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Part 5 6 Part 5 6 Document Transcript

  • PartvManaging l{urnanResources
  • 18Mobilizing Existing The purpose of this chapter is to discuss an approach to mobilizing existing nursing resources according to levels of expertise, consid- ering work and education experience. Assignment patterns are dis- cussed in terms of organizational variables, nursing resources, and patient care needs. On completion of this chapter, the reader will be able to: 1. Discuss nursing resources as a concept. 2. Differentiate between recruitment and retention activities. 3. Explain factors related to the nursing shortage. 4. Relate competency and relicensure issues to availability of professional nursing resources. 5. Describe a data-based methodology for selecting a nursing as- signment pattern that meets patient care and organizational needs. 5. Propose several solutions to recruitment and retention prob- lems.Trying to understand recruitment and retention problems in nursingtoday is like looking for a straw in the wind and trying to describe itspath. The wind keeps shifting, and a tornadic gust threatens to blowthe whole issue out of our sphere of influence, if not out of nursingsarea of responsibility. Many hospitals have moved in the direction ofnonnursing control of nursing recruitment and retention through theestablishment of human resource departments that control hiring andfiring of all health personnel. Nursing is the focal point for the the delivery of patient care in allhealth care delivery settings. Failure to change or implement new as-signment patterns, such as primary nursing, may be the result of a lack 249
  • 250 MANAGING HUMAN RESOURCESof understanding of nursing resources and of the appropriate use ofnurses according to experience and expertise.NURSING RESOURCESNursing resources have been defined by Munson, Beckman, Clinton,Kever, and Simms (1) in terms of selected variables all of which haverelevance for care assignment and quality care. Table 18.1 identifiesand explains the various nursing resource components, ranging fromstaff mix and preparation to commitment, stability, availability, andspecial training. This conceptualization provides a broad perspectiveon the components of a nursing resource configuration. These compo-nents are covered in greater detail later in this chapter in the discussionof assignment patterns. iRECRUITMENT, RETENTION, AND TURNOVERHistorically, nursing has experienced high turnover and cyclical short- 6 ! qages. In 1982, discussions of the nursing shortage were especially ramp- ( oant. By 1984, the economy and the advent of prospective payment had 0 cchanged the entire picture of recruitment and retention. Because of the :large number of nurses in the work force, recruitment became an ir- a- k rrl U F.relevant issue, and retention of high-quality, satisfied nurses seemed tobe a possibility for the first time in many years. Recruitment refers to all those activities carried out by a nursing orpersonnel department to attract nurses to a particular work setting forpurposes of interviewing and hiring. Retention activities designed tokeep nurses in the work setting have received less than appropriate at-tention. Dramatic attempts have sometimes been undertaken to recruit o a)regardless of qualifications. The problems that have lead to nursing dshortages and the difficulties of retaining nurses have not been addressed Iron a large scale by nursing and the health care industry. a According to Wolf (2), administrative philosophy and policies con- lrtribute more than any other factors to a high turnover rate, which is cthe direct result of inadequate attention to retention and staff satisfac- .^.o cd !tion. Wolf further describes salary and job conditions as the leading .. bocauses of high turnover. Salaries by and large are simply not at the *A is .o,same level as those of other workers with comparable education in oursociety. In addition, there is little difference in nursing pay scales ac- ;.7 rs acording to level of preparation and experience. Aiken, Blendon, andRogers (3) also cite the limited growth in nurses salaries as a primefactor in retention and turnover difficulties. They further suggest that View slide
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  • 252 MANAGING HUMAN RESOURCES in relation to those of other workers, more nursesas nurses incomes rise Johns<become available for hospital employment, and vacancy rates decline. leakage Why do nurses quit their jobs? The following reasons have been ob- I evidenceserved by the authors over time and have been documented in the lit- Over theerature by many others: of nurses enty-five Low salaries and little reward for experience in the 19r Low prestige ing child. Much responsibility and little recognition visualize< Inflexible hours and schedules Variout and VauS Excessive overtime mand for Anger expressed by physicians toward nurses faster th: Gap between education and practice higher ac Lack of autonomy delivery < Too much work Rose (7. Quantity of assignments interferes with quality tional tur The supp Frequent reassignment to unfamiliar units the emph Assignment to units not compatible with skills simply d< Poor physician-nurse relationships sired. Mo Incompetent and unsupportive supervisors lection o. Lack of opportunity for advancement professior are no lor There may be other contributing factors, but these issues appear over Aiken (.and over again in the literature. Equal pay for equal work is no doubt nursesp: incomes aa major influencing variable, as the gap between nurses and physicians responseincomes has widened dramatically over the last several years (3). in relativr control ov ceived sh<THE PERCEIVED NURSING SHORTAGE sonnel is s could be <In recent years, much attention has been focused on the critical shortage Beyers (of nurses, particularly in hospitals. For the following reasons, it is dif- and careeficult to understand why a shortage is perceived to exist (if, indeed, one as opposedoes any more): agency. Te not be cot One fin:1. There has been an overall decline in the growth of hospitals over the the vast nr past three decades. Since 1950, the ratio of hospital beds to population are opport has dropped by one-third (a). settings th2. Since 1950, the general hospital occupancy rate has declined signif- ing admin icantly (4). ploring su3. Since 1950, the nations output of nurses has doubled (5). model cou
  • MOBILIZING EXISTING RESOURCES 253ore nurses Johnson and Vaughn (6) find no statistical evidence of significant:s decline. leakage from the profession. On the contrary, they observe that most: been ob- evidence provided to support a shortage is based on anecdotal material. in the lit- Over the last 10 to l5 years, there has been steady growth in the supply ofnurses. There has also been an increase ofnewly licensed nurses. Sev- enty-five percent of all nurses are employed, an increase from 55 percent in the 1960s. Even though nurses may vacate positions temporarily dur- ing childbirth, they do return. The current supply of nurses should be visualized as a dynamic, constantly changing, constantly growing entity. Various reasons are cited for the perceived shortage of nurses. Johnson and Vaughn (6) call attention to the high probability that employee de- mand for nurses has been increasing and continues to increase at a rate faster than the supply of nurses is increasing. This may be due to the higher acuity rate in all settings and the technological revolution in the delivery of care. Rose (7) describes the problem as one of intensity of annual institu- tional turnover, which ranges from 35 percent to 60 percent nationwide. The supply of nurses is also influenced by payment mechanisms. With the emphasis on cost containment, government ceilings on care costs simply do not allow for the number of nursing positions needed or de- sired. Moreover, the womens movement continues to influence the se- lection of nursing as a career, as women may increasingly choose professions in medicine, law, dentistry, the sciences, or the ministry and are no longer bound to those in teaching or nursing.ppear over Aiken (3) equates the perceived shortage to the dramatic increase ins no doubt nursesparticipation in temporary service agencies to maximize theirphysicians incomes and control their working hours. Agencies have proliferated inrs (3). response to the increased need for temporary services and the decline in relative income for nurses. In addition, nurses wish to have more control over their working hours. One often forgotten reason for the per- ceived shortage is that the differential cost of a nurse over other per- sonnel is so small that hospitals may be substituting nurses in jobs that could be done by nonnurses.:al shortage Beyers (8) believes that not enough attention is paid to job promotionrs, ir is dif- and career advancement, which provide functional turnover patterns,.ndeed, one as opposed to the dysfunctional turnover when employees leave the agency. Temporary vacancies exist with functional tumover that should not be counted or depicted as a nursing shortage.lls over the One final rcason for the pcrceived shortage is thc incomplete usc of the vast nursing expertise in schools of nursing around the country. Thcre population are opportunrties for facultir practice in acutc, long-term, and home carc se ttings that could be attraitive to schools of nursing, but, to date, nurs-ined signif- ing administrators and educators have not taken the initiative in ex- ploring such options. A contract for scrvices or a shared consultation). model could be developed in most settings.
  • 262 MANAGING HUMAN eE9QrrRqES _ 9. Sta3. Interest in flexible hours with more leisure time and social oppor- Nur tunities (21). 10. Mic4. Need for role transition guidance (22). Reli soci Perhaps most important is the element of support services. Nurses 1l. Claare more satisfied and more likely to stay in organizations where support ed.services are adequate and they do not have to carry out extensive non- 12. Joh tionnursing tasks. 13. Horr U.rp PublSUMMARY 14. Shu. JourThe nurse administrator should support the competency of nurses by 15. Betzbuilding on the educational preparation appropriate for their assigned Marrroles and by using assignment patterns selected through data-based de- 16. Eliolcisions. Such an approach to using nursing resources differs from that high t 3(1(found in traditional nursing texts. The availability of nursing personnel, 17. Carkcoupled with organizalional and patient characteristics, should dictate primnursing assignment patterns. Selection of any model without considering Junethese variables usually is a contributing factor in dissatisfaction and 18. Shukhigh nurse turnover. Servi 19. Friss pensiREFERENCES Decer 20. Duxb Joum L Munson, F.C., Beckman, J.S., Clinton, J., Kever, C., and Simms, L.M. Nursing 21. Vik, ] Assignment Patterns. Ann Arbor, Mi.: Health Administration Press, 1980. The J, 2. Wolf, G.A. Nursing turnover: some causes and solutions. Nursing Outlook, April 1981, 29(4), 233-236. 22. Dear, hospi 3. Aiken, L.H., Blendon, R.J., and Rogers, D.E. The shortage of hospital nurses: 1982, a new perspe ctle. American J ournal of N ursing, September 1981, 8 1 (9), 1612- 1618. 4. American Hospital Association. Hospital Statistics: Data from the American Hospital Associtttion 1979 Annual Suwey. Chicago: American Hospital As- sociation,1980. BIBLIO 5. U.S. Department of Health and Human Services, Division of Health Profes- sions Analysis. Supply of Manpower in Selected Health Occupations, 1950- Hofmann, 1990. DHHS publication no. (HRA) 80-35. Washington, D.C.: Government reducti< Printing Office, 1980. tI (11-r 6. Johnson, W.L. and Vaughn, J.C. Supply and demand relations and the Munson, I shortage of nurses. Nursing and Heabh Care, November 1982, 3(9),497-507 . search, . 7. Rose, M.A. Factors affecting nurse supply and demand: an exploration. The Weisman, Iournal of Nursing Administration, February 1982, 12(2), 3l-34. Journal 8. Beyers, M., Mullner, R., Byre, C.S., and Whitehead, S.F. Results of the nursing personnel survey, part 2: RN vacancies and turnover. Journal of Nursing Administration, May 1983, 13(5), 26-31.
  • MOBILIZINC EXISTING RESOURCES 261 in the same hospital. Shukla (14) found that on matched units, where nurses had similar educational backgrounds and experience, differences in quality of care between primary and team nursing disappeared. Thisen by the raised the question as to what makes the real difference in quality and satisfaction: the competency of the nurse or the nursing assignment pat-Ig the care tcrn. Betz (15) also found that nurses were not always more satisfied withvolved in primary nursing. Betz compared three team nursing units with threeers for a primary nursing units over a year and discovered that primary nurses were less satisfied than team nurses, depending on educational level.nners for a Primary nurses had difficulty delegating responsibility, utilizing per- sonnel, and setting priorities. B.S.N.s showed the greatest drop in sat-nsible for a isfaction when moved to team nursing.stay on a In the long-term care setting, Eliopoulos (16) explores the use of the registered nurse in a professional manner. She believes it is an unrealistic)ommon goal in long-term care to increase the ratio of registered nurses, in lightrf nursing of the number of tasks that can be delegated to nurse assistants. Herit common preferred approach is the team assignment pattern.)lvement In a large research hospital survey, Carlsen and Malley (17) determinedvolvement that neither team nor primary nursing afforded sufficient opportunities)atients for self-fulfillment, decision making, or independent judgment. Neitherns (CCC) system provides sufficient opportunities to meet self-actualization needs.;C) The need for primary nurses to be superwised was an unexpected finding.dof In dealing with high turnover, the nurse administrator must not as-rift sume that primary nursing is the answer. Jumping on the primary nurseNursing As- bandwagon may be possible only if qualified baccalaureate-prepareds, 1980, p.5. nurses are available for the primary nurse role. Shukla (18) suggestedacting other that when nurse competency is controlled, the primary nursing structureve or simplv does not provide more direct care than does the team or the modular structure. On the contrary, the primary nursing structure provides the least amount of direct care, suggesting that the competency of the nurs- ing staff may have a greater impact than the structure. An additional finding in Shuklas work was that the modular structure is most pro-ve way to ductive. Registered nurses did not perform as many nonprofessional oruate high indirect care tasks. Modular nursing has been defined as a miniteam,t for con- as it provides the features of both team and primary nursing assignmentoss units. patterns. The R.N. works in a subunit, or module, with an L.P.N. or aideand R.N./ but does not follow the same patients if they are transferred to another subunit. Other important issues in dealing with turnover problems are pur- ported to be:e, but its 1. The propensity to leave the organization (19).;ing units 2. Inadequate information about leavers and stayers (20).
  • 260 MANAGING HUMAN RESOURCESTABLE I8.3Elements of the Nursing Assignment Pattern in the nursesVariable Name Basis for t ariable Definition in qualNursing care integration (NCI) The proportion of total care given by the raised person providing the most care satisfarCare management integration The number of persons managing the care tern.(cMr) process at a given time BetzPlan-do integration (PDI) The proportion of care givers involved in primar the planning of care primarNursing care continuity (NCC) The average number of care givers for a patient over a seven-day period rvere leCare management continuily The average number of care planners for a Primar(CMC) patient over a seven-day period sonnel,Care management continuity Whether a care planner is responsible for a isfactioacross settings (CMCI) patient before or after patients stay on a In th unit registerNursing coordination (NC) An index that records the most common goal in pattern of on-unit coordination of nursing of the r care activities for a patient preferrtCare-cure coordination (CCC) Two indexes that record the most commonPatient services coordination pattern of the. nurses direct involvement Inal,(PSC) and the proactiveness" of that involvement that nei in coordinating other inputs to patients for self- care requirements from physicians (CCC) system and from other professionals (PSC) The neeIntershift coordination (ISC) An index that records the method of In der communication by which intershift coordination is achieved sume th bandwaSOURCE: F. Munson, J. Beckman, J. Clinton, C. Kever, and L.M. Simms, Nursing Assigwnent Pattens LIsers Manual. Ann Arbor, Mi.: Health Administration Press, 1980, p. 5. nurses i"Proactiye: taking the initiative in coordination activities, for example, contacting other that wh personnel, making referrals, problem solving. Reactire.not initiating: a passive or simply does no cooperative response to coordination initiatives from others. structur least an ing staftImplications finding ductive.This study has several implications. By providing an effective way to indirectacquire a data base, the nursing administrator can better evaluate high as it procost assignment patterns, can select a particular component for con- patternscentrated study, or can more logically make comparisons across units. but doesThis study further suggests the need to view staff satisfaction and R.N./ subunit.L.P.N. ratios as important aspects of nursing resources. Other ported tImplication for Turutover ProblemsPrimary nursing may be a better system for organizing care, but its 1. The peffectiveness is not uniform for all types of nurses, even on nursing units 2. Inade
  • MOBILIZING EXISTING BEIQUBQES 259 TABLE I8.2 Hospitaloutcomes Central Elements of the "y"9 |1.g.l-:4}tt"11 !!t"_c!!!9" Contirtuitv Coordination Nursing care Nursing care Nursing coordination integration (NCI) conrinuity (NCc) (NC) Care management Care management Care-care coordination integration (CMI) continuity (cMC) (ccc) Plan-do integration Care management Patient services Patient (PDI) continuity across coordination (PSC) care qua lity settings (CMCI)outcomes Additional integration, continuity, and coordination variables were conceptualizedro complete the profile. Note on Table 18.3 the elements Person nel+ satisfaction of integration, care management, continuity across settings, and the co- outcomes ordination elements of care-cure, patienl services, and intershift coor- dination. - Cost of care By collecting specific data, a nursing unit can determine the type of- outcomes assignment pattern actually in use. It is also possible to look at patient(Reprinted characteristics and consider which elements of the nursing assignment,on, Joanne pattern are most closely related to the needs of the patients. For example,M. Simms, a patient with high psychosocial support needs may benefit tremen-)80.) dously from a high level of nursing care integration, that is, care provided by a single person. By contrast, the patient with multiple and complexwhich the care requirements may benefit from the care of several specialists.ere devel- Based on nursing resources, it is also possible for a unit to consider(13) were whether it is appropriate to move toward greatcr care management in-/eness, ac- tegration, a different level of care management continuity, or a differentdeveloped type of intershift coordination. In summary, the elements of a nursings, nursing assignment pattern can be prioritized in order of importance according to the availability and competence of the nursing resources.ized: care A great advantage in using this approach is the opportunity to lookt includes for the weak and strong points in organizational support. For example,ulation of it is difficult to have high levels of care management continuity whenrventions, nurse staffing or scheduling systems provide a constant rotation of theof nursing nursing staff within a hospital. Scheduling and staffing policy are in- a nursing tricately related to nursing assignment pattern decisions. The findings in the Michigan study suggest a betler way to look atnagement assignment patterns. The identification of the key elements of the nursingssignment assignment patlern lead to the development of data collection instru-llans. In a ments specific to three variables: patient characteristics, nursing rc-rf the hall sources, and organizational support. The study further demonstratedr. Nursing that this kind of infcrrmation can bc quantified and displayed in a format, patterns, lhat can be used to defend an existing pattern or a change to a newlumber of pattern.
  • 258 MANAGING HUMAN RESOURCES I nfluencing Professtonal Nursing Quality standards Hospital TABLE factors: judgments and unit for nursing empirical structu re process: outcomes: Central research that esta bilsh and policy: rtt"s!! re lations: Nursinp integrat T-----*---t Care mz Patient I I Comprehensiveness I integrat characteristics l- Connective Nursing I Accountability I PIan-dottursinc resources propostlons Assignment -+l Patient | | pattern I Continuity i ! care (PDD I i L-.>j quality Organizational I i Coordination I I support L__________.1 outcomes J i f--------- r Addit | Schedulinc I concept i ^sturiinc i i Personnel p_- of integr t---r----- +----- --------.1 satisfaction outcomes ordinati I Dailv allocations I rl I dinatior t---l L-_:_-______-l | - Cost of care By co outcomes assignmFIGURE 18.1 Nursing assignment pattern conceptual framework. (Reprintedfrom Nursing Assignment Pattenls (Jsers Manual, by Fred C. Munson, Joanne characteSchultz Beckman, Jacqueline Clinton, Carolyn Kever, and Lillian M. Simms, pattern iby permission of Health Administration Press, Ann Arb<tr, Mi., O 19S0.) a patien dously fr the organization. Figure 18.1 shows the framework within which the by a sinl definition of the elements of a nursing assignment pattern were devel- care reql oped. Four quality attributes identified by Horn and parker (13) were Basedused as the basis for the conceptual framework: comprehensiveness, ac- whethercountability, continuity, and coordination. Instruments were developed tegratior to measure the influencing factors of patient characteristics, nursing type of irresources, and organizational support. assignm( within [he nursing process, two basic activities are recognized: care to the avgiving and care planning, or management. Care management includes A greaassessment of patient requirements for nursing care, formulation of for the wnursing diagnosis, stating outcomes of care and nursing interventions, it is diffiand evaluation. care giving refers only to the implementation of nursing nurse stainterventions. Table 18.2 highlights the four central elements of a nursing nursing sassignment pattern. tricately These elements vary across assignment patterns. Care management The finintegration (cMI) would be relatively high in a functional assignment assignmeipattern and in a primary nursing pattern where one person plans. In a assignmeteam assignment pattern in which the team changes sides of the hall ments spevery week, care management continuity (CMC) would be lower. Nursing sources, icare integration (NCI) would be high in most primary nursing patterns, that this Ilower in team, and lowest in functional, with the greatest number of that cancare givers. pattern.
