation, 1983.16. Eliopoulos, C. The director of nursing in the nursing home setting: an Pr emerging dynamic role in gerontological nursing. Journal of Gerontological N ursing, August 1982, 8(8), 448-450.17. Benson, E.R. and McDevitt, J.Q. Health promotion by nursing in care of the Nu elderly. Nursing and Heahh Care, January 1982,3(1), 39-43.18. Gershowitz, S.Z. Adding life to years: remotivating elderly people in insti- tutions. Nursing and Heakh Care, March 1982, 3(3), l4l-145.19. Feier, C.D. and Leight, G.L. A communication-cognition program for elderly nursing home residents. The Gerontologisl, August 198 l, 2 1 (4), 408416.20. Sperbeck, D.J. and Whitbourne, S.K. Dependency in the institutional setting: a behavioral training program for geriatric staff. The Gerontologisl, June 1981 , 21 (3) , 268-27 5.21. Benson, E.R. Attitudes toward the elderly. Journal of Gerontological Nursing, May 1982, 8(5), 279-281.22. Mlller, D.B. Society changes and the human resources component in long- term care. Nursing Homes, July/August 1982,31(4),4-9.23. Adelson, R., Nasti, A., Sprafkin, J.N., Marinelli, R., Primavera, L.H., and Gorman, B.S. Behavioral ratings of health professionals interactions with the geriatric patient. The Gerontologlsl, June 1982, 22(3),277-281 .24. LilIard, J. A double-edged sword: ageism and sexism. Journal of Geronto- logical Nursing, November 1982, 8(l l),630-634.25. Simms, L. M. and Lindberg, J. Women and the lengthening life span, inThe Nurse Person New York: Harper & Row, 1978.BIBLIOGRAPHYU.S. Department of Commerce, Bureau of the Census. Statistical Abstract of the United States:1981. Washington, D.C.: Government Printing Office, 1981.U.S. Department of Health and Human Services. The Need for Long-Term Care: A Chartbook of the Federal Council on Aging. Washington, D.C.: Government Printing Oliice, 198 l.

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