  • MoBILIZINc EXISTING RESoURCES 257I settings.d division could functionally assign tasks within the team itself, with less concern:n evolved for the number of personnel rendering direct care to an individual pa-,d a redis- tient. In functional nursing, the picture of variation is less clear, for few:luded the nursing departments now identify with this structure. Yet one can rec-nsed prac- ognize this structure in hospitals, where there is a separate specialiston getting for activities such as discharge planning, patient education, medications time and administration, and so on.asks-cat-ortance to;kill levels. A NEW APPROACH TO NURSING ASSIGNMENTients care PATTERNS[ed within The purpose of a recent two-year study at the University of Michiganre basis of was to develop useful tools for nurses in management and clinical prac- personnel tice who are faced with nursing assignment pattern decisions. The pro-m nursing ject included (1) development of instruments to measure nursing as-iary work- signment patterns, patient characteristics, nursing resources, andhe diverse organizational support; and (2) the publication of a nursing assignmented nurses. users manual (1); decisions This demonstration project collected data in four hospitals. Prelim-:am leader inary work was essential to the quality of the project and included::mbers.[or nursing l. Development of a conceptual framework within which the definitionrg requires of the elements of a nursing pattern could be developed.lager-per- 2. Literature review of about 270 items selected for their potential con-s aide ac- tribution to an understanding of the linkage between patient char-atient and acteristics, nursing resources, and organizational support and ap-I practical propriate nursing assignment patterns.:ontinuum 3. Development of connective propositions from the literature review nurse. De- that could translate the data into appropriatc recommendations for: giver and a units nursing assignment pattern.ather thaning assign- 4. Development of the instruments..nd no one In developing the essential instmments, the study group found it useful1e pattern, to go beyond the traditional nursing assignment patterns (functional,he primary team, or primary) and to think of three major dimensions in any nurse plans and utilization pattern: patient characteristics, nursing resources, and or-scharge or ganizational support.rsing unit.lnagement Conceptual Frameworkrder mightlch patient The pattern of nursing assignmcnt on any patient unit may be seen as:am leader a link between problems, as presented by different patient populations, and purpose, as expressed bv professional standards and purposes of
  • 256 MANAGING HUMAN RESoURcESof the use of nursing personnel in providing care in hospital settings.One type of assignment pattern focuses on specialization and division could frof labor, or functional nursing. This type of assignment pattern evolved lor thein response to political and economic factors that demanded a redis- tient. Irtribution of registered nurses during World War II and included the nursingcreation of new nursing personnel categories such as the licensed prac- ognize 1tical nurse and the nurses aide. Functional nursing focuses on getting for actir.the greatest amount of task work done at the least cost in time and administraining. This pattern is accomplished by assigning specific tasks-cat-egorized or ordered according to degree of difficulty and importance topatient well-being-to nursing personnel with corresponding skill levels. A NEWThe use of multiple personnel to provide elements of a patients care PATTErequires a level of coordination and decision making best handled withina formal unit structure with a well-defined hierarchy. The purl Following the focus on specific technical excellence as the basis of rvas to dtassignment patterns was an emphasis on integrating nursing personnel tice whoof varying skill levels into a democratic, close-knit team. Team nursing ject inclrrepresents another way of adjusting care to the influx of auxiliary work- signmeners and was created to improve patient care by utilizing the diverse organizatskills of team members under the close guidance of registered nurses. users meThis pattern shifted much of the authority for making nursing decisions This deto a lower level in the nursing hierarchy: the registered nurse team leader inary worwho assumes responsibility for care given by other team members. The most recent pattern to develop places the responsibility for nursing 1. Develccare management within the direct care giver. Primary nursing requires of the ,that the registered nurses activities change from care manager-per- 2. Literatsonnel organizer to care manager-care implementer. Nurses aide ac- tributitivities are refocused away from direct contact with the patient and acteristoward equipment and supplies. The services of the licensed practical propri:nurse are not used in this pattern or fall somewhere on a continuumfrom direct patient care to direct assistance to the registered nurse. De- 3. Develocisions in the care process are usually made by a single care giver and that coare facilitated through horizontal consultation with peers, rather than a unitswith line authority. Primary nursing has been the basic nursing assign- -1. Develolment pattern used in community health nursing. Each assignment pattern has had its day of popularity, and no one In devekbest way has emerged for all settings.Indeed, within the same pattern, to go beycthere is no clear description of nursing responsibility. Within the primary ieam, or pnursing pattern, the time duration in which a primary nurse plans and utilizationgives care to a patient might span hospital admission to discharge or sanizationbe limited to a patients length of stay on a particular nursing unit.Within a given day, primary nurse responsibility for care management Conceptuimay vary from 8 to 24 hours. In team nursing, the team leader mightcarefully match patient needs to team member skills so that each patient The pattenmust cope with only a limited number of personnel; or the team leader alink betw and purpor
  • MoBrLrzrQl>(EuNE BqgouRCES 255 competent in their assigned roles. However, these assigned roles cannot be determined in educational settings away from the work environment. The technological revolution has created a situation in which educationle past 10 is far behind practice. Nurse administrators are the professionals in thedecreased best position to see the needs of the patients and the organization.lant under Johnson (12) describes competency by the standards of the state ofill become New Jersey as "being functionally able to perform duties of an assigned: questions role. The functions are performed having drawn conclusion for this ac-f nursing? tion from a sound knowledge of related sciences. The judgments madeork? What are based on a logical assessment of a given situation. Both deductive;e workers and inductive reasoning are imperative to competent practice."sing prac- The licensed practical nursing role is a dependent role. For minimal- level competency in todays dynamic health care system, the practical onal nurs- nurse should be prepared at the associate degree level. Registered nursesnursing is should be prepared at the baccalaureate level and have studied super-red knowl- vision and management. As nurse administrators conduct job and nurs-Lvioral sci- ing staff analyses, they need to have competent nurses and nurse as-ndividuals sistants in order to develop assignment patterns designed for quality, es or who cost-effective care delivery.vention or:red nurse It is no longer acceptable to deny the legal accountability of the professional nurse by creating such titles as primary or team leader or practical modular nurse. Prospective payment legislation demands a quantifi-oerformed cation of nursing services. The first unknown to be defined in the equa-cr dentist.o minimal tion is nurse. The nurse administrator has the best key to solving theprofession, following:ference in n * assignment pattern : quality care)s, contro-N.s. Inev- education The assignment pattern is easy to identify once a clear decision has been frequently made about n (nurse).ent would Institutional licensure is greatly feared as the antithesis of independentement for professional licensure. If nurses do not assume responsibility for practice as defined in most state practice acts, it may be only a matter of time a trained before institutional licensure takes over as a method of competency;sion with maintenance for relicensure. Nurse administrators must create practicetability to environments that address the best use of nurses, associate degreestitutions through doctorate. Nursing assignment patterns based on the creationlities, and of new titles without attention to the competence of the participantsls for who lack credibility.r the basicrrs, beforent pattern TRADITIONAL ASSIGNMENT PATTERNSrncerning During the last three decades, an extensive literature has developed onnurses be the subject of nursing assignment patterns, reflecting the importance
  • 254 IVIANAC!G Iu I44N &E!9 U 3e El compelCOMPETENCY AND RELICENSURE be dete The tecThe pool of employed nurses has steadily increased over the past 10years, and the proportion of inactive nurses has substantially decreased is far br(a).If a clear identification of nursing services is really important under best poprospective payment, perhaps an analysis of nursing jobs will become Johns New Jeias mandatory as continuing education is in many states. Some questionsto be answered in such analysis include: What is the work of nursing? role. ThWhat should it be? Who should be doing which parts of the work? What tion fro. are basrwill be the competencies of the workers? How will the nurse workers and indrmaintain competency according to their level of expertise? Most states have health occupation legislation covering nursing prac- The litice and licensure provisions that specifically address professional nurs- level cor nurse sh,ing. In the state of Michigan, for example, the practice of nursing is should bdefined as "the systematic application of substantial specialized knowl- vision aredge and skill derived from the biological, physical, and behavioral sci-ences, to the care, treatment, counsel, and health teaching of individuals ing staff sistants iwho are experiencing changes in the normal health processes or who cost-effecrequire assistance in the maintenance of health and the prevention ormanagement of illness, injury, or disability" (9). The registered nurse It is nr professioengages in the practice of nursing; the practice of licensed practicalnursing is considered a subfield of the practice of nursing performed modular cation ofonly under the supervision of a registered nurse, physician, or dentist.Incompetence means a departure from or failure to conform to minimal tion is ne followingstandards of acceptable and prevailing practice for the health profession,whether or not actual injury to an individual occurs. Although the laws in most states clearly describe the difference inlevels of competency between registered and practical nurses, contro-versy continues to iage about substitution of L.P.N.s for R.N.s. Inev-itably, nursing must come to grips with the idea of a standard education The assigrfor a professional activity. Although "B.S.N. or equivalent" is frequently made aboused to state a position requirement, no personnel department would Instituti professionrever argue for an M.D. or equivalent as the minimum requirement fora physicians appointment. as defined Over the years, nursing has evolved from the services of a trained before insnurse who learned skills at the bedside to those of a profession with maintenarstandards of education and practice and recognized accountability to environm,the public. Credentialing at graduation from accredited institutions through drsuggests that minimal criteria with respect to faculty, facilities, and of new tit.program have been met. Nurse administrators set the standards for who lack credilwill do what in nursing in their settings. They need to consider the basiceducational competency of the participants, among other factors, beforedeciding on a particular organizational structure or assignment pattern TRADITI(10). Fragmented, irreler,ant discussions prevail nationwide concerning During thecompetencies for registered nurses (11). It is important that nurses be the subjecl
  • !!QB4rzre EXIIIING 3Eq9!4cEq _ _z03 9. State of Michigan Public Health Code, Article 15, Occupations Part 172,oppor- Nursing. 1978. 10. Michigan Nurses Association Task Force. Position Paper on Competency for Relicensure of Michigan Nurses. East Lansing, Mi.: Michigan Nurses As- sociation, 1978.Nurses 11. Clayton, G.M. Identification of professional competencies, in N.L. Chaska, ed. The Nursing Profession. New York: McGraw-Hill, 1983.;upport 12. Johnson, H. Maintaining competency: a call for collaboration. lssrzes, Na-ue non- tional Council of State Boards of Nursing, Summer 1983,4(2),3. 13. Horn, B.J. and Parker, J.C. Reorganization of Nursing Resources in Hospitals. Unpublished manuscript. Ann Arbor, Mi.: University of Michigan School of Public Health, 1975. 14. Shukla, R.K. Primary nursing? Two conditions determine the choice. The Journal of Nursing Administration, November 1982, f 2Q1),12-15.rses by 15, Betz, M. Some hidden costs of primary nursing. Nursing and Heakh Care,;signed March 1981, 11(3), 150-154.sed de- 16. Eliopoulos, C. Nurse staffing in long-term care facilties: the case against arm that high ratio of RNs. The Journal of Nursing Administration, October 1983, /3(r0), 29-31.sonnel, 17. Carlsen, R.H. and Malley, J.D. Job satisfaction of staff registered nurses indictate primary and team nursing delivery systems. Research in Nursing and Health,;idering June 1981, 4(2), 251-260.on and 18. Shukla, R.K. Nursing care structures and productivity. Hospiteil and Health S ent ic es Admini s trat iorz, November/Deccmber 19 82, 27 (6), 45-5 8. 19. Friss, L. Why RNs quit: the need for management reappraisal of the "pro- pensity to leave." Hospital and Health Services Administration, November/ December 1982, 27(6), 28-44. 20. Duxbury, M. and Armstrong, G.D. Calculating nurse turnover indices.The Journal of Nursing Administration, March 1982, 12(3), 18-24.Nursing1980. 21. Vik, A.G. and Mackay, R.C. How does the l2-hour shift affect patient care? The Joutnal of Nursing Administration, January 1982, 12(l), 11-14.)utlook, 22. Dear, M.R., Celentano, D.D., Weisman, C.S., and Keen, M.F. Evaluating a hospital nursing internship. The Joumal of Nursing Administration, Novembernurses: 1982 , 1 201,), 16-20 .t, 1612-nericanital As- BIBLIOGRAPHY Profes- 1950- Hofmann, P.B. Accurate measurement of nursing turnover: the first step in its nment reduction. The J ournal of N ursing Administration, November/December 1 98 l, 1 t (t t-12) , 37 -39 . nd the Munson, F. and Clinton, J. Defining nursing assignment patterns. Nursing Re- 7-507. search, July/August 1979, 27(4), 243-249. >n. The Weisman, C.S. Recruit from within: hospital nurse retention in the l980s.The Journal of Nursing Administration, May t982, 12(5),24-31. rursing tursing
  • 19 istrato staffinl Nurs pretati,Stafnng and Schefuling compol cation. personl entailsYvonne M. Abdoo on pati signme A gre staffing The purpose of this chapter is to discuss requirements and consid- describ erations in nurse staffing and scheduling. The evolution of nurse (l) asse staffing is briefly explained, and current state-of-the-art systems are described. Various scheduling methodologies and trends in Nurse st sound ra workday length are explored. On completion of this chapter, the required reader will be able to: patients number l. Describe the trends in the development of patient classification and kin< systems in nursing. week. . . 2. State four work measurement methods that have been utilized public tl to measure nursing activity times. and the 3. Identify at least five factors related to physical surroundings and professional nursing practice that could affect nursing The p activity times. tifiable, 4. Describe the advantages and disadvantages of: must in a. Cyclical scheduling. needs (p to meet b. Block scheduling. gorithm c. Float, or supplemental, nurse staffing. sonal flr d. A 10-hour workday and a 4-day workweek. variable e. A l2-hour workday and a 3-day workweek. Devia f. Centralized versus decentralized scheduling. proach , 5. Discuss the physiological effects of shift rotation and cisions 1 the implications for nurse staffing. its comlOne of the most critical issues confronting nursing service administratorstoday is nurse staffing. Staffing policies and needs affect the nursing THE Edepartment budget, staff productivity, quality of care provided to clients,nursing staff morale, and even turnover. At the same time, nurse staffing Nurse strequirements are affected by overall hospital policies and by nearly every publisheother department in the organization, including admitting, lab, x-ray, on the udietary, and the like. Thus, it is essential that nursing service admin- the deve264 a hospitr
  • slAl l,lN{;ANl}:i( lnrt)lrilN(, .l/ 272 MANA(;tN(;tttlMAN l{lis()tllt(t,s Itctcttctlo rt grtl:trrl ;,l,rrr,,r Pt,rtcclrttc wirs n()l s.trr lry rrrrlsinl. pr.r:,orrnr.lof nursing carc rcquircrncnts. llris schcnra rcsults in 3u, ol ti I , pt-rssiblc as citlrtrcsstttli;rl ot rlt:.itlrlrlt.l[rc wotlt sccltttrrcrlrrrtl l)ir((w(11.ri(.1basic classification configurations, cach with its own mean nursing timc by othcr kirrrls ol plior itits" ( I ).and variance to reflect the nursing work load of medical patients and Improvcntcttl irtttl trlirrr,rttcttts in dctcrmirri-rtiorr ol nrrrsirrg irctivilyanother 81 means and variances for surgical patients.Intravenous ther- times can ottl.y occur il thc rrurse has a basic unclcr-starnclirrg ol wolltapy, catheter care, dressing care, and isolation are included in a special measuremcnt principlcs so that effective collabroratiorr witlt irrclr-rstlitrIprocedures section, since these activities have been found to reflect a engineers will occur. Four basic work mcasurcntcnt tcclrniclucs lrirvthigh amount o[ nursing time. been utilized in nursing studies to determine thc timc involvccl irr rrtrrsirrli activities (22):WORK MEASUREMENT IN NURSING 1. Time study and task frequency 2. Work sampling of nurse activityThe determination of the amount of nursing time required by each pa- 3. Continuous observation of nurses performing activiticstient for every shift is an essential but by no means simple component 4. Self-reporting of nurse activity.of a staffing methodology. Nursing has relied primarily upon industrialengineers and engineering work measurement techniques to quantify Difficulties encountered by nursing in using industrial-basccl w,rl<nursing actions, but there are often problems with the values obtained measurement methods to measure nursing practice are as follows:For example, many of the allocated time values for patient care dealonly with technical tasks. Difficulties in quantifying nursing times can 1. Many of the allotted time values deal with technical tasks, sirr.t,rlrt,be attributed to several causes: industrial engineer or observer does not recognize thc assr.ssrrrt,rrr, evaluation, and psychosocial aspects of the nurse-paticnl torr llrt t .1. The industrial engineer or nonnurse observer does not recognize the Thus, a patient who requires technical tasks could very likcl.y bc r.irlr.rl assessment, evaluation, and psychosocial aspects of the nurse-patient in a higher category than one who requires psychosocial or- tcirt.lrinli contact, and the nurse often does not convey these components of activities. professional nursing practice to the industrial engineer, due to the 2. In developing a patient classification system, some nursing clcltirr.t- nurses unfamiliarity with work measurement techniques. ments borrow the nursing times from the classification systcrrrs ol2. It is often difficult to differentiate between the start and completion others. It is important to realize that the times for one agcncy nt:rv of a nursing activity. For example, while giving a patient a bath, the not be accurate for another, since the nursing policies and proccclrrr.t,s, nurse interacts with the patient. How much of the time spent with unit architecture, experience of the nurse, and methocls o[ irrrplt the patient should be allocated to the technical task of bath giving menting the work can vary from agency to agency. and how much to assessment and interaction? 3. Many systems employ the mean time for a task without any corrsitl3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colleagues (23) havc fburrcl tlr.t dustrial engineers cannot easily measure the time spent in assessment nursing tasks often vary widely with who performs thc activity irnrl and interaction. Measurement of repetitious, technical tasks can the method utilized. For example, report time on oruc stucliccl trrrit readily be done, but determination of times involving professional ranged from 15 to 90 minutes, with a mean of 30 minr-rtcs. judgment and skills is much more difficult. 4. The educational and experience background ol thc obscrvcc is rltt not considered, nor is a differcntiation made among thc lcvcls ol l{.N., Hudsons dissertation, summarized in Aydelottc (1), presents "criteria L.P.N., and nurse assistant or aide.that support the classification of nursing work as nonrepctitive. He also 5. Mosl stuclics ckr rrol corrsiclcr:examines questions relating to variations in task prediction time, t<-rprocedure development, and 1o thc inccntivc problcm. Hudson found it er. Thc it1-r;-rl-oltriirlrtttss ttl lht rtursing irrtclvtrrliorr ort ulling lrl tlrt.difficult to encourage inclivicluals to contplctc task zrssignmcnts withir-r Iirttr ol ittltt vctrl iorr.the time predictcd lirr tlrcir- acconrplislrnrcnt. l-Ic concluclccl thart a tzrshs b.llrc stall irrg, silrrrtlior;rl llrc littrtol tlrtslrrtll,(ovt.1 , r1(l(1 , ()rtime variation was cluc rrot orrly to tlrc irrclivirlrrirlit.y ol tlrc p:tticnt itrttl slr IislactoliIy slr Iltt I)his c1;nclition ltrrt trlso lo llrtirrrlivitltrlrlily ol tltc tttttsc, lttt tottccltt ol t. Wlrtllrtrprintiu,, lrrrrt liorr;rl, or lt.:rrrr rrtrlr,inli ,;r., rrr r.llr.r l.nursirrg 1-rllrt litt, irrrrl llrtplttontrivrtl ttoliotr ol lrorv l<t lrttlot ttt it. Acl-
  • st Atrtil N(; AND SqIIEDUIING_ 273272 MANAGING HUMAN RESOURCES herence to a present pran or proccdun- w:rs .r sccn by nursing personnelof nursing care requirements. This schema results in 3o, or 81, possible as either essential or dcsirzibrc. Thc wr.kbasic classification configurations, each with its own mean nursing time scclu.,,."urrJfuce were set by other kinds of prioritics,, (l).and variance to reflect the nursing work load of medical patients and Improvement and refincmcnts in dctcrn-riertionanother 81 means and variances for surgical patients.Intravenous ther- times can only occur if rhe nurse has a of nursing activity basicapy, catheter care, dressing care, and isolation are included in a special measurement principles so that eflectivc "na".rturriing of work collaborati", *iir, industriarprocedures section, since these activities have been found to reflect a engineers will occur. Four basic workhigh amount of nursing time. mcasurcment techniques havc been utilized in nursing studies to deterrnine the time irrrir"a in nursing activities (22):WORK MEASUREMENT IN NURSING 1. Time study and task frequency 2. Work sampling o[ nurse activitvThe determination of the amount of nursing time required by each pa- 3. Continuous observation of .rt-r.r", perfbrmingtient for every shift is an essential but by no means simple component activities 4. Self-reporting of nurse activity.of a staffing methodology. Nursing has relied primarily upon industrialengineers and engineering work measurement techniques to quantify Difficulties encountered by nursing innursing actions, but there are often problems with the values obtained. using industrial-based w<_rrk measurement methods to measure nursingFor example, many of the allocated time values for patient care deal p.J.ti." u." ., follo*s:only with technical tasks. Difficulties in quantifying nursing times can 1 Many of the allotted time values deal withbe attributed to several causes: industrial engineer or observer d""r ,rot technical tasks, since thc recognize the asscssmcnt, evaluarion, and psychosocial urp".r,l. The industrial engineer or nonnurse observer does not recognize the of the conracr. assessment, evaluation, and psychosocial aspects of the nurse-patient Thus, a patient whorequire. t".ii..t ";;_p;;r tasks could very likcr.y bc r.tccr category thin one who requir", pry.hosoiial contact, and the nurse often does not convey these components of professional nursing practice to the industrial engineer, due to the ff*:Ll* ,,,. r"u.hiug nurses unfamiliarity with work measurement techniques. 2 In developing a patient classification system, somc nur.sirrg rlt.rrr.r_ ments borrow the nursing times from2. It is often difficult to differentiate between the start and completion others It is imporrant to realize that the crassifi.u,i.r,,ror,t.rrrs .r of a nursing activity. For example, while giving a patient a bath, the the ,i;;"r".:;,,.i,,*,,,,,.u ,,,,,u not be accurate for another, since the nurse interacts with the patient. How much of the time spent with nursing unit architecture, experience of the nurse, policics ^rrtr the patient should be allocated to the technical task of bath giving and and how much to assessment and interaction? menting the work can vary from agency to agcncy. rctrr,rrs,r irrrr,. rrx.t.rrrrr.s, 3 Many systems employ the mean time for u3. Although often referred to as time-study or efficiency experts, in- eration of the variance. Abdoo and colrcagucs *irr,,,,,, ;rrrt,rr:.itl ,,,1t dustrial engineers cannot easily measure the time spent in assessment (z.r) irrru,.r,,,,,,,r rr,,,t nursing tasks oftenvary widely with who and interaction. Measurement of repetitious, technical tasks can pcr-lirr.rrs rlrr.;rr rrrr. ;rrrtl the method utilized nor readily be done, but determination of times involving professional judgment and skills is much more difficult. ranged from l5 to 90 minutes, with "*u-pl", a"p,rrr tirrrtrrr t)rt,:.rr rrrr,,rr ,rrir orr"r,,,,l 3O 4 The educational and experience backglrurrrl .l rrrrrrrtr.r, rlrt.,lr,,r,r r{,(. r,)lr(., Hudsons dissertation, summarized in Aydelotte (l), prcscnts "criteria not considered, nor is a differentiationir,,,r,irr(),,,, L.P.N., antl nurst, assislanl or aidc. rr,,. l,.r,rr., ,r ri.N.,that support the classification of nursing work as nonrepctitivc. Hc alsoexamines questions rclating to variations in task prcdiction tinrc, to 5. M<tsl slutlits rlo rrol corrsiclcr:procedure dcvelopmcnt, ancl to thc inccntivc prt.rblcnr. llrrclsorr lbtrncl it it.llrt. :rp;lr.olrr.irrlt,nt.ss ol lltt. nutsiltg ttllr.t.r,t,trlt()n 1r{ r til Iilt,, ;rl lltt,difficult to cnc<-rt.rlagc: irrrlivitlurrls to corrrplr:lt: lask rrssigrrrrrcrrls within Iirttt. ol inl(.1 r.(.nIiorIthctin-rcprccliclttl lirlllrtillrtrotttplislttrrrrrt.llttorrtlrrtltrl llrll irllrsks ll.llrt sl;rllrrr1, .,rlr:rtr.r ;rt llrtlilrrtol lltt,s,lrrrlt (.rtintc varilrliorr r,virs tlrrtrrol orrly lo tlrtintlivitlrrlrlilv ol llrtpirlitlrl lrrrrl slrlisl;rr lot rlr ,.l,rll, rl) I ln{lr.t , otlri. , r"r,lili,,rr lrrrl ,rlqr l, llr,. i,r,li*,i,ltr,,litr, ,l llt, rrrrr..,. lr,.r, rrrr,,.rrl rrl
  • SJAFFING AND SCHEDULING 265 istrators thoroughly understand the components and issues in nurse staffing. Nurse staffing is a term often used but subject to a variety of inter- pretations. For purposes of this discussion, nurse staffing is a broad area composed of three main components: planning, scheduling, and allo- cation. Planning encompasses determination of the number of nursing personnel needed over a long-term period. The scheduling cornponent entails assigning nursing staff for specific time periods by shift, based on patient care needs. Allocation of nursing staff involves staffing as- signments or readjustments on a daily basis. A great wealth of information has been written in the realm of nurse staffing, but the articles tend to recount personal experiences and to describe trial-and-error, rather than scientific, approaches. Aydelotte (1) asserts that: Nurse staffing methodology should be an orderly, systematic process, based upon sound rationale, applied to determine the number and kind of nursing personnel required to provide nursing care of a predetermined standard to a group of patients in a particular setting. The end result is prediction of the kind and number of staff required to give care to patients. This prediction of the number and kinds ol personnel to give patients nursing care 24 hours a day,7 days a week . . . is no small task. The aim is to provide, at reasonable cost to the general public the agency serves, a standard of nursing care acceptable to its clientele and the nursing staff serving it (p. 3). The planning or staffing methodology phase should be based on quan- tifiable, measurable data. This systematic nurse staffing determination must include the following variables: 1) an assessment of patient care needs (patient classification), 2) an assessment of required nursing time to meet patient needs (nursing work load determination), and 3) an al- gorithm that uses the first two variables. Average occupancy and sea- sonal fluctuations in the occupancy rate are also helpful supplemental variables. Deviation from the intuitive approach to a systematic research ap- proach can be achieved only after those involved in nurse staffing de- cisions thoroughly understand the history of nurse staffing, its trends, its complexity, and its needs.lors;ing THE EVOLUTION OF NURSE STAFFING SYSTEMSnts,[ing Nurse staffing systems have evolved since early 1960, when Connor (2)/ery published a research report, based on his earlier doctoral dissertation,ray, on the utilization of nursing staff. A major result of Connors work wasnin- the development of a three-category patient classification tool in which a hospitals medical and surgical inpatients are identified as category
  • 21 1 MANA(;tN(;il|MAN t{t.r.i()trt{(.t s SI AIII,IN( ; AND SCHE,DULING At pn:scnt, thcrc i.s a lack ol rc.scerrclr clcarling with these issues to support what diflcrcntiations should bc mzrdc. the personncl sclterlrrlinl. ( iur lrt1lirr. At lirst gluncc, scheduling seems In summary, dctcrnination of accurate nursing activity times is very to be an easy task ol nrlrliirrp, orr lrrtl oll rllvs on scheduling sheets. But complex but extremcly important, since it, along with a reliable ani in reality, effcctivc sclrtrlulirrl: is:r st icrrtc us wcll as an art. The most valid patient classification system, should serve as the foundation for overwhelming problcrrr is Ilrt irrItrrtlaIcclrrcss between the staffing clc- the determination of the number of nursing staff required. termination and thc sclrttlrrlirrg lirrrctiorr, sirrcc thc weekend and holicla.y- off policies havc a clircct irrrpirit orr tlrc ncccssary number of budgctccl nursing positions to pnrviclc tlirily covcr:.rgc. For example, if the pol ic.y BUDGETING, QUALITY ASSURANCE, is every other wcckcncl oll urrrl ir rrrirrirntrm o[ four nurses are necclctl AND FUTURE DIRECTIONS IN NURSE STAFFING daily on the day shi[t, thcrr zrtlclitional uursing positions are nccdccl to provide the necessary pcr-sonr)cl on wcckcnds and required days oll. Daily patient acuity information and the nursing staff predicted nec- Weekend staffing policics also havc clirect impact on the nursing buclgct, essary can be utilized for budget forecasting and in quality assurance since the number of extra pcrsonrrcl nccdcd will vary with the nunrbcr programs. The predicted number of staff should be compared with actual of weekends off in a givcn schcrluling pcriod. Othcr institutional policit.s, staffing on a daily, weekly, and monrhly basis. The iniormation should for example, shift rotation :rnd numbcr of different shifts workccl irr rr also be aggregated by day of the week, which could help allocation of week, also affect schedulir-rg. staffing during scheduling. For example, if a surgical unit consistently Various scheduling systcms have been published and deserve c<.rnsitl shows less staff needed than usually provided on Tuesday, the scheduler eration: cyclic, supplcmental, block, and computerized. There docs rrot may be able to adjust future schedules accordingly. appear to be much diffcrence bctween cyclic and block scheduling, tx The development of nurse staffing systems arose from the concern of cept that the assignment pattern of the former repeats itsell in cytlt.s, most nursing dcpartments that there are enough personnel to provide One advantage of the cyclic method is that the staff can determinc tlrtir the necessary nursing care. But does the fact that actual staff equals or schedule far in advance if the system is strictly adhered to. Rcclrrtsts exceeds recommended staff mean that patients receive the necessary for certain days off can also be eliminated, since the nursing pcls()nn(,1nursing care? unfortunately, this can not be concluded for sevcral rea- would be responsible for switching their days off with somconc t.lst.sons. It is important 1o realize that inexperienced personnel, lack of pro- Both cyclical and block scheduling lend themselves easily to c<-rrrrlrrrl-ductivity, inadequate support services, and unpredicted patient crises erized scheduling.affect the accuracy of the prcdicted number of nursing staff. overstaffing The practice of float, or supplemental, scheduling has bccn cmplovt.tldoes not assure that the patients receive more attention. ongoing rnd intermittently. At one time, float nursing pools were common in ltosretrospective audits are necessary to evaluatc the nursing care services pitals, but they were eliminated as nursing dcpartments wcrc lorccrl t,rprovided. cut their budgets. Now the pendulum seems to havc swllng in tlrto;r Computer technology, diagnosis related groups (DRGs), and fee_for_ posite direction, and more agencies are reinstituting a floert pool to srrlrservices arrangements are the factors that will probably havc the greatest plement daily nursing needs. Even "dial-a-nurse," or agcncy rrrrrsirrli,impact on the further development of nursing stafling systems. More has come into the picture. A number of factors must bc corrsirlcrttl lirrand more nursing departments are purchasing microcomputers and, as n successful float pool: selection of float pcrsonncl, iob sertislirctiorr, irra result, will be utilizing computer-aidcd staffing systems. The rela- scrvice cducation, method of unit assignmcnt, support systcnt, arrtl ollrt.rtionship between patient classification (acuity) and DRGs, as wcll as lzrctors. The use of float nurses is a viablc, cclst-c[1lctivc ol.rtiorr rvlrt.rrthe feasibility of fces for services, based on nursing carc providcd, are rrsccl propcrly. Trivedi (2 l) discusscs how lloat nurscs can bc utilizt.rlbeing studied in a number of institutions. clr-rring the allocation (claily schcclulirrg), or-"linc-trrrring," phlst. Corrtputcrizccl nttrsc schctlrrling was origirtrllv corrttivctl rrs llrt t rrlt lrll lol tlrc tt-tonotortv ol tttttstsclrctlrrling, rrs rvtll :rs lr (()sl t.llr.t livtsrrSCHEDULING AND WORKWEEK PATTERNS Itrliort to scltcclr-rlirtll PIrrlrl.ttts. A tturstorsllrllirrl. t ltrli rvorrlrl rro lorr1,,t.rFOR NURSING PERSONNEL lrc rtccclccl lo tlo lltt ltt lrttit;rl l:rsk ol stltt<lrrlirr1, p,t s,rrrnr1. ( rrlit st trr.tl trlirrg ltrrtls itstll rrirlrltlrllt l() ( r)nrl)lll(tit.trlion, ..-irr, t ;rlt,r rltlirrirrl llrt.Oncc thc long-t-ltttgc cltlcttttittitliort ol Ilrt ;rvtrlr1r,t ol rrrirrrrrrrrrrr rrurllrr.r. tottslutittls, lltt:rllior.illttn tr1rt;rl:. rlscll. llrrl sl:rllrrrl .,.,lt rrr., llr;rl lrorrorof nursing Pctsorlrtl rrttrlttl lo srrPPlt,tl:ril1,Plrlrt.rrl rrt,r.tls lr;r,- lrt.,,rr ru:rtlt., rrnprlo,,ttt;ttrsls lot rl;rt.,,,11, r,,;rrirtslrill rol,rllorr lr.,,. ,
  • MANAGING HUMAN RESOURCES a partrI, self-care; category II, partial or intermediate care; or category III, classifintensive or total care, by the units head nurse. Guidelines describing three pthe typical characteristics of a patient in a particular category were remairdeveloped for the head nurse to use in categorizing patients. was ca An average nursing time for each patient category was determined the avethrough work measurement studies, and each of the average times was varianrfound to be significantly different from each other when tested statis- determtically. A staffing algorithm utilizing a patient care index (I) was de-veloped: 1 : .5Nr + 1.04/, + 2.54/3 (1) PATII OF NI.where 1 is the patient care index, N is the number of patients in eachcategory, the constants represent the amount of direct care in hours, The corand the subscripts represent the specific classification level (2). of the t Connor noted even in 1960 the effect of the variation of patient needs as theon the nursing work load. The nursing work load varied only slightly if basis othe number and distribution of patients by classification were constant. servabl"On the other hand," noted Connor, "if the number of each class of pa- the grotients is also variable, we may expect wide variation in total daily de- physicamand on staff. It is, therefore, important to determine how the classes many fiof patients vary within the census, for this, in conjunction with the av- velopederage times required, would permit the estimation of variation in nursing Accorstaff requirements for a single ward or in the hospital." (2). cation,I The Commission for Administrative Services in Hospitals (CASH) (3) actuallladapted the work of Connor and his colleagues from the Johns Hopkins ficationUniversity utilizing additional systems analysis and other industrial en- cepts togineering techniques to prepare a staffing manual to assist hospitals in ficationdetermining their own nurse staffing requirements. The components of identifythe staffing system include: (1) a three-level patient classification tool The n(self-care, partial care, and total care); (2) standard time allowance for lationshthe performance of each nursing procedure or task; (3) census data (the and to snumber of admissions, discharges, transfers, and occupied beds); and can be t(4) the number and types of personnel employed on a nursing unit. The understzfollowing reports, as summarizedby Aydelotte (l), can then be generated: of manip are ofler Actual staffing plan (as it is in operation) also faci Recommended staffing plan relations Report of accumulated hours, giving the amount of time for each worker and each task Work distribution sampling PATIEA Recommendations for redistribution of the procedure (the work) Since l9( or group Other staffing systems (4,5,6,7, 8) developed during the 1960s and ments fotearly 1970s for specific hospitals adapted the work of Connor (2) to fit
  • 27<t MANA(;tN(;iltJMANt{liS()llt((lrs SlAl llNr, iNl):i( lll.lrtlllN( // putcr progr"lnri.g. warncr (24) clcscr.ibes his mcthod,l,gy lbr morc Ctlst sttvirrlis, il irnt, rrnl ,nly lo llttttttplovct ,lrttl ;tlso lo llttttttlrlottt flexible staffing <,rpri<.rns with the compurcr; it is based on biiilding in a (lbl cxirrrrlrlc lottl rl;ry rvt,t lv((l(s clirrlirrlrttottttlltvs rvot lll ol rltiv large number of assumptions and definitions in the computer program ing). algorithm. warners system initially appeared successful but still re- .5. Prcscnt ovrt lintt wollictl lly rtursing stall orr tiglrt-lrotrr r.vorlitlrtys. quired human handwork afterward to fine-tune the schedule. For ex- ample, on Tuesday, there may be only four nurses assigned (the defined Since thesc livc c<.rr-rsiclcrertions can vary [ror-r-r instittttiort to itrsliltrliotr, minimum number needed) while on Wednesday, ,"u"r"r,rr.res might <-rne ideal workday lcngth for every agency ntely tl()l c.rist.llrtr( ttlitv be assigned to the same unit. not even be unanimous consensus for all units withirr orrc irrstitrrtiorr. cost savings cannot accurately be determined with most of the de- Shift rotation is another important compctttcnt ol ntttsc scllctltrlirrli. velclped computer systems, since one must consider the hardware The preferred trend at presenl is to hire stall lbr cach ol thc slrills, lrrrl and software cosls. More highly skilled personnel are usually required since there is often difficulty finding cnough pcrsonncl to worli itlltr to work with such systems. Thus, the movement toward computerized noons and midnights, thc day-shift pcrsonnel must oftcr-r totittc. litllort nurse scheduling has been diminishing. when staff vacancies (25) has written an interesting rep<-rrt concerning hcr Iinclings ltllrtttl are min_ imal, a good staffing clerk can produce a good schedule as eflicientlv to the effects of shift rotation on physiological body rhythms: "Il)e l(rrr as can a computer. when staff vacancies are high, a computer peraturc and potassium levels did not return to thc bcf<rrc-night 11)trli()n ...r.ro, replace the human judgment necessary to adjusl th" .r,r.ri.rg levels even 10 days post night duty. In addition to avcraging orttlttttl :t resources to provide adequate staffing .ou..ug". quarter hours less slcep during the day when subjccts workccl nl rriltlrl, - Innovative practices from industry regarcling the length of the workday five factors were related to a higher disruption of the qui,rlity ol tlrtir have also affected nursing. Debate continues over g-liour, lO-hour, sleep and restfulness: (1) trouble staying asleep, (2) troublc slctpirrli lrt ani 12-hour workdays, as well as one-week-on, one-week-rff patterns. cause of noise or environmental temperature, (3) fatiguc, (4) dilli( rrllv The l0-hour workday has been found to work best in u."u, *h"." continuous switching from night to day shift, and (5) requiring a wcck lo rrtlirr:,1 24-hour coverage is not essential. If 24-hour coverage is required, bowel habits after night duty. One factor was related to lowcl rlisnrpliorr then a mechanism must exist to provide an additional 4"hours of .orr"rug". satisfaction with the regular work schedulc" (25). More studics ttg,rrrrlirrl some nursing units utilize overrapping shifts or use a combination shift rotation of nurses and circadian rhythms, as well as a ccltttlt:.tt isotr of two lO-hour shifts and one g-hour shift to provide 24-hour coverage. of the physiological effects among day-to-night, day-to-aftctrtoort, ruttl Two advantages of the lO-hour workday are extra days off in the afternoon-to-night rotating shifts are needed. One implication tlrtrs lirr work-week and decreased transportation-relatld expenses. pot".,tiui is that it is better for a regular day-shift employee to work scvctltl ctttt- child_caredifficulties, fatigue, and hanclling of call-ins are somc of the disadvan_ secutive night shifts rather than to work a day-night-off, clay-niglrt-olltages. In addition, workers may not be utihzed in the best manner type of rotation. whenoverlapping shifts occur, which can result in extra ,rulrr.rg ro. a two- The issue of centralization adds another dimcnsion t<,r thc schctlrrlirrphour period. and staffing issue. Proponents of decentralization feel thal this at1-rptrrirt lt Twelve-hour shifts easily provide the necessary 24-hour coverage. conveys an interest in the individual needs of the employccr, wlriltllrtAclvantages are similar to those of the l0-hour dav, while the cmployee may feel hc or she is only a number when dcaling witlr ir ( (rr disaclvan-tages could be more s^evere, for example, the employees may tralized scheduling office. A centralized scheduling olficc cittt ttstutlly noticernore fatigue, and slaff may not be able t,, *o.k ,rucitime to provide a better-balanced schedule in tcrms of persor-rncl lbrcatlr slrilt, cover acall-in. whereas a decentralized system may have difliculty proviclirrg rrtlttlturlt Although compressed workweeks have been gaining popularity in coverage on certain shifts, especially if thc unit is totzrlly r-cs1ronsilrlc lonursing settings, more research is necded rcgarding ratigue, pr<-rvide its own personnel. The queslion ariscs zrs to wlriclt ty1rtol "r-,ipl,ry""employee productivity, cost effectivcnesr, r,r-rd Iatiglc-produccct schcduling is more cost elfcctivc and which is bcltcr erblc to trtilizt llrt crrors.Each method must be examined rcgarcling: nccdcd nursing stalf bzrsccl <ln thc paticnt classi[icatiott tllttit.1. Adaptability to institutional pcr-sorrrrr.l urrcl plvrrrll SUMMARY Policics:rrrrl pro_ cedures.2. Impact on n()nllutsilr11 clt;xrr.l rrrt,rrls. Ntttst sl:rllirrli rottsisls ttl rrt,r;tl ,,,tttpontnls: plrtrrrrirry, ., lrtrltrlirrli, ;rrrtl3 Willirrg;rltss ol lltttttttsinll sllrll lo rvolli rrorrlr.:rtlilisrr;rl lr,,rrrs. irllot:tliotr Ilrtyrl:rrttrittl. {)l ,l.rllrrr1i rtrtlltorlolol.,lrlt;r,., :,lrorrlrl lr,lr:r:,ttl
  • STAFFING AND SCHEDULING 267 a particular insritutions specific needs. Although a modification of theegory III, classification tool mi-sht occur-for example, expanding the tool fromIescribing three patient category typcs to four or fivc types with descriptive criteria,lory were remained the samc. The average amount of nursing care time nceded was calculated from the patient classification input and convertcd to:termined the average number of nursing staff needed to provide nursing care. Thetimes was variances of the average nursing care time and nursing staff were notted statis- determined.[) was de- (1) PATIENT CLASSIFICATION AS A COMPONENT OF NURSE STAFFING SYSTEMSts in each in hours, The component of traditional nurse staffing systems essential to all facets2). of the total system is patient classification. Classification rnay be defined.ent needs as thc ordering or arrangement of objects inlo groups or scts on theslightly if basis of their relationships. These relationships can bc based on ob-constant. servable or inferred propcrties (9). The process of classifying involveslass of pa- the grouping together of similar objects or properties conceptually, daily de- physically, or in both ways. This proccss has long been employed inhe classes many ficlds and is evidenced by various taxonomics that havc bcen de-th the av- veloped in most scicnces.in nursing According to Sokal (9), taxonomy is thc thcoretical study o[ classifi- cation, including its bases, principles, procedures, and rules. TaxonomyCASH) (3) actually includes two phases: classification and idenrilication. Identi-s Hopkins fication cncompasscs assigning previously unidcntified objccts or con-rstrial en- cepts to the proper or correct class according to an established classi-rspitals in fication system. Thus, taxonomy is thc science of how to classify andronents of identify.ation tool The major purpose of classification is to describc the structure or rc-wance for lationship of the constituent objects to each othcr and to similar objects, data (the and to simplifu these relationships in such a way that gencral statementsreds); and can bc made about classes of objccts (9), which should facilitate the unit. The understanding of users. Anothcr goal of a classification system is ease,nerated: of manipulation or retrieval of information, since complex relationships are oflen simplified by a classification schema. Classification systems also facilitate economy of memory by summarizing inlormation about relationships and attaching a specified label.: for each PATIENT CLASSIFICATION TOOLSwork) Since 1960, patient classification tools have becn devcloped to categorize or group patients according to their prospective nursing care require-1960s and ments for a specified period of timc. Since thc health needs-and, as: (2) to fit
  • 278 MANA(;lN(; IItJMAN l<l:s()llli( IS Sl n lrlrl N(;ANl) S( lllll)lrllN(, )79 nutsc stalling dctcr-on c;r"rarrrtiliablc, mcarsurable clerta. This systcmatic REFERENCESmination nrr,rst includc thc following variablcs: 1) an asscssmcnt o[pa- of requiredticnt car-c n""d, (pufi""f tfuttlfical-ion) 2) an assessment l. Aydelotte, M.K. Narse Stalling Mctluttkskryv:,rl 1?rr,irrl rttttl (t ttrrltr, rtl Srlutetl work load determination)nursing titnc to -".i puii""i necds.(nursing Literature. DHEW publication no. (NIH) 73-433. U.S. l)tprrr lrrrlrrl ol llealth, :1"." algorithm tirat uses the first two variables Education and Welfare, Division o[Nursirrg, Wi.tshingtorr, lx (,(,v(rnnlcnt""a prcdict"a .,,,IlU"t oi The staff can be utilized for budgeting Printing Office, January 1973. ""tti"g of scheduling options- are currently 2. Connor, R.J., Flagle, C.D., Hsien, R.K.; Prcst<.ur, iL.A., ancl Sirr1.t r, S lrllit tivcand personnel ,.h"d"ii-"g a tzrti"ti use of nursing resources: a rescarch rcport. flr.tspitals, Mrrv l, l()trl, l5(()), workweek (with 1O-hour andused by nursing dcpartments: compressed 30 -39. or supplemental; and cen- 12-hour workdays); .vtfittf , lf tck and float 3. Des Ormeaux, S.P. Implementation of the CASH patient classilit :rlr( n st(rntralizcdor<lccentralizcd.Itisimportanttorealizethatwhatworkswell well in a different for staffing determination. Superuisor Nurse, April 1977 ,8(4), 29 5in onc institution or even one unit may not work 4. Georgette, J.K. Staffing by patient classification. Nursing Clirtit.: ttl Nrtt rlrinstitution or unit. Although many nurse stafling systems have evolved America, June 1970, 5(2), 329-339. diagnosis related groupsovcr thc past 25 yJ;;, ;;;putcr technology 5. McCormick, P., Roche, J.M. and Steinwacks, D.M. Predicting nursc stallrrrl.. will have further impact onio*"rj, una f""-ffr-services arrangements Hospitals, May 1, 1973, 47(9), 68, 73-77 . th" d"u"lopment of future staffing systcms 6. Cochran, J. and Derr, D. Patient acuity system for nurse staffing. Hos1titttl Progress, November 1975, 56(l l), 5l-54. 7. Minetti, R. and Hutchinson, J. System achieves optimal staffing. Hospitals, May l, 1975, 49(9), 6l-64. STUDY QUESTIONS 8. Center for Hospital Management Engineering. Nurse Scheduling: An Ex- for a 500-bed acute care amination of Case Studies, Proceedings ofa Forum. Chicago: American Hos- l. You, as the nursing service administrator classification pital Association, 1978. r,"#ri.r, t.u" ,t" tlsk of evaluating rhe presenr patient 9. Sokal, R. R. Classification: purposes, principles, progress, prospects. Science, System.Describeindetailthestcpsyouwoulclfollowandthecriteria September 27 , 1974, 185(4157), 1 1 15-1 123. you would use 10. Giovannetti, P. Patient Classification Systems in Nursing: A Description and recommends 2. In amove to decrease costs, the hospital administration Analysis. DHEW publication no. (HRA) 78-22, Hyattsville, Md.: July 1978. and supplemented when I L Abdellah, F.G. and Levine, E. Better Patient Care Through Nursing Research. that the ,"g.rfu,^ttt"ing siaff be reduced necessary with agency nurses Do you agree or disagree with this New York: Macmillan, 1965. 12. Chagnon, M. Audette, L.M., Lebrun, L. and Tilquin, C. A patient classification recommendationi Support your stand system by level of nursing care requirements. Nursing Research, March/April 3Anotherpossiblecosteffectiverccommendationbyanadministrator 1978, 27(2), 107-1 13. istodecreasethenumberofpart-timestaff(sincemostofthescpeople 13. Norby, R.B. and Freund, L.E. A m<ldel for nurse staffing and organizational are in the float ;;ti;;;;I) which should reduce pavroll costs and analysis. Nursing Administration Quarterly, Summer 1977, l (4), l-13. overhead. H"* ;;;ldlo" t"tpottd to this recommcndation? Support 14. Norby, R.B. Freund, L.E. and Wagner, B. A nurse staffing system based a detailed analysis of your positio" lrr" *itt"t ttpot that includes upon assignment difficulty. Joumal of Nursing Administration, November 1977 ,7(9),2-24. costs. 15. Meyer, D. GRASP: A Patient Inlbnnation and Work Load Management System. 4.Thestaffnursesintheintensivecareunithavesubmittedaletterto current workday be Morganton, N.C.: MCS, 1978. nursing administration requestin-g that -the period) to 16. Meyer, D. Work load managcment systcm ensures stable nurse-patient ratio. changed f..- ;;;;li tto" *otkdlv (8O-hour two-week Hospitals, March l, 1978, 52(5), 8 l-85. the_ considerations a 10_hour *"rk;;;-ri;ur_day workweck). Discuss this rcquest and 17. Freund, L.E. and Mauksch, I. Optimal Nrtrsing Assignments Based on Dffi- nccessary in o,Jtit""uch a decision concerning cuhy. Final Project Report USPHS l-Rl8-Hs001391. Washington, D.C.: the staff nurscs describe thc actions you would take with Government Printing Office, 1975. units are unhappy 18. Clark, E.L. arrcl Diggs, W.W. Quantilyirrg pnticrrt cule nrccls. Il().spitals, Sep- 5. The stafl nurscs in the gencral mcdical-surgical unit. Thcv arc tcnrbcr 16, 197 | , -1.5( I tt), 96, 98, 100. abour bcing p.;ll;.it., o lhurt-rtaffcd medical-strrgical tlrat cilch ul-rit I9. iltrnt,rtli, W.M., Sr11:rl, l)., l{ostirlirrski, M., Abtlrxr, Y.M., l)tltoslr, S., anrl tlrcv licl rcqucsting a".""i,..,iir.ccl scl.rccluling, sir-tcc (orrrv:r. ( A r otttpttlrr :ritlttl pirlitrrl t l:rssilit lrti()n sysl(nr rvltttt vrrr ilrliorr slrrt.lltl,rs. ll<lw wotrlcl w,.lc[ llrt,rr [tt,,...r1r.r,rsil-,1" li,r.c.,vc.iirg its.rvrr u,illrrrr .r lr,llrlnl , l,r,,rlr,.rltorr is torrsirlrrttl, irr ( . l ilt1rirr, ttl.,.Sts/rrrrr Sri srr1,,1,.trttrl r()lrrliorr,) (ttttttt ll,,tltlt ( rtt Iotrtttltt Itt1;111t,,,, Itttss. l()iil y0rr lurrrtllt, tt,,,i ,lirr,,risllrt.liorr lrrrtl tlrt.ir.
  • 268 MANAGING HUMAN RESOURCESresult, the nursing needs-vary from patient to patient, tools have been Oncdeveloped to predict the nursing time required based upon the identified systenpatient needs at a given time. According to Giovannetti (10), the "concept arise.of patient classification entails the categorization or grouping of patients systenaccording to some assessment of their nursing care requirements over for exra specified period of time." standa Determining and agreeing on assessment criteria are not simple feats, howevhowever, since there are several ways of viewing patients requirements what ifor nursing care. A major issue that must first be resolved is whether utilizethe assessment categories should focus on health maintenance, illness detaileproblems, or degree of independence in meeting ones own health or order .illness needs. It is Abdellah and Levine (l l) discussed the concept of patient classification are noas an area of interest for nurse researchers in I 965. Patient classification lated twas defined as a scaling scheme in which the underlying continuum classescan be conceptualized as expressing a quantitative statement of a pa- sirabletients requirements for nursing services. These may range from no re- clusivequirements at all-representing a condition of maximum self-help abil- that scity-to the other extreme, total requirements for nursing 5slvisss- viewpcrepresenting a condition of minimum self-help ability. One may also Sokavisualize the continuum as levels of wellness. The degree or amount of be hiernursing care required by the patient is not necessarily positively cor- inavarelated with the level of wellness: one cannot say that the less well the lappinlpatient, the more nursing care he or she will require. For example, a clusiviterminally ill patient may require fewer nursing services than a person omic uwith a fractured leg (moderate level of illness). numbe The early patient classification systems documented in the literature, tortion(2, 12, 13, 14, 15, 16) are based on defining the patients physical needs resentduring hospitalization and tend to exclude psychosocial and long-range do denhealth maintenance and sustenance needs. Various nursing theories have Ther,evolved since 1970-for example, those of Roy, Orem, Kinlein, and Rog- in useers-that do not view the patient according to an illness or disease state, tiouslyas in the traditional medical model, but, rather, look at the whole person, pitals.including the persons health maintenance and promotion needs and have sehis or her relationship to the total environment. Since the advent ofthese theories, patient classification criteria based solely on physical 1. Cateneeds have been heavily criticized by nurses. indi, Thus, establishing the viewpoint for a patient classification system is comnot simple. The issue has been compounded by the expanding and a.Cchanging role of nursing, lack of nursing research on the topic, and reex- b.samination of the patients health-illness status since 1970. A perusal ofthe published patient classification schemes indicates that the majority c.Ahave been developed for adult populations in acute care settings and d.Rfocus on determining the degree of patient dependency on nursing per- e.Ssonnel to meet the patients basic needs. f.P
  • 290 _- r4ANAGTNG IIUMAN l{t1s()ll(( t:s20. Trivedi, V.M. and Hancock, W.M. Meitsurcnlcnt olnutsittg wot k loitd ttsittg head nurses perceptions. Nursing Researclz, Scptcmbcr/Octobe r 1975, 24(5), 37t-76.21. Trivedi, V.M. Daily allocation of nursing resources, in J. R. Griflith ct zrl., eds., Cosr Contrcl in Hospitals. Ann Arbor, Mi.: Health Administration Press,22. 1976. Williams, M.A. Quantification of direct nursing care activities. Journal of Nursing Administration, October 1977 ,7(8), l5-18. koductivity23. Abdoo, Y.M. Hancock, W.M., Luttman, R. and Rostafinski, M. Determination of nurse staffing requirements: a case study. Unpublished report. Ann Arbor, Mi.: University of Michigan, May 1979. The purpose of this chaptcr is24. Warner, D.M. Computer-aided system for nurse scheduling, in J.R. Griffith, t. prcscnt lhe c,rr*r ,r rrrr1, ed., Cost Control in Hospitals. Ann Arbor, Mi.: Health Administration Press, as an important human componcnt cll.ntzrnagitrg r.t,sorrr.t r.,, Al rrxrrrt foush productivity has not ;i-*" ;; zr c()r)(.(.r., ,l rrrrr:.irr1,, rlrr. 1976.25. Felton, G. Body rhythm effects on rotating work shifts. Joumal of Nursing current emphasis on cost containmcnt Administrat ion, Marchl April I 975, 5(3 ), I 6- I 9. her.s r,.rrt, ir :rrr irrrlr,r r;rrr issue. on compretion of this.h;;;;;,;;; rcacrcr.wi, rrt.rrr,rt. r, l. Define producti^vity as a human charactcr_islit.. 2. Explain units of pioduction 3. Describe methods of measuring productivit.y. 4. Describe the relation*ip "-"irJp"rocluctivity, l)irtit.rrl r lrrs sification systems, and nursing Jrjrn_"n, - 5. Describe reasons for low p."J;;;l;r. 1_rattcr.rrs. 5. Develop energizing upp.ou.h., i r-ou"..,r,,ing ity. low 1_rr.*lrrt.l iv The idea of apprying productivity concepts to nursing hers n.t r..ct,ivt.tr wide acceptance standards, ti-" r;;;"s, productivity concepts from indus,rfhuu" productin r.zrrcs, .rr<r ,rrr.r. ministrators who berieve thut becn rcsistccl by rrtrr.st. ;rrl i. u p.of"rrin errrcr cann()[ us srrt.rr be quantified. However, resistance ""r.i-.rg must be active in developing and --.,.t u. frii;;;;;;;:;;;,, Nrrr.sirrg relevant issues in producti"i",y.- - r"ti-g methodorogics trr.t.rt<,rrrr r, --".-" Is the concept of productivi"ty rerevant the individual nur.e free to..ti,rru"iJrs and applicerblc irr nur-sirrg,) rs desires? or is rhere a basic *q;r.;i;*Ll much or as rittrc ers rrr..r.srrt. of "o,-,rour,,for;r sct.irit.irilv defined type of nurse? Does trt" by the ratio of staff to patienls *"rk u, fu.t or as srowr.y r.t,tlrrirr.tr "".r" rufp".,s during a shift? If the nursing staff *ut ^s to exist on er spccir.ic.rrrrir on u irn,, can accomprish a, rrrt, rrt.t. o.," .,,.," is off, why should ,h.:;:i:i;;i;;,,,,t :::1%::*-when ,,,,,,.. r,.. Unlike doctors, nurses arc gcl.rcrall.y rx_rt p:rirl rrrorr. lly.st,t,irr11 Rcgrr*ll..rr patients or accomplishing rnorr. "producc"nurses c:tl()r ,,,ir. ,,ot i. ,,i r,,;*l,rrrt.lr rlrt.v rrsrrirrv rtirktrrr,rtirrr,rrrr.(,r conrp(si.ri,rr Nrrrsts rrrt,rrtrr r<.w:rr.<rt.tr ri.(.(.iv(,rtrt.rrrt,t sitllrlv irrt lt,lrscs, btrl r;u:rrrlilv ol st,r.vir.t.s r,r <;rr;rt,,, i,,,1 1,,,,,,,,,,i,rr ,r is rrsrr;rll rrr.rvr.rl orrl1, 111.1,;1 ,)ii I
  • STAFF].G AND SCHEDULING 269have been Once the viewpoint for the development of the patient classification identified system has been decided, problems uith generics and semantics cane "concept arise. Common categorization schema ol many patient classificationrf patients systems currently in existence utilize three or four general groupings,lents over for example, self-care, partial care, and total care; or minimal care, standard care, intensive care, and critical care. The terms by themselves,nple feats, however, are not self-explanatory or mutually exclusive. For example,uirements what is the distinction between the intensive and critical care categoriess whether utilized in a particular patient tool? Thus, it is imperative that clear,ce, illness detailed explanations describe the various classification groupings inhealth or order that any existing ambiguity might be minimized. It is important to realize that the patients in a particular classificationssification are not necessarily identical but, rather, possess many similarities re-;sification lated to the defined classification characteristics. Nor are the givenontinuum classes mutually exclusive, though some authorities believe this is de-.t of a pa- sirable. According to Giovannetti, "each class should be mutually ex-om no re- clusive-classes should not overlap. However, it has already been shownhelp abil- that some overlapping is usually unavoidable because of variations inervices- viewpoint which must be accommodated" (10). may also Sokal (9), on the other hand, points out that classifications need notmount of be hierarchic, and the clusters may overlap (intersect). "From studiesively cor- in a variety of fields, the representation of taxonomic structure as over-; well the lapping clusters or as ordinations appears far preferable to mutual ex-:ample, a clusivity. By ordination, we mean projection of the operational taxon- a person omic units (OTUs) in a space of fewer dimensions than the original number of descriptors. When tested by any of several measures of dis-terature, tortion, ordinations in as few as two or three dimensions frequently rep-:al needs resent the original similarity matrices considerably more faithfully thanng-range do dendrograms" (9, p. 1121).ries have There are currently a wide variety of patient classification instrumentslnd Rog- in use in hospitals throughout the United States. It is sometimes face-rse state, tiously remarked that there are as many different tools as there are hos-3 person, pitals. The tools vary in format and length. Patient classification schemes:eds and have several common characteristics:Cvent ofphysical 1. Categories are utilized that describe patient characteristics or critical indicators of a patients nursing care requirements that might en- ystem is compass any or all of the following, as mentioned by Aydelotte (1): ing and a. Capabilities of the patient to care for himself or herself nd reex- rusal of b. Special characteristics of the patient related to sensory deprivation rajority c. Acuity of illncss rgs and d. Requiremcnts for specific nursing activities ng per- e. Skill level of personnel required in the care f. Patients geographic placemenl or slatus in the hospital system.
  • tivtlV. llrltl ir, tl it illils(rrrrPl()ytt rl()tr tt0l (()ttll ll)tll(illl ((ltlill sllill( is llrttltltrtttl ()t litli(tt lly llrc l)l1l;l N Ill( )N ( )l; lrlt( )l)t l("1l V llYI9 llrrrrrril rvorli l.,irtl, tlistiplirrrry;rtliottrrttt st lrtltttittisl t ;tlot . T<l itttptovrptorlttr Itvilv tttt:rtts lo protlrrt(nr()l(r,villr llrcsitrrrclult()Lu)[ llew Ittttclr cull ill "lrvgt1gt" tlttls("ptoclttcc" ()ll it Illc(lical tlllit ils ol htttttarr ellirr l. l.rrlrorprrrtlrrtlivilv is llrttlliticrrry witlr wlrich outputopl.losccl tcl ar strlgicll rrrrit? Is passirrg rnc(licaltions to 2.5 [)tltictlts eqLtiv- is pt-oclttcccl [r.y llrtl(s()ur(cs Lrsccl.llrc nr(lrsur(nrcnt L:iln bc pcrson-lrltrrt to chzrnging drcssings on l0 paticnts? Docs a ncw gr;rduatc helvc hours workccl or total hotrrs pnir[ lor rncusuratrlc or.rtpr-rt (4).Iorvtrproductivity standards than a graduatc of l0 ycars ago? What is This definition causcs problcnrs lbr rr-rcersr-rring pr<-rcluctivity in nursingtlrr,. irrccrrtivc lor a nurse to strive for a produclivity standard of fivc because output is difficult to mcursur-c. In community hcalth nursing,lrorrre visits a day or the complction of care plans on two ncwly admitted an output measure of home visits per day has bcen acccptable, but thislrirticrrts? What is a rcasonable assignment in a long-lerm care facility? cannot be the only one if productivity is an index of quality as well as llrc corrccpt of productivity goes far beyond the idea of gaining greater quantity. Some objective means of determining what are acceptableorrlput ernd being efficient. Todays nurses have different values and ex- productivity standards for nursing in various settings must be estab-prclations from those of predecessors of a few years ago. The people lished.isstrcs can no longer be ignored. According to Bennett (1), a great changeIurs occurrcd in the work world. Workers are not less motivated. Theircxpcctations of the work environment have risen. The quality of the UNITS OF PRODUCTION Irrrrrran cxperiencc is of paramount importance and is linked to several llrttors: thc work itself, the work environment, and personal factors. In order to know what current productivity is, a nurse administrator Alth<-rugh hours and pay are still important, it is the human element must have an objective measurement. Without such a measurement, tlrat clcmands recognition. Like workers in factories, nurses in health(luc clclivcry settings raise the hue and cry, "I want to matter. Know the administrator has little basis upon which to plan changes in pro- ductivity level. What level of staffing is the optimum for what is needed lhat I am here." As Rosten (2) states so eloquently: "I cannot believe to be completed each year, each month, each week, each day, and each tlrat thc purpose of life is to behuppy.I think the purpose of life is to shift? There are very few objective data to assist nurse administrators lrc r-rsclul, to be responsible, to be honorable, to be compassionate. It is, in answering these questions. al"rovc all, to matter, to count, to stand for something, to have it make In quantitative terms, productivity equals the relationship between s<rrrrc diflerence that you lived at all" (p. a). resources and units of production: Sl<inncr (3) proposes four reasons why employees are not as productive, Ioyal, and dedicated to thcir companies as they could be: resources Productivity : l. Achicving wholehearted cooperation, energy, and commitment from units of production largc numbers of people is difficult, and managers are unrealistic in thcir hopes to do so. The question arises in health service settings as to what constitutes nursings unit of production. Dollars per patient day and hours per pa-2. Concepts concerning management of large numbers of people convey tient day continue to be the prevalent expressions in the health care c<,rntradictory messages to managers. field. Unfortunately, states Hanson (5), neither dollars nor hours are3. Critical problems in corporate management of personnel are largely human resources or adequate expressions of human resources. Dollars unreso]ved. are units of exchange with which to purchase human resources and a4. Some management assumptions undermine the efforts of managers. constraint on the acquisition of human resources. Patient days are therefore not meaningful units of production. Wholehearted cooperation, energy, and commitment demand the best A more realistic unit of production is patient contact hours, a trueof individuals, which, in the final analysis, depends on individual pride measure of nursing services. Patient classification systems can be a ve-and creativity in spirit and work. Large groups cannot reach maximum hicle for measuring productivity by providing a quantitative measureproductivity unless individuals are willing and eager to move beyond of need for nursing services. With the advent of the Tax Equity andminimum expectations. Eagerness is a part of productivity but not the Fiscal Responsibility Act (TEFRA) legislation and related diagnosis re-total concept. lated groups (DRG) mandate, productivity and cost containment have become top priorities for nursing administrators.
  • 270 MANAQING HUMAN RESOURCES 2. Most schemes include class designations ranging in number from three to nine, with descriptive statements regarding patient char- reg acteristics for each level. Examples of labels assigned to classes are ing self-care, partial care, and complete care; or I (minimum care), II too (average care), III (more than average care), and IV (maximum care). not The patient is then categorized as either a I, II, III, or IV based on terr the most characteristics the patient exhibits. anc3. Physiological dimensions of nursing care are definitely designated, F while psychosocial, religious, and cultural behavioral needs or re- grot quirements are generally not considered. nur4. Most systems define nursing care times that can be assigned to ac- are tivities in the appropriate class or category designation. for sign5. Many patient classification schemes have not been tested for validitv achi and reliability. syst CI In examining a patient classification system, one should critically sificanalyze whether it recognizes professional nursing activities other than anetechnical tasks. Connors work in 1960 (2), the first published work in (P) Ithis area, emphasizes technical, or task, components of nursing care.But connors classification must be considered in the context of whatnurses did at that time in nursing history. An increasing number of toolsnow are designating emotional support needs and teaching needs. one should also realize that a very complex patient classification tool whemay not be any more accurate or reliable in determining the number patirof nursing staff needed than a very simple system. The necessity of read- patiring lengthy directions may lead to utter frustration and increase the mennumber of mistakes made while trying to follow the directions. The totalamount of time required to complete the classification tool must also of pebe considered. Important goals for a patient classification system are shift(1) internal consistency, or a high interrater reliability; (2/ simplicity to brof use; and (3) minimal time and cost for the users. It It is important to note that most patient classification systems have numbeen developed for acute medical-surgical patient populations and are titatinot necessarily generalizable to psychiatric, maternity, community Inmhealth, or pediatric patients. nurs_ disct and 1DEVELOPMENT OF CURRENT STAFFING SYSTEMS load time,During the 1970s, several commercial staffing systems were introduced Hathat have gained popularity. The Medicus system (13,14,17) utilizes a develcomputer-read classification tool with weights assigned to each of ap- timeproximately 25 classification indicators. An algorithm utilizing the sum The sof the weights for the inpatient census and coefficients obtained from (20, t gorie
  • lrr llrtilrl);rrr( nr ,r ilnrr,, p;rrrt.rrr tl;r1:, lr;rr.r.lr..t.rr rr:,,.r1 r() 1l)llrlrrr(,. l{t.t.trrl cll()r lt) ltttl, Plllitrrl t llrssilitltli()tl rvillr p|otlrrt livilV ltltvttt- 1., tltttsittl, rorl,,.1nrr)nf llr, ,lr;r1,;1,,tis It,llrlt.rl 1,;()ul)s:trr<l r.:rlt rrlrrlr.llrt.silllr(l irrllrttltvtl,,1,,,,,,1 rll tttitlivttrxrlslttt ttltltstttilllllllllsiltlltllir|t :llll()lllll lrlritl l,)l ltlll!tttl.,:rrr. l ltt ;rtt <litrrr rrrtllrotl ltrrs rr1tl llt.t.rr srrl. s(l vi(( I (((lllly <ltvt:1,1-tttll.ru: ,..*,,rt,plt, ir trtitlrvtsltt tt lt,silltl ttttt sirrll isliltlo|v,:rrrrl llr,Ntr,,,.1ttsry l)tP:rrl rrrr,nl ol llr.:rltlr irriliirtcrl scvcr.alir I)irlict classilir.uliorr ltxrl llrirt nr(irsurcs I)r1)(llr(tivity irr stirllirrg ol stuclics rrrrtltr rlrt rlitt rirr.I (ilirrrirltli rrrrtl Mit.lrt.lcili (r)) to clcvclop,,,,1,r.ru a claily itrtcl rttotltltly llasis ittttl trrltkcs lltrtlgttn|y l)|.().iccti()lls carc rtnotllcr wily l() lll(itriltl ( procltrctivit.y arncl allocalt rtrrr.sirrg costs. Thervillrirr c()st cont.rinnlcllt rcstlictions- I-inkagc witlr c1r-rality llatict-tt rnost viarblc.rc llrctl.tivc itcrrsit-y mczrsllr.cs (RlMs) stuclics. The RIM is also tlnclcr studY (6). rcscarchcrs tl-iccl to clcvclop an allocertion mcthocl that would specifically variablc llcsiclcs units ol pr<lduction, thc othcr l|cc1uc[rtly tlllknown relate the patients usc of nursing rcsollrccs to his <_rr hcr medical con- irr thc pr.ocluctivity cquation is humarn lcsourccs. Accolding to Hanson dition. Nursing resources are dcfined in tcrms of minutes of nursing (5), lour clcments nccd to bc considcrcd: care received; the larger the number of minutes, the grcater the amouni of resources consumed. These studies may be used t6 identify paymentl. Knowledge and skill rates related to the specific diagnosis_related groups.2. Encrgy (physical, mental, and cmotional) Leah curtin (10) describes another potentiafm"urrr." of productivity3. Motivation in her discussion of nursing care strategies (NCSs). In cssence, these arl4. Sclf-direction detailed nursing care plans that includ" di.""t and indirect care needed and allow for variances in both the interdependent and the independent impact on A deficiency in one or all of the four elements has great functions of nurses related to patients severity of illness within each productivity. Fo. failure to. utilize nursing resources according DRG. To determine the average amount of time needed to deliver nursing "^ample, among nurs- to cducation and skill creates confusion and dissatisfaction care for each DRG or NCS, patienrs should be classified claily according cs. The blame for ineffective utilization of nursing resources cannot be to the number and complexity of their nursing care needs. assumption of re- ;i.;"J on the .drr.uio,, There must be a combined seriously examining existing ip."Juiir,y, with nurse administrators not create a fit be- nurse utilizution patt"r.,, tt-ut are outdated and do LOW PRODUCTIVITY tween professional nurse and job description Many subjective symptoms of low productivity may exist: Complaints of not enough staff METHODS OF MEASURING PRODUCTIVITY High absenteeism before any Failure to complete patient care items on each shift A valid method o[ mcasuring productivity is necessary .hu.rg", can be undcrtaken to <:hattge productivity For-community is the Low number of home visits pcr day per public health nurse health nursing, onc mcthod that is very uieful and uncomplicated (7) Complaints by medical staff .us"load/*orf load analysis tool deveioped by Easley and Stortjell to Complaints by patients if,i, toot provides . -".r,r." of the nurses productivity in relation *r,uirequiredinhercaseload.Theresultisanobjectivecomparison However, some of these symptoms may be the result of burnout or in the time of what the nurse docs do and what can be accomplished another phenomenon. The other complicating factor is that too little or he or she has availablc. The use of this kind of tool in an inpatient setting too much staff can also result in low produciivity. would be morc complex but could be utilized one of the most frequently described barriers to productivity is burn- developed Another method oi indirectly measuring productivity-was out. Lavendero (11) and Seuntjens (12) describe buinout as a piysically (8) The method was for an outpatient setting by Henningcr and Dailey and p-sychologically debilitating condition brought about by wo.k-re- stan- J"u"l"p"a to predict ttnit" sta{fing needs by means of assigning a fore- lated frustrations that results in lowered productirity. Low morale then After dard valuc time to all direct and indirect nursing procedures produces negative fcclings about self and the organization. casting thc amount o[ work thc nursing staff would be requircd to com- if the seuntjens (12) furthc. dcscribcd burnout in terms of the following plctc ibr thc fiscal year, calcul:rlion-s were done to determine symptoms, all of which zrrc clctrimental to any organization: .,r-,rrcnt stllllcvcl was sullicicnt lir; thc projccted work load
  • STFFIG AND SCHEDULING 271:r fromrt char- regression analysis from prer ious t ork determines the numbcr of nurs-ises are ing personnel needed to provide the care. Although the classification:are), II tool is computer-read using Scan-rron sheers, the original system didn care). not operate in real time. Some hospitals ha.e attempted to run the sys-lsed on tem in real time, while other institutions batch the classification sheets and obtain monthly reports for budgeting purposes. From the work of Poland, English, Thornton, and Or.rens-the PETOgnated, group-evolved the GRASP (Grace-Re1nolds Application Study of PETO)s or re- nurse staffing system (15, 16, l8). The patient care units (PCUs) utilized are obtained from the patient classification tool for inpatients, and PCUsI to ac- for incoming admissions are also estimated. Neu admissions are as- signed a bed on a nursing unit with the lor.vest PCU count in order tovalidity achieve an even distribution of work load among the nursing units. The system is not yet computerized. Chagnon, Audette, Lebrun, and Tilquin (12) developed a patient clas-itically sification tool listing 129 possible nursing interventions, each havingrer than an estimated weighting for a 24-hour period. The number of staff neededwork in (P) is determined using the following equation:]g care.of what ^ D_ (s + TUP) of tools - 360:ds.ion tool where P is the number of staff needed for a particular shift, S is therumber patient care time, TUP are the tasks performed unrelated to individualof read- patients, and 360 is the amount of productive time available by a staff ase the member, with time for breaks, meetings, and so on subtracted from thens. The total paid work time (12). The census form, which includes the numberrst also of patients on the unit and their classification, is completed before each em are shilt and submitted to the nursing office in order to facilitate decisionsrplicity to balance supply and demand of nursing staff. It is interesting to note that the published staffing systems derive thers have number of nursing personnel needed to provide care but do not quan-rnd are titatively deal with the variance in the number of nursing hours needed.nunity In most cases, the unit is staffed at the mean, and the variance of the nursing staff around the mean is not calculated. Although Connor (2) discussed how variation in patient needs affects the nursing work load and the GRASP system attempts to reduce the variation in nursing work load by admitting the patient to a bed where there is available nursing time, no attempt has been made to estimate the variance.rduced Hancock, Segal, Rostafinski, Abdoo, DeRosa, and Conrvay (19) haveilizcs a developed a computer-aided nurse staffing system that operates in realr of ap- time and considers the variation within nurse staffin-e requirements.hc sum The systcm utilizes a patient classification schema adapted from Trivedid from (20,21) using the ambulation, bathing, feeding, and orientation cate- gories with three possible ler.els-l ,2, and 3-as the initial indicators
  • l .rlt1ttt itrtr tl,rlrlt l,-,rrl. l, rllt tt ;r,,,1 .llr( r(n( .rttrl ;rtotlttt lrviltlrtrrl in( r( ir:,((l Artrit.lt ltlrsttrlttt:,ttr, I lr, l l, ;rrrrl orr l r r1ltl :,:rl rolrrylt. ( irrilt litlurvior rrl lrtt lrlrsttl :tttitltnls I rr r plr ire rl sl)(ccll ENIII{Gl 7.t N(; RIISIDONSI ll I l,Ill liS (.iogrritivc loor clccisiorr nrakilrg OF THts NURSI] ADMINISIITAI0II Forgctlulr-rcss Or-g:.rnizntionaI Abscntccisn-t Sonrc reccnI cost contitir.trttcnt stuclics hnvc shown thart as much as 47 Turnclvcr pcrccnt of a nurscs tinc is consunrcd irr nonnursirrg tasks (14). If nursing Low productivity productivity is low, scvcral avcnucs of study may bc needcd to determine Lcss cclmmitmcnt the rcasons, so that corrective actions may bc taken. If study shows that Job dissatisfaction much o[ nurses time is spcnt in nclnnursing areas, administration must also determinc iI it would be cost cffective to hire other categories of personnel to assume the nonnursing duties, thus decreasing the number For the burr-rcd-out nursc, thc pcrceived nonimportance of self and of nurses, or to maintain a pcrcentage of nonnursing tasks in each nurses tlrc pcrceivcd lack of opportunity makc any work or pay schedule un- assignment. If all nonnursing tasks were taken away from nurses (thatrcasonable. The scnse o[ accomplishment that comes from satisfaction is, if all of them could be identified), the need for nurses could conceiv-ll<-rm a job wcll done becomcs nonexistent. Burned-out nurses lose re- ably be decreased by a sizable amount.s1-rcct for their superiors, and their personal lives become uncertain and The nurse administrator must weigh the need for professional .f udg-tlisrupted. Thc nursing administrator nceds to assess the source of job- ment in nonnursing tasks and in relating them to paticnt care. Manyrclated stress and determinc organizational strategies for stress man- categories of nonnurses can be trained to perform tasks, but only thelrgement long bcfore burnoul and decreascd productivity can occur. professional nurse has the knowledge and cxperience to put the non- Nowhere in the annals o[ adminrstrative literature is there a more nursing tasks into the context of total patient care. Instead of bcing con- litting description of the motivational crisis in organizations today than cerned with giving away tasks, the nurse administrator may explore the Levinson (13) description of "the great jackass fallacy." Levinson ways of eliminating tasks, spreading them more equitably across thetlcscribcd the jackass fallacy as an unconscious managerial assumption nursing staff, or assigning them to pcrsonnel under the control of nursing.irbout people and how they should be motivated. It results in the pow- The central objective of nursing administration is to maximize thetr[ul treating the powerless as objects and the perpetuation of anach- use of human resources toward the achievement of maximum produc- rrrnistic organizalional struclures that destroy the individuals sense of tion. There is no automatic way to cnhance worker motivation, thc key worth and accomplishmcnt. factor influencing productivity and quality of performance. If nursing Many nursing administrators are fearful of losing control of their di- administrators are to cnergize and create motivating environments, they vision and fall into the trap of insensitivity to human feelings and treat- must understand motivation theories. Amply discussed in Chapter 9, on ing employees as objects. The first image that comes to mind in thinking human potential, motivation theorics are presented in this chaptcr inolthe carrot-and-stick philosophy is that of a jackass-characterized by their application to productivity. Theories of motivation provide frame- stubbornness, stupidity, willfulness, and unwillingness to go where works and tools for assessing specific situations and generating creativc someone is driving it. People respond to the carrot-and-stick by trying ideas on how to develop productive environments (15). to get more of the carrot while protecting themselves against the stick. Thcre is no such thing as an unmotivated person. All people are mo- This has led to the formation of unions, suspicion of managements mo- tivated. It is a challenge for nurse administrators to speculatc about tivational techniques, and outright sabotage of managements moti- why peoplc behave as they do. Goals are accomplished through peoplc vational efforts as well as organizational changes (13). and by people. Rclles and positions do not intcract; people interact, and When employees perceive that they are viewed as jackasses, they au- they do so within thcir perccptual fields. A chasm of misunderstanding tomatically see management as manipulative and resist. As long as those between the nurse administrator and staff can rcsult from difference in in leadcrship roles havc a reward-punishment attitude toward moti- the economic, sociological , gcographical, and environmcntal factors un- vation, they implicitly assumc thal employees are in a jackass position der which each pcrsons pcr-ccptual field was formcd (16).
  • tlt.vt.l,rI lr;r:.it;rlly lr()nl lVo lylrr.s ()l rrl:rlr()rrsltiP:; (/l l:tlllllV:lll(l Cl()scotall ol)l)()rlrilrily l() |tlrtir|st llrtp|tstrrllrliorr (,l lr Pr(,jtt I l().r p,r1)ul)of influcncial lcarclcrs irr tlrc orgurrizlrliorr. lr.irrrrls :rrrtl (f) ;trrrltssitlrr;rl lrrrtl olllcr irrll((lll(lll t oltl:tt 1". llrtt.rrrr19tr tttlr,votl<itt1i lr,rrltl lrtlrvtttt l:rrrrilV lttttl t lt:tl|icrrdS is:l The mentor must so(iillizttlttl)rr)t(rg(i into u tt-rntPttitivtrrtvirtrtrnttnt.Female nurses, like many womcn, i.u-c noI prcperrcd lol this clirrrcrrsion sirnilnrity ()l ltclicls, vl,l.,,.ir, irlliltttlts, rttttl soci:tl ()r rlrrt Srllrport arrtlof the workplace. In a sensc, nurscs arc similar to thc Nobcl laurcertc in[orrtrntittrl cxclrltltgtcltlttltctctizt llrt lrorrtl llctrvtttt ptoltssionals arrtlwho described his need for a sponsor in order to compete in thc insti- othcr sociarl c()lltitcts. (irettt<lvcll(l ()tr)t:tlcgotiztrl l:trlrilv and closttution of science: "I knew the technique . . . I had a lot of knowledge. I friends ers strong tics tlrat cxcrt a srrlrslrrttli..l inllrrtrr. trrtt lltc behaviorhad the words, the libretto, but not the music. What was missing was of those in thc nctwork. C<lnmunicitliorr prtLtctns tttttl to lltprcdictablcan opportunity to work with men of high quality" (13, p. 123). uniform, and rcpctitivc. Mcmbcrs 9lstre [t rrctworks :rrt ttsttlllly few and Nurses are firmly grounded in their knowledge of nursing care, but thus havc limifcd access to a widc v:ricty of infotrrrrrlr()lr s()llrces Professional and social contacts etlt considered rvtlrli tits llclation-they are not equally schooled in the effective discharge of this function ships within such a network structurc cxcrcise less ipllrrtrrttort thc be-in a competitive environment. To establish successful career patterns,nurse administrators need to increase their sphere of influence, project hauior of members than do Strong ties. Because commlttti,:rlitrtr pittternscredibility, be acccpted as an important contributor: 1o the policy for- ur" l"r, predictable, more varied-, and not repetitive wt:rli l.its p;gvide greater opportunity for the communication of original rttttl trPttl itt-mulation of their institutions, and be treated as equals with other in- lir rrrrlirlritcdfluential people in the system. Career advances in an organization re- For,,,utio.r. This pattern of communication and its potenti^lquire the socializing influence of a sponsor. The central purpose of Sources of information is the rationale for the strength ol rvtrrli tits irtmentoring is to provide the prot6g6 with a competitive advantage so facilitating career progress. Thus, the weak-tie theory suppolts lltt tr()li()ttthat ability can be transformed into effective leadership skills. For some, that mobilizing alarge weak-tie network enables one to gain rttttss l<r (x( trl);rmentoring may not be possible, advantageous, or desirable. However, individuals, groups, and systems for the purpose of achicvingwhatever the nature of the support, we all need someone with whom tional, professional, personal, and social goalswe can share our hopes and career aspirations, a person who will pro-mote our ideas and our best work and place us in a competitive spherein which we can prove our abilities and worth. Mentors are in a real MEN AND WOMEN AND NETWORKING BEHAVIORsense a necessary ingredient of self-actualization in the workplace.Maestro and pianist, master and artist, and rabbi and student have been Kleiman (30) consiclers networks "a step beyond role models and men-paired throughout history so that the very best could give to the best tors, a necessary next step for women if they want to achieve theirin an effort to preserve the continuity of excellence. While mentors are professional andcareet goilt" (p. 6). Increasingly, women are turningnot a substitute for competence, commitment, ability, and hard work, to other women in an elfort to gain professional visibility, exchangc:these things alone, unfortunately, do not bring the success and reputation information, identify iob opportunities, reduce isolationism for womcrtthat women and men of ability deserve in the workplace. in token positions, trrppo.t one .nother in professional growth endcavots and prorride emotional reinforcement However, networking is a rcl:r- tivety new experience for women. what men achieve quite naturzrlly iD their contacts and support of each Other is not as commonplacc lorTHEORY OF NETWORKING women.In addition to researching mentor affiliations as a strategy of promoting Patricia wyskocil, vice presidcnt and director of marketing for tht:career advancement and opportunities, social scientists have investi- First Los Angeles Bank, tbs""c that "men bond naturally and networ-kgated the phenomenon of networking. Data indicate that inclusion in a instinctively; (30, p. 8). Joscfowitz (31) suggests that "just as men rclerxprofession is associated with career success. A measurement of the degree in a very special way whcn alonc wilh their own sex group women to() have a ,p"iiul boncling thzlt occurs whcn they are together without men"of inclusion in ones profession is in turn associated with networking and women to network togethcr (p. 101).It is equally iirport:.rnt lbr nrcnactivities (27). Networking provides the visibility and means to dissem-inate ones ability, talents, and professional support to others. ir u -i*"d-g"r,d". support grl)Lrp, according to Josefowitz(31) group The <liscomfort a wt;rtr:I1 lllily lccl cntering a male-dominated Aldrich (28) defines a network as the totality of all the units connectedby a certain type of relationship and is constructed by finding the ties is identical to thc lcclirrgs ol a uran c:ntering an all-female group. How-between all the members within a bounded system. Further, networks ever, an cffort must [t., nrl|rl|. lty ltotlr men and women to gain admission t
  • l. Wlrirt cilrtrrrrslirrrcts irrrrl silrr:rliorrs rvitlrirr v()ul ()rllllnizlrliotr lttt: pltli.r:rlrll,lrotrr lltr,,.t rrtllr ,,tttttl;tt (l)(t t(tt( rr, A ttltttlot , ottltl ptovtrlr bcst suitccl lirr inctr:lrsinlt y()ul visibilitv? knor.vlt.tll,;rl)l( :r,,,,r,,1;urr r rrtllr ,tt, lr ;rtolrlttttr,.llttts, ttttttlor irr; ir ltrtrlirrl <lltcs;rtts,,rr:rl lrtl;t lo;r l;ll,trlttl l)(l:,()tt. llltirrrlrltlv, llrtlll(lll(,1 lllll:,1 2. What attitudcs arncl belraviors iuc rtwarclccl [>y yclur su1-rctvisors itt your organizati<-rn? bc willinlt, lo prrl lrrs or lrtr rtprtl;rliorr ott tlrtlirttlor llttlrtolt1,1"s s11lr. (25). .1 .l). Wtrlsorr, lrrrrr.tl Nolrtl lrtrncirlt, ttttuttlittl, ltrrttt lltt pttsptt livt 3. What are the organizations formal and informal critcrizr fbr pro- of zt yourrg scit.trtisl, "lt is txlllr oltlirurrilv itrlrot lltrrl llt:rl vott ltitvt rt motion and salary adjustment beyond the nursing dircctor level o[ ...patron bccausc tlrcrcll bc tirrrcs wltttt y<ttt itttlrorttttl losltiktit llrrtl management? and yclull nccd somcbocly to corrvirrcc 1-lcopltlltirl vott ltttIrttl ittt 4. Who are the decision makers involved in your advancement in the sponsiblc" (13, pp. i 34-1 3-5). organization? The critical shortage of qualilicd, compctcllI plolissi<trritl ttttrsc tttlttt 5. Who speaks for you at board meetings and policy planning sessions agers in the higher echelons of hcalth cilrc erclrrtinislrltiott strggcsts llrc when you are not invited or are unable to attend? need for the carly identification of leadcrship tarlcnt ancl tlrc sporrsotslti;r 6. Who can nominate you for promotions, prizes, awards, or important of that talent by other talented and rcspectcd nurscs. In this cra ol rirpiclly committee assignments or simply indicate you are the best person changing health care demands, nurses musl bc trainccl to assurlc lcittl- to get a certain job done? ership roles. The time requircd to prcparc compctcnt lcardcrship nttrst 7. Who defends you when ideas and people come together in conflicting be shortened and addresscd as a profcssional rcsp<-rnsibility. Thc talcrrls patterns? Who makes certain you are heard even when you voice of our current leaders must not bc lost. unpopular or controversial ideas (someone to steady the boat you have just rocked)? 8. How is "inside information" disseminated, policy created, approval MENTORING ATTITUDES AND BEHAVIOR for successful change projects achieved, and important decisions regarding staffing, budget, salary, and so on made? Mentors must reconcile the differing perceptions inherent in thc Iolcs of mentor and prot6g6 by making explicit the extent to which thcv carr 9. Who are the powerful and important people in your organization and will offer guidance concerning personal and professionzrl isstrcs. and who has their ear? Some authorities suggest that the signing of a contract by both pitltigs10. Does your organizations structure support role changes and exten- in agreement to the terms of the mentorship relationship assurcs cla;ity sions with respect to nurses and other professionals? of purpose and direction (26). Whether the relationship is fcrrrnitl o| in- formal, it is important to know its parameters and constraints erlrtirtlBeing able to answer these questions in some detail provides the frame- of time.work for a decision with respect to ones need for a mentor. The mentor must providc feedback to the prot6g6 as a functi<,ln ol tlrc mentorship relationship. Such feedback should be framed in an ob.icclivt context that prcsenls praise and criticism as specifically as possiblr.BECOMING A MENTOR The mentor should bc preparccl to stand by the prot6g6. The profcssiorurl stature of the fledgling leadcr must be protected. At times, thc mcrtlotIn deciding whether to become a mentor, one must consider what one may give the prot6g6 an addcd clcgrcc of credibility and growth lclvittt-can offer a prot6g6. Equally important is a consideration of the benefits tage by letting others know thc protig6 speaks for the mentor. Fotcx-one can derive from a mentoring relationship. What one can offer a pro- ample, the prot6g6 can rcplatcc tlrc rTrcnlors contributions at mcclil-rgs,t6g6 has a great dcal to do with the allocation of ones time and energy. presentations, and conlcrcnccs. The mentor may begin by providing the prot6gd visibility at meetings, As much as possiblc, tlrc nulsc aclr-r-rinistrator-mentor should inclucltbusiness luncheons, and preparation and feedback sessions in conjunc- other nurses in both pt-olcssiotrtl arrcl inlbrmal activities. Inviting a nov-tion with presentations and projects initiated by the prot6g6. Many men ice manager to a lunclrcorr sr.ssiorr with scnior management pcrsons isand women appreciate a mentors assistance with appropriate dress, an effective way to aclvcl list llrc nlcntors investment in the prolcgi.hairstyle, and body language. The management of career, marriage, and Mentoring need only cor ts i s I ol i rr lirrrlr in g a junior colleague of availablcchildbearing is a crucial area of conflict for women, and learning to resourccs and bcir-rg willirtp lo sttppttrt his or her professional endeavors.juggle these competing responsibilities necessitates a support system, This support may cortsisl ol lrtlvicc atbout job advancement, strategics,
  • o[tcn sllllccl irr rrriclrllt-nriurirlr,(nr(rrl lrosilittrts lrttrtttst llrty lirt li visi- uuNt,Irtts (il; Mt,:Nt()tU N(; trottUIIU MENTORbility ancl opltortr-rrritics lirr tlrtrrrtrr wlro lle itt 1-lt-rwc:rt() scc lltcrrr lltllitvc ANI) ll llr llt()lli(;1,:effectively (20). Bcrrclits lirr tltc ltrrrtcgc irrcludc rccognition, encouragement, and an op- portunit-y to cstablish a confidential sounding board. Increased morale and productivity are often related benefits (23). Honesl criticism, in-WOMEN MENTORING WOMEN formal feedback, nonjudgmental guidance, and an insistcnce by thc mentor that the only performance isthe best performancc arc vitzrl tcrWomen often are not supportive of each others efforts in the workplace. leadership growth. Knowing that one is being groomed for lcardcrshipHalsey (21) uses the phrase queen bee to describe senior managers who by a recognized mentor is an experience that has no equal. The nursclack interest in the careers of their juniors and give them little assistance administrator who demonstrates a power stance beyond his or her ex-in securing promotion and advancement. pected role needs the support and direction of a recognized mentor who The queen bee is unwilling to see her role as a sponsor of other women. can smooth the way and access power and influence. The nurse admin-She is motivated by self-interest and fear of losing a position that she istrators credibility and reputation require facilitation by another whobelieves she earned through her own hard work and initiative. Spitzer is accepted and respected within the organization.(22) summarizes the queen bee syndrome in nursing as: Benefits for the mentor include an opportunity to pass on ones values and standards, increasing the satisfaction that coi.nes from helping an-1. Identification with those in higher hierarchical positions. other develop the attributes of leadership. The potential to discover2. Alignment with the establishment and resistence to change. oneself by helping others is not a new or different idea. The relationship can help the mentor fulfill professional responsibilities as a supervisor3. Projection of antifeminist beliefs about other women. who is interested in those in the lower ranks. It also provides the mentor-4. A need to run the show at the expense of other competent women (p. manager a support system for policies and activities affecting people in 22). the lower ranks of the organization with whom the prot6g6 may have daily contact. Within the context of nursing administration, there exists Research has shown that there is another side to the issue of womens for the mentor a nurse administrator prot6g6 who can execute asupporting each other. Warihay (5) has found that the support giver and smoother, more cooperative management triad among nursing and sup-the support receiver have different perceptions of the amount of support port staff, nursing management, and agency adminislration. The per-given. Those in the upper echelons always report giving more than their ceived dichotomy between administration and service, which tends tojunior colleagues report receiving. Such perceptions ae troublesome, es- polarize administrators and practitioners, can be ameliorated throughpecially in situations in which there are few women at the top levels of the joint efforts of the mentor and the prot6g6. Such depolarization, inmanagement and many in the lower echelons. These perceptions inhibit turn, bcnelits the organizat ion.women in top management from facilitating the career development ofother women. How men in nursing are affected by cross-gender and same-gender CHOOSING MENTORSHIPmentor-prot6g6 affiliations is not precisely known. There is a paucityof data addressing the issue of male nursing careers and their mentorship It is advisable for upwardly mobile men and women to seek a mentor.experiences. Until the number of men in nursing increases substantially, Several may be needed at various junctures in a career to serve as in-nursing will continue to be identified as a profession of women. It is formation conduits, provide support, and assist in developing leadershipimportant to assume, however, that men in nursing administration are behaviors. The following queslions and statements are intended to assistconfronted with similar obstacles with respect to cross-gender mentor- the nurse administrator in asscssing his or her need and desire for spon-prot6gd relationships. Same-gender mentor-prot6g6 affiliations may be sorship in career dcvclopmcnt (24). Thc questions can be altered to adaptmore favorable for the career promotion of men in nursing management, to a particular institution or malnrrgcmcnt level. They are not intendedgiven the tendency of mcn in senior management ranks to support their to be comprehensivc; rzrthcr, thcir purpose is to stimulate a career-plan-junior counterparts. ning mode of thought:
  • Ittclct t crl ptrrvirlct olglrrrizlr I ion ( ll( )), Ittvrlrrlrzlrliorr ol srll, 224 22tr lor ttrttl,rlr,rtt, l, l, Vcrlr;rl ronnnrrrrr(,tltott, .) l(1,)ll 320 l{oys lrtLrpllrliorr nrotlt1, 20 2I .tt tt I t, Morlrl, Vrr rrliott;rl rrllrltrll, tttlttp;ttttl lrt Product concept, markcting nrzulagctllcrII llttory X ol ttt:ttt;t1.rrttt ttl, 1.t ptrrlcssiott:tl ttttt sittl, {r 312 llrcoly Y ol tttirtt:r1itttttrtl, l2. Productivity, 281,292 Schcduling, .see Staffing and schcclulirrg Thcory Z ol trtittrtgcttrtrrl, .l2 .l.l Wlli{( I l()us( (()rrl(rllt t ort Alirrll ( li)l{ I ) definition, 283 Schematic drawings, fhcilitics plzrnnir.rg, Tinre zrnd chancc. 5 l-52 165 energizing responsibilities, 287 -29O 199,200 Transccndencc, 43 Wotrtctt tttttl tttctttttt s, 2()ll )()() nursings contribution, 289 Segmentation, market, 314-3 l5 Turnover, recruitment, retention ancl, Wotttctr tttclttotittg wotttttt, l(X) performance planning, 290 Self-actualization, 40 250,252 Wrrrk nrcitsttlctrrcnl ,272 2/4 technical and professional roles, Self-communi cation, 222-227 Workwcqk lratttttts, sclteclLtlitt1" )74 ; /l 288-289 angcr, 224 Units of production, 283-284 low productivity, 285-287 one-to-one,226 227 Utilizzrtion, nursing research, 243 244 Zcm-b:lsccl buclgctirrg (Zllll), l.].1 methods of measuring, 284-285 revi talization, 224-226 units of production, 283-284 Self-criticism, 222 Profession, defined, 4-5 Selling concept, marketing management, Professional networking, 306-307 312 Professional nursing, compared to Situation depicting theories, 14-15 vocational nursing, 6 Situation-producing theory, I 5 Professional nursing practice, 3-l I Situation relating theories, l5 disciplines, 7-10 Skinners theory, I I 1-l 12 nature of,5-6 Social issues, practice settings, 327-328 profession and professionalism, 4-5 Space program, facilities planning, Professional practice disciplines, 4-5, 193-199 7-10 Span of control,T4 Promotional activi tics, marketing Sponsor, 296-297. See also Mentorship; campaign, 318-319 Networking Prospective reimbursement, 122 Staff authority, 75 Public speakin g, 233-234 Staffi ng and schedulin g, 264-28O Punch line, 349 budgeting, quality assurance, and future directions,2T4 development, 27O-272 Quality assurance, 204-220 evolution of,265-267 fiscal implications, 217-218 patient classification and, 267 -27 0 future directions in nurse staf{ing, work development, 272-27 4 274 workweek patterns, 27 4-277 program implementati on, 21 4-217 Strategies of changc, 85-87 structure, process, and oulcome Structure, organizational, 72-7 4, 77 -80 relationships, 205*2 I 4 centralization, 78 Quality patient care, 360-361 components, 73 Oue.n bce syndrome, 37 decentralization, 77 -7 8 matrix management, 78-80 Recruitment, retention, and turnover, 250-252 Target market, 311 Reimbursemcnt issues, 121-124 Task force, 72 DRG system, 122-123 Tax Equity and Fiscal Responsibility Act health care expenditures, l2l (TEFRA), 283 implications, 123-124 Technical and professional roles, 288-289 prospective, 122 Theories: retrospective, 122 conceptual, of nursing practice, 16-21 Resistance to change, 90-91 Levines thcory, 19-20 Restraint-of-trade activities, 319 320 Orems framework, l6-19 Retrospective rcimbursement, I 22 Roys adaptation model, 20-2 I
  • l nr)l( (lll(. V"l h(.t , Jlli llr..rrn .rrr,I r,,1,. .,trrrlr,, l:rt iliIy Plrrrrrrirrl,,, tlr,rlnlr;rrr1 r r.l1rl rt .i)ali r., (lr",llrr 0l ,1I Il( IIll( , ()) I8,!1 I,){) /o Lctrrlt r , ;rrlrrrrrrisl r;r{or its, l,{ .1,) l() l l l)ur l)o( rrrrrl lrlrlosoplrl, (r() Morkls, l5 ltr prrxlrtr lrvrlv, .)ltl .l().1 slrrrr ol rottl trrl, /4 I r.rlcls :rrrtl lollorvtrs, tlt,vt.lolrrrrt.trl ol l,rr r. lurngt, 1.}7,90 il4 il6 stirllirrg :rrrtl st lrttlrrlirrg, l()-l ,l8o sl rrrr l rrlc, 72 74 corrcclrtual, ol nursing practicc, l6_2I intcgt ntiort, etluc:rI iorr, antl lcse:rlclr, centlalization, T8 I r:rtlt.r sltip: Lcvines theory, l9-20 , ;rr, ol tltltl ly, 154-170 352-366 dcccntral izat i on, 77 -78 Orems framcwork, l6 l9 marketing scrvices, 3lO 322 matrix management, 78-80 rtr,lts :rrrtl (xce llcr)ce, 43_46 Roys adaptation n-roclcl, 20-21 l.rrirrt.s tlrcor.y, I 9-20 mentcrrship and networkin g, 295-3O9 Organizational change, 85-93 environment, 63-65 practice,5.5-104 models, 87-90 I ilr. r.rpt.r.t:rrrcy, 155-l 58 of intcgration, 356-358 I irrt. :rntl stall :ruthclrity, cnvironment, 57-67 intervention thgoiy and mcthods, Lr rrv lrrrrtluctivity, 285-287 7-5 operational izing prof cssional nursing, 95-96 organization, 68-84 8e-e0 i organizational change, 85-93 organizational development, B8-89 see also Theories operationalizing professional nursing, planned, 87-88 Mt ( lrrskys thcory, 40-43 Motivation, 109-112 M;ur:r11ttrrcnt science, 28 94-l04 resistance, 90-9 I Multi-attributc urility method (MAUT), practice settings, 323-338 strategies, 85-87 Mrr r r;r1.trrrcn I theories, 24_35 179 lr..l r;r vior.:rl school, 25-28 thcorics and models, 12-23 Organizational development model, r l;rssicrrl school, 25-27 conceptual, l6-2t 88-89 National Labor Rclations Act. 150 managcn-rcnt, 24-35 r orrlirrgcncy movement, 3l Negotiation, 147-148 models, l5-16 Patient care units (PCUs), 271 1i,"rrt.rlrl systcms theory, 29_31 Networking: I I r;t nltllcntcnt science school, 2g thcony fbrmulation, 12.-15 Patient classifi cation tools, 267 -27 O bchavior, 305-306 Nursing czrrc intcgration (NCi), 258-259 Perfbrmance planning, 290 tlrtoly X and theory y, 32 professional, 306-307 tlrcor-y Z, 32,33 Nursing practicc: Pcrsonal attributes, 46 50 theory, 304-305 c<-rn.rponcnts ol, 9 conviction, 48-49M:rlktt irrg scrvices, 3 10.322 see also Mentorship tlisciplinc, n:rtrrlc of, 5-6 courage, 47-48 311 Nonvariable phenomcna, l3 nt1il.t:rgcntent tools, 3 I 5_320 Nursing rcsearch, 236 245 crcativity, 49-50 Nonverbal comntunication, 23 I zrpplications to practicc, 243 Personzrl support systems,50-5 I t.onrpeti tion, 3 I g _320 Nursing zrdministration : tost and pricing, 317-318 coll:rbolirtivc, 240-241 Persuasion, 228-229 adrninistrators rolc, 36-54 cnrpllrsis ()r pr()srarn, 241-243 Philosophies: irrlirlmation and research. 3I5-31 7 as leader,38-39 rcscirlchable pnrblcms, 238-240 conflict rnanagement, l4l -l 42 l)rurnotion,3lS-319 leadcrship styles and exccllence, strutcgies,3lT rolc ol nclntirtistrltor-, 236-237 marketing management, 312-3 l4 43-46 utiIizaliorr,243-244 organ izational structurc, 69-70 rrtrrsirrg arcna, 314-3 | 5 Maslorv and McCluskys theorjes, Nursing shorlugc, 252 253 Physical evaluation, facility plzrnning, ;rlri losophics, 312-3 I 4 43,46 nrarkcting, 312-314 190-191 pcrsonai,46-.51 Onc to trrrt rorrrrrrrrrricat it)n, 226-227 Planned change, 87-88 product conccpt, 312 timc and chancc, 5l-52 sclling concept,3l2 Opcr-atirrg btrtlgct, 129- 130 Planned Programmed Budgcting Systcm challenges, l05-170 f)pcrlt iorr:r I izi rr11 pnrltssional nursing, (PPBS),132,t33M:rslows thcory of motivation, 39_40 carc of clderly, 154-l7OMlstcr progranl, facilitics planning, 94 t04 Planning, 265 conflict managcnent, 140-153 lisc:rl irrrplit:rliorrs, l0l 102 Planning function, 135-136 l9l_193 {iscal managcment, I 20-139 ()6, ()tl 99Mlrt r-ix management, 78-80 rrtoclel, 95 Political context, decision processcs andMttlicaid-Medicare, l2 l, 33 I human potcntial, l07 -l 19 ttstol. ()) I0I styles, 181-182 c<.rmedy and managcment, 339-351 tt;uisilcs, ()(r ()7 Pcrlitical issues, practice settings, 328-329Mtrr trrrship, 295-309 1lt-ct conccptual framework, 3-l I pttrlcssiorr:rl rrrrr sirrl,, ()6 Postoccupancy evaluation, facilities attitudcs and behavior, 303-304 disciplincs, 7-10 bccoming mentor, 302-303 Opcr-atiorr:rl l:rxorrornit rrrrits (OTUs), 269 planning, 202-203 rta(urc of nursing,5-6 Opctaliorts r tst ru clr, .lll Power,41-42 bcncfits,30l profession and professionalism, 4-5 chzrracteristic s, 297 -298 Ot crrrs t orrt t1rl rr:rI Ir ;rrrrt rvolli, I 6--I B Practice settings, -323-338 facilitating prolessional practice, Otgltniz:rl iorr, (rl3 11,l continuity of carc, 331-333 choosing mentorship, 301 l7 t-245 -302 autholitv ri l;rliorrslrips, 7,1 77 cconomic issues, 325-327 cr-oss,genderin g, 298,299 communication, 22 1 -235 rrrcaning ot,296-297 rlt:rirr ,,1 ( (,nrnr;rr(1, /() ethical dilemmas, 334-335 decision-making, I 73-184 clcltgrrl iorr rtl,/tt / / ethics,333-334 in nursing, 299-3OO facilities planning, 185-203 r<:lc, 296 litttt liotrlrl, /5 health promotion and disease women mentoring women, 300 nursing research, 236-245 lirrc lrrtl slirll. / prcvention, 329-331 quality assurance, 204-220 bylarvs,70 7l political issues, 328-329 see also Networking human resourccs managcment, 247 -2g2 ct.rrrrnrilltts. 7 l /.) social issues, 327 328
  • (lltrssitirl llttrrry ol nr;ur;lll( nr( nl , .t ./ ( orl .rrrrl.;rt ir rrr;,, lr, :rlllr ,:rrc irtrltlttltorts, f :f tvttrrtrttlttl , ttI {,i II.rIIt, IIttt ttttIII, I()/Collabolaliorr, l4ll 149 lli lllJ "/ ;ilrllr(,t tl, (, (t I (it.rrrlrr lrtrlllr,,ttt,ylt ttt, l(r.lCollaborzrtivc placticc, 35ll ( osl lrctrtlil iutitlysis (( llA), I79 ( ;l{nSl (( ;r ;rr c l(t yrrolrl,, Appltr ;tl t,rtt t ottt t;rl ttltl lt;rltttr:tt ltts, r() {r I interdisciplinary, 35tt 36-j ( osl tlltt livcrtcss lnllysis (CliA), I79 liscal irrrplit :rt iotts, (r5 Slrrrlv ol Ilrl ( )) svstr.rrr, ,tl ICollaborative research, 240-241 (lrrrr:rgt, 47 4tl rrrotlcl, 63-65 (itrlttlt trrtttttttttll( :lli{)ll, .. / ) )lCollective bargaining, 149 150 Cllcativit.y,49-50 Ethicarl clilctrttttrts, .334 335 tleb:rlr, ll()Comedy and management, 339-351 Closs gender mentoring, 298 299 Ethics, 333-334 Ptrstt;lsiott, .).)tl 22() gender gap,346-347 Evaluation, budgcting prrrcss, I37 history, 344-346 Debate,229 Existing resourccs, nrobiliz-ing, 249 263 l lcalllt t lrrr (xl)(tl(liltlt (, lit orvl lt ol. l . I humorizing management, 347 -349 Decentralized organizational structure, assignment pat tcrns, 255-262 llcalth tlre latilitics, ltt5 2Ol nature of comedy, 341-343 77-78 ccntral elenrcnts, 2-59 dcsigtt pirrt t ss, l Btt 2Ol punch line, 349 Decision making, 173-184 new approach,257 262 role o{ lrtrrsirrg, 186 ltllt researchers, 343-344 decision process, 17 5-176 traditional, 225-257 stralegic pllrnnirrg, ltl.5 Ill() state of comic art, 340-341 making decisions about, 179-l8l compctency and relicensure, 254 255 Health organizartion e nvit ottl)r(rrl, (r(l ( IComic art, 340-341 political context, l8 l-182 perceived shortagc, 252-253 Hcalth prorn<,rtion, 329- 33 IComic history,344-346 techniques, 176-179 recruitment, rctention, and turnover, Human potential, 107 I l9Comic research, 343-344 Decis theory, 111 250-252 changing behavior, l0B- I (x)Committees, 7l-72 Deductive theory, 13 Expecta.ncy thcory, I l0-l I I developmcntal psychology, l ll I I 1Communication,22l 235 Delegation of aulhority, 7 6-77 Expressive nccds,42 leaders and followers, ll4 llo computer technology, 232-233 Design, organizational, 69 meeting needs and maxirrrizirrl,, I l / formal and informal groups, 231-232 Design development, facilities planning, Facilities planning, I 85-203 motivation, l09-112 grotp,227-229 200-201 dcsign process, 188-203 and powcr of educalion, 107 lotl debate,229 Design process, facility planning, 188-203 rolc of nursing, I86-188 Human resources mana!{cl1ltrt1,,?l7 .)().) persuasion, 228-229 construction documents, 201-202 stlertcgic planning, 185-l86 mobilizing existing rrs()trr( (s, .)rlt) .t(r I interviews, 227 design development, 20O-2O I Factor-isolating lheory, 14 productivity, 281-292 nonverbal,23l master program, 191-193 Fiedlcrs thcory, 45-46 staffing and scheduling, 264 2l{() with oneself, 222-227 mission and role study, 188-190 Financial nlzrn:rgcment, 124-127 Humorizing managemcnt, 347 ll() anger,224 move-in schedule, 202 basic :tcc<ltnl ing, 124-126 one-to-one, 226-227 physical and functional evaluation, conccpts antl clclinitions, 126-127 Implementation, nursing cat e pl:rtt, revitalization, 224-226 190-191 Fiscal mnttitgerrrcrtt, I 20-l 39 136-137 public speakin g, 233-234 postoccupancy evaluation, 202-2A3 buclgcting,127-l3l Inductive theorY, 13 verbal, 230-231 schematic drawings, 199-2OO c()rtccpt, 127 130 Influence needs,42Competency and relicensure, 254-255 space program, 193-199 ri l:rl iorrsltip l. ttttt sing proccss, Informal committees, 7lCompetition, 319-320 Developmental psychology, I l2-l l3 133.137 Inlegration, 352-366C<-rmputerized scheduling, 27 5-27 6 Diagnosis-related groups (DRG), 122-123, typts ol irpptrrittltcs, 130-133 collaborative practice, 358Computer technology, 232-233 283,285 firrarrci:rl nrirllilg(rlrcrtt, 124-126 inlerdisciplinary, 358-363Conflict management, 140-1 53 "Dial-a-nurse," 275 leirrrbrrlstttttttt issttcs, l2l -124 historical Pcrspectivc, 353-354 characteristics, 143 Disciplines, professional practice, 7-10 DI{(i sysltrrr, 122 123 models, 356-358 functional and dysfunctional, 142-143 Disease prevention, 329-331 Itcal I lr r:rrt crpcrrtliltttcs, I2I need for,354-356 philosophical and historical Dysfuncti<-rnal conflict, 142-143 itnplitrrliotts, 12. 124 Interdisciplinary collaborativc pt :tr I it r, background, l4l-142 pRrsptt livt, I22 358-363 sources of,145-147 Economic issues, practice settings, r(t11)sl)(( l ivt, I 22 Intcrdisciplinary quality assurar)( ( strategies,147-150 325-327 Fixctl btrtlgt tirrll, I lO Lt l program, 209-214 collaboration, 148-149 Education, human potential and, 107-108 Flcxitrle lrrrtll,tlirr1., I ll l.l2 Intergroup, or interorganizatiorral collective bargaining, 149-150 Elderly, care of, 154-170 Forrtt:rl :trttl ittlottttrtl lttr)ttl)s, 231 232 conflict, 145 negotiation, 147-148 aging process and, 162*164 Forntal ctttttrttil lrts, / I Internal environment, 57 types of, 143-145 assuming leadership, 164-166 Futtr li,tr:rl ;rrrllror ilr, 7 Interpersonal conflict, 144 ()0Construction documents, 201-202 elderly women, 168 Functiorr:rl tottllir l, l12 lll Intervention theory and methods, ll9Contingcncy management movement, 3 I obstacles to geriatric emphasis, Furrctiorrirl rvrtltt:tliott, l:rt ilitv pllrrrrrirrg, Interviews, 227Continuity of care, 331-333 166-168 190 l(t l IntraPersonal conflict, 144Contributive needs, 42 persons ages 55 and over, 154Conviction, 48-49 chart, 155 Gcttctirl sVsl(tlts llrlor y, 2() l I Joint Practice Commission Model,Coping needs, 42 standards of health care, 16O-162 Gcrtet lrl vlrt i:tltlts t ttttt t1tls, I I 36 I -363
  • S1rt.r lrr.rlr, lr. .l ., ltrtr, ! /o S;rlzcr. lt.. .17, 5l, .l(l) Vr;rlt lt, l{. M., .l I l, .1 l.l . I t/ Vt rrtl.;r, l{olxrt 1.., l l(). J)1, Spl;rlkirr, .l . N., I7o Vtrrlrrr:r, M. l{., 240, 2./.5 Slttlt, S., /,{.1 Vili, A. (i., i(r.l Strirrlrt.rg, l;. V., I 70 Sltirrw:rcks, D. M., 279 Vr-otrnr, V . ll., I ltl, 179, lll4 Subject Index Sltvtrrs, llalltzrra, 21, 23 Wagner, 8., 279 Srtvt.rrs, B. J., 14l , 152,227,235 Wald,F., 14,23 Strxlgill, R. M.,.5.1 Wal i gora-Sera hn, 8., 245 Sl()k(s, C. S., 328, 337 Wandelt, M. A., 67, 316, 322 Slokty, E., 183 Warfel, B. L., 169 Strrrrt, J. D.,221 , 234 Warihay, P., 300, 306,308 Strrr Ijcll, J.,284, 291 Warner, D. M., ,183, 276,280 Slr:rrrch, Ralph, 178, 183 Warner, K., /8-l Slr;urss, 4., 13, 22, 147, 1 52 Watson, J. D., 303 Str:rrrss, A. L., 308Stulrlrs, l. R., ll7, 119 Weeks, L.8., 124, 138 Weihrich, H., 184 Acc<runting, basic principles, 124-126 Attitudes, mentoring, 303-304Srlvker Gordon, R., 163, 164,155, 179 Weisman, C.5., 263 Ad hoc committees, 7l-72 Authority, 62-63, 74-77Slylts, M. M.,366 Werner, J., 362, 366 Administrative theory, 25-35 chain of command, 76Srrlr;rlitt, J.T-,336 Westbury, S. A.,337 behavioral, 2l-28 delegation of,76-77Swilt, M. H.,230, 235 Wlritebourne, 5.K., 166, 170 classical,25-27 functional, 75l:rppcr, M.,44, 53 Whitehead, 5.F.,262 contingency management, 3 I line and staff, 75laylor, A. G., /83 Widdowson, R. R.,67, 316,322 general systems, 29-30laylor, Frederick W-,25, 34 Wiedenbach, E.,23 management science, 28 Behavioral school of management, 27-28laylor, J. W., 220 Wilenski, H., ,1,1 theory X and theory Y assumptions,32 Behaviors:lh<rnrpson, P., 297, 309 Williams, M. A.,280 theory Z organization, 32-33 learning new, 108-109l-horeau, Henry David, 341 Wilmot, W. W., 145, 152 Administrators role, 36-54 mentoring, 303-304llrornc, I. M., ll5, 11B Wolf, G. A.,25O, 262 as leader,38-39 Budgeting, 127 -137lilquin, C.,271, 279 Worthlcy, J. A.,232, 235 leadership st.ylcs and excellence, 43*46 concept,127-l3Olingcy, S., 84 Wyskocil, Patricia, 305 McCluskys thcory, 40-43 future directions in nurse staffing,274lrcgoe, B. 8., 177, I 82 Maslows theory, 39-40 relationship to nursing process,lrivcdi, V. M., 271,275, 280 Yetton, P., 179, 184 pcrs<lnal attributcs, 46-50 133-137-lvcrsky, conviction, 48-49 assessment, 1 34- 1 35 A., 177,182, 183 Zaleznik, A.,38, 53, 67 couragt, 47-48 cvaluation, l3T Zaltman, G.,90,93 clc:rtivity,49-50 implementation, I 36-137Van de Ven, A. H., 220 Zeckhauser, R. A., ,/83 pe rsonal suJ)l)olt systcrns, 50-51 planning function, 135-136Vash, Carolyn L.,347, 351 Zimmer,M. J.,219 tinre :rntl clrrrrrcc, 5 I -52 types of approaches, 130-133Vaughn, J.C.,253,262 Zimring, C.,203 Age ncy rrrrr sirrg, 27.5 Bylaws,70-71Vaupcl, J.,178,182 Zuckerman, G.,298, 309 Agirrg prrrt tss , 162 -164. See also Elderly, clle ol Capital budget, 129 Allocntiorr, rrtrlsirrg stal l, 265 Care management continuity (CMC), Amcric:rrr Nrrlsts Asstx iation (ANA), 258-259 t49 I 50 Care management integration (CMI), Anrcric:rrr Nrrrsts Assr.rt iitliott Codc lbr 258-259 Ntttsts,64,.]54 Cash budget, 130 Amcricarr Nrrrsts Associutiort Congrcss Centralized organizational structure, 78 lirr Ntrlsirrg |tt:rt lict, 6 Chain of command, 76 Angcr, 224 Challenges, 105-170 Asscssnr(nl, ot lirt trrtslittg, I34.- 135 care of elderly, 154-l7O Assignrrrtrrl l):rll(r ns, 255 262 conflict management, 140- I 53 cctrtt-rtl tltrtttttls, 25() fiscal management, 120-139 rttw rrlrprrrirt lt , 27 )b) human potential, lO7 -l 19 iri.trlit iorr:tl, 255 257 Change, see Organizational change 373
  • r(.,(.,,((.,,r rr,,.ru,r,,riJ.iliniilil,,l,ii,,,"ill::l;,,1;:ll,1].l;:lli,:ii,lli:,,l],il,l;liii Nrrtsiltli Sttvitt :rtttl Ntusitrlr, llrlrrr:rlrorr. lt;r;ritl ( ilv, So. l)rrk.: St,pltlrrlrt.r. 16, t9U0. t). llrt Nrttiorrlrl .loittl l)trttlite (lorrurrissi<tt. (ittithlirrt.s litr listultlisltirtg.loitrl ttr (ollttltotttrivt lnutitrt irt IIospitul.s. (lrit.llgo: Nce ly irr.inting co., l9t3 l. lo Mrtrttittta,.l . P. Ncw conccpt hirs pxrrrrisc arrrl pnrblcnrs.fhc Hosltital Mcdical Auflror Index .Srrrl/, MLrlch 1981, l0(3),2-5. I I . llrrlcs, B. Doctor antl nursc: changing roles and rclations.Ne w EnglantlJotrr- rtttl ol Medicine, Iuly 16, 1982,783(3),129-134. 12. Atlclsrrrr, B. ancl wcrner, J. Fostering collaborativc relationships.The Hospital Mulicul Staff , March 1981, 10(3), 5-l l. I 11. N:rycr, D. D. unification: bringing nursing service and nursing education Iogcthcr. American Journal of Nursing, June 1980, 2S(6), ll l0-Il 14. Numbcrs in italics refer to names that Beckman, J. 5.,250, 262 l1. st.yles, M. M. our future is now. Keynote address, American societv for appear in the reference sections. Behn, R., 178,182 Nrrrsing Service Administration. Minneapolis: October ll, 19g3. Benne, K., 85, 87, 93 Bennett, A. C., 54,282, 291 Abdellah, F. G., 169,268, 279 Bennett, R., 1B3 Abdoo, Y. M., 271,273, 279, 280 Bennis, W.,87 , 93III I]LIOGRAPHY Ackhoff, R., 174, 182 Benoliel, J. Q., 3J8 Adelson, 8.,362, 366 Benson, E. R., 167, 170 Adelson, R., 167, 170 Bergson, H., 342, 345, 35 1l):rvirlson, R. A., Fletchg.,-.H.,and Earp, J. A. Role disagreement in primary Aiken, L. H.,250,253, 262 Berkowitz, E. N., 315, 321 t:rr: lrractice.Jountal of Community Health, Winter lggl ,7(2),93_102. Aldrich, H.,304, 309 Berman, H. J., 124, 138l)rlttrs.c, J _Imqlemglting the basic elements of collaborative practic e. The Hos- Alexander, E., 178, 183 Bernhardt, J., 203 ltitttl Medical Staff, March 1981, j0(3), 19-25. Alexander, E. L., 67 BeIz, M.,261, 263lllrlirt, K. S. Service and education together: a working moclel. Nursing Ad.min- Allan, C., 169 Beyers, M.,253, 262 i.st ru t ion Quarterly, Spring 1979, 3(3), l-5. Alward, R. R., 314, 321 Blackburn, R. T.,298, 309llrrckabay, L. M. Point of view: nursing service and education-is there a chasm? Archbold, P. C., 235 Blake, R. R., 44, 5-l N t rs ing Administration Quarterly, Spring 197 9, 3(3), 5 l-54. r Archer, 5.F,., l4l ,152 Blanchard, Kenneth, 339, 350 Argyris, C.,89,93, 145, 152 Blcndon, R. J., 25O, 262.loirrt Practice Committee of the State Medical Society of Wisconsin. Guidelines Armstrong, G. D., 263 Bordon, G. A.,221 , 234 lirr implementation of joint practice of physicians u.rcl ,r,rrr"s. wisconsin Med- Bradley, J. C., 231 Armstrong, P.,,1B3 itul Journal, June 1980, 79(6),30-33. Arndt, C., 144,152,203 Brogan, D. R., 245M:rilick, M. D. and Jordan, P. A multimodel approach to collaborative practice Arora, R., 203 Brotman, H., 169 i rr lrealth settings. Social Work H ealth C are,- Summer 1977, 2(4), 445_454. Aroskar, M., 183 Brcrwn, P. J.,74, 84Iteccl,,J. D., Neglett, P. P., and Neblett, R. Using an integrated physician-nurse Aspinall, M. J., 183 Brubaker, B. H., 337 rrrcdical record. The Hospital Medical Staff, March lg81 , t0e), )l*Zt. Atwood, A. H., 309 Buchanan, C., 309sirnms, L. M., Dalsto.r, {. w.and Roberts, p.w. collaborative practice: myth Audette, L. M., 271 , 279 Bullough, 8., 365 rrr reality. Hospital and Heahh Seruices Administration. (i,n press). Aydelotte, M. K., 146, 152,265,266,269, Burlingame, J.F., 104Stccl, J- E. Putting joint p_ractice into practice. American Jout-nal of Nursing, )7 ) )70 Burnside, I. M., 164, 170 May 1981, 81 (5), 964-967. Butler, Robert, 154 Baldridge, J. V., 143, I 52 Byrc, C.5., 262Stcenson, c. B. and Sulliva^n, A. R- support services in the school setting: the Barnard, Chester, 30, 35 nursing model. Jounnl of School Health, May 1980, 50(5), 249_9. Barnes, L.8., 67 Calkin, J. D., 53, 54 Bates, B., 220, 366 Cameron, S. M., 298, 309 Bealty, S. R.,337 Cantor, M. M., 84 Beattie, James, 344 Capp, Al, 342,351 Beckett, K., 346, 347, 35 1 Corey, R., ,183 Beckhard. R..88,93 Carlsen, R. H.,261 , 263 367
  • l)(ts(,nn(l rvill lrtt^xPtrlttl lo P1r11lllt.r,oPlrrslit:rlttl, (()sl-(ll(.livt.P:rlit.rrl w()t lilt, tlr ( ()ll( t tl ott :r t,1.ttl;tl lrlt.i., ttr)l ll Yllll lrt lll.ll.{ . llrl. lllt t lt :tt t lrttsttl ()lt t (s(itl ( lt. l{tsr;tt t lt t:, l lrt pr irrr:rt y ntcluts ol rlot rrrrrtrrtirtg Ilttorrplr o,,:rstott:tl, t;tstt:tl ( rr(()lttll(t :.tlltt livtrrtss arrtl cllicicnc.v ()l rrrrrsirrl, trlrrrlrliorr lrrcl placticc, ill)cl llLuscs llrc lirrrtlot ptrxt;tstirt:tliott is ot,t r. A: Slvl,, (ll) .1;r1, ()lt:.1v, " "r) rl{rt irr llrc tt(uuluturc will bc cxpcctccl to prrrviclc clatar to iustily nulsirrgs "Ou1 llttrpc is rrorv.".l rrsl irs lilortrrrt Nrllrtrrr;,rl, rlrr rrrrl tlr.ltrrrlrit lxrlliorr ol cclrrcution erncl hcaltlr ciuc c()sts. conclitiorrs corrtribrrtirrg lo lltttlt;rllr ol llrrlr.lt.,,1,1t, r, trr lltt( tittttit, llris btrck .rttcmpts to rcach thc heart and soul of thc practicing nurse so too czltl wc irt rttttsirrg lrtlttrirrlslt;tltott ,r"No trt,ttt !" ll l: lirrrc lotrrtlrrrirristmtor. At no time in the history of nursing has there bcen a nurscs lo eISSttn)c Iltc ttuutllt ol prolt:.-i,,tt:rl lr, lt;rvior, rvrtlr rrll its in-bcttcr-opporturrity flor the profession to move from adolescence to full hcrent privilcgcs ltttcl trspottsilrilitit:, :urrl rl r, littt,."lot rrrtlsc itdmin- nraturity. Thc major studies of the decade carried out by nonnursing istrators irr lllscttings lo rssun)(llr,lt:rtlt r.lrr;,l,,t ptolcssiottlrl Irursing.ltrl)Lrps support the mandate for leadership within nursing. Although lcaclcrship needs to be present in education, research, and clinical prac- ticc, it is in administration that leadership is most likely to make the STUDY QUESTIONSsigrrificant difference in bringing the profcssion to maturity. l3y virtue of personal skills as well as clinical and administrative l. Review Chapter lT, "Nulsirrg lkscan lr irr a Profcssional Practice Cli-lirrowledge, the practicing nurse administrator has the opportunity to mate." Then dcscribc thlcc l)()t(nlial rcscarch projects which couldt ltatc a professional practice environment that optimizes the devel- utilize the expertise ol cclltcutots artcl ltlactitioncrs.opmcnt of staff to the fullest potential and enhances quality care delivery. 2. Visualize your setting for aclrrrinistrzrtivc practicc. Dcscribe a collab-llris we believe. We also believe that the results of effective leadership orative nursing m<-rdel thal links servicc and a relatcd educationalin nursing administration can be measured in terms of: setting. 3. In thc same setting, identify the key factors essential for collegial Rccognized professional nursing image throughout the institution. relationships with physicians and administration. Ongoing credible nursing research. 4. Identify the fcrrces in your setting that interfere with the development Scholarly nursing publications by nurse administrator and staff rnem- of collcgial relationships within nursing. With other disciplines. bers. 5. To what cxtcnt does your nursing environment need to change in High lcvel of staff satisfaction. order to cstablish a climate for research based decisions? Consiclcl- current and projected necds for substantive data. Quality patient care. Projects that demonstrate attention to changing trends (for example), special concern for aged or drug abuse). Cost-cffective assignment patterns. REFERENCES Clinical and administrative ladder. Upgrading of entire nursing division programs by incrcase in masters l. Bullough, V. L. and Bullough, B. The Emergence of Modem Nrrr.si rrg, 2tl ttl. prepared nurses in head nurse roles and B.S.N.s in primary nurse London: The Macmillan C<1., 1969. roles. 2. Gclinas, A.NursingandNursingEducation. NewYork: TheCotlntottrvtitlllt Fund, E.L. Hildreth and Co., 1946. Demonstrated collaboration with other health professionals (for ex- 3. Goodnow , M. Nursing History. Philadelphia: Saunders, 1942. ample, interdisciplinary research). 4. Goldmark, J . N ur sing and N ursing E ducatiott in the U nited S tu c s, ( t i t t,, ! t t r r r r r Intcgrated practice-education model in place. lbr the Study of Nursing Education. New York: Macmillan, 1923. Dccrcased number of voluntary lcavers. 5. Powers, M. J. The unilication model in nursing. Nursing Outhxtlt, Attllrtsl 1976, 24(8), 482-487. Dcmonstrated ability to atlract, recruit, and retain excellent nurses 6. Christman, L. The center of cxccllence in nursing: the conccptuitl tttorltl at erll lcvcls. Paper prcsentcd at thc Third Annuerl Nursc Educator Confcrcttcc. l)clrrril. 7. Cltristr-r-rarr, L. Orr thc stcrrc: rrrritirrg strvittanrl cclttcntion lt Rttslt Itts lrr tlrc housc with effectivc nursing leadership, people know each othcr, lrytclian St. l.trkt"s Mttlitlrl (trrler-. Ntrrsirrs, Atlrrrittislntlitnr Qtrurltrlv, Splirrlrlllk to cach clthcr, zrrrcl :rlc cnthusiastic about common goals. Thcy are 1979 , .t( t), 7 40.
  • ti...",,..i.ii,,;;i i,t,,i...l;;,;;;;,,,t"""" scor)c ()t rrrrsirrs ;rrrrr r!lrr, lr ,,,ll.rlr,rr.rlrilrr l,rht, 1rl;r, tlttltr"trrr ;rlrf ,i. t,ilt.,, tilil:,r..,.rrrrl ,rtlIntcgr-ating tlrc llaticrrl ttroltl irr lr rrurrrrrtrtlrut rcllccts botlr rrrrrst rttittislr:rlor:, rl,;r,tt,l. tl;,,,tt lltt :,tt1rlrot I ol lrtolcr,r,tou:rl lrrrlorrr)lr .lril and physician asscssrrrcnt arrcl acliorr llrt sllrr itrl, ul t;ttt ;tr ltvilics lrtlv((rt ;nr(l ir( r()s 1r:rt lir t1r:rltrrli tlr:,r i plirrts. Conducting joint nursc-physicizrn ptrticrrt carc rccord rcvicws. lrrtcrclistilrlitrirty tollltlrortlivt Pltrlict rrt,tls lo lrt t()r( (l)trr;rlrz,rl, plitrrrrccl, sttppot lttl, irntl tv:rltrrrltrl, l:rltirrlr irrlo lrt t orrrrl llr. :,p,, rlr.Advantages of the Joint Practice Model charractcristics ol lltc orgarrizitliott lrtrtl tlrt irrtlivitlrr:rl prrlr(ul (.rr( ,,rt uation. [n dctcr-rnirring citlrcl tltt rrt.ttl lol or lrllrrrrrirrl, llrt tr;rlrr;rlr,,lMany advantages are cited in the literature as being attributable to jointpractice. Mamana (10) discusses joint practice as a new concept with of selcctcd rlodcls, or-rc rtriglrt r,vtll tirist tlrt r;urstr.rr; llr, t1,,,r, ,,n,promise and problems. Bates (l l) emphasizes the importance of level know if collabclrativc pr-:.rctirc cxisls in rr inslilrrliorr, lls rrislcrrt t t,rrr be rccognizcd by thc Iollowirtg critclil: (l)tllttlivttorrrrrrrrrrrt,rtr,rrof preparation for an expanded role such as the clinical nurse specialist. patterns, vcrbal ancl writtcn, bclwccrt arrcl :rrrrorrli plrysit ilrns, nur,,(".,Adelson and Werner (12) also emphasize the importance of profession- and administrators; (2) thc rcwettclirrg ol itttptrrvttl lxrlitrrt t;rr :rrrtl rrrrrt:,alism and competence for the role. in which it is practiccd; and (3) cstablisltccl cllicitrrt rrrrrl tlltrtrvtsrrplxrr In general, the following advantages are described (13): I services. If these critcriar arc noI nrct, collirbolrrlivt Pllrrlitc rlots rr,t really exist.l. One primary nurse care giver: no nursing care is given by nonprofes- sionals. Clinical nursing functions are carried out by registered nurses, with minimal or no delegation of nursing tasks to others.2. Increased job satisfaction: contributions of the registered nurse are SUMMARY recognizable. There is improved accountability and less blurring of the lines around who delivered what care to whom. This promotes Integration of nursing service and cducation ancl irrtcrtlist iplirr;rr 1 1,rrrl individual recognition. practice are of importance for nurse administrzrtt.rls. lltr lrlrtrrorrrtrr:r resemble rcligion, and proponents of integrertiorr arc likt lrorn rrl,rrirr Itt3. Improved recruitment and retention: although hard data are not lievers, flag bearers for the truth. The c<-rncepts <,rl intcglirliorr irnrl rol available, a joint practice emphasis is thought to be related to an laboration are not new. They are developing p:,rttcr-rrs ol ptoltssi.rtr:rl improvement in recruitment and retention. organization in health care settings in which nursirrg uclrrrinistr;rtrorr,4. Recognition of nursing: joint practice legitimizes nursing inputs and practicc, education, and research are intcgratcd arrcl consolirlirlttl irrlo emphasizes the importance of optimal physician-nurse relationships. a professibnal entity recognized by other health prolcssiorrrrls. Furthermore, it promotes the integration of medical cure and nursing Resurgence of interest in intra- and interdisciplinerry irrlt1r,r ;rlrorr r, care philosophies. most likcly due to the maturing of the profession and tlrc r((()l,,nilr()n5. Professional nursing competence: it is thc expectation in joint practice by profcssi<-lnal nurses that clinical practice without rcscurclr is rroI r t r that thc primary nurse is knowledgeable, competent, and supporlive ognized in the professional world. Research is basic to adrrtirristr;rtirr. of 24-hour responsibility. practicc, and education, and good research comes out of collalror:rli,,rr6. Ongoing evaluation: in a sense, joint practice is an ongoing form of belwecn nursing service and education as well as across disciplirrts. evaluation of care. The integrated record provides a readily available Nursing is a clinical practice discipline. To teach effectivc rrrrrsirrll data source for reviewing obscrvations, treatments, and actions. Joint practicc, laculty mcmbers must be involved in clinical settings in s,rrr. discussion of care problcms and goals further enhances the quality way in ordcr to have credibility and to have access to rcscarclr crrvi of care. ronments. Nurscs in clinical practice lose credibility if they ckr nor7. Communication, competcncy, and trust: these three elements are re- maintain cxpcrtise through continued education and research urtilizrr peatedly cited as essentials for and advantages of joint practice. tion. Throughout thc 1980s, therc will be an increased emphasis on rcscurt lr The goal of joint practice is to improve health care, not to protect or that has rclcvancc for both nursing practice and education. Facultvpreserve professional prerogatives. Interdependent relationships and mcmbcrs will be increasingly criticized for their lack of practice bascclwillingness to reformulatc roles are facilitated when practitioners are research and their rrsty clinical skills. On the othcr hand, nursing scrvice
  • Mttlitrrl Assot irrliort, llrr Atttt trr;rr Nlrr:.t"- Assotiltliott, rttttl llrt W.ls. tollr1,t,tl tnlrt.tt llott ltottt ;trltnt:,:,tott lo rlt.r lt;rtl.( ( {rn( rt n ,ttrrut r lrlKrllogli lirrrrrrllrliorr,:urrl il tslrrlrlislr,rl ;,.rrrrltlints lirrntltscs llrr(l l)lty- lirrtultol t;ur lrrt llrtr ..rlrltl)()t ls joirrl pl;rrrrrrr;.siti:rrrs lo rrliliztirr trrlllrborutirrll lrs collrlr11rrts irr prrrvirlirrg 1litticttt t:ttc. llrc cr.rrrcrrt cruplrlrsis on .i()int plrrt litt(ilrr l)(: attributccl [o r-cilsorls Conllicls in lrnagcs olNursingrclntccl to charrging timcs ancl changirrg prulcssi<-rnal goals: Histoticallv, Ittccl icirttltttrl ntttsirtll llrr,,t:rlrv:rrs lrtrrr:rllr, tl :rrorrrrtlr:u,l. Emcrgcncc of prolcssional nursing o{thcsickar-rcl hclplcsslti.rticrrt.Asllrtrrtttlsol lrrrrrurrulylr:rvttlr:rrrp,trl,2. Upgrading of education for nurses thc sc<-lpc o[ nursirrg lrns broacltrtctl bcyontl tlrttlrrtol tlrtsirli. trr tlrt3. Increased interest in patient-centered care last dccadc, nursing has bccn rcconcrptrrrrliztcl lis ltgitirrrrrltlv lrtin1,. involvcd in wcllncss arnd illncss. Hcalth is no lorrgcl corrsitltrttl rrs lrtin1,,4. Conflict in images of nursing projected by nursing service and nursing the mere abscncc o[ discasc but, r;rthcr, as optirrrunr biolrs.vclrosoci:rl educaticln functioning and the ability to copc with problcms o[ clail.y livirrg.llris5. Breakdown in communications among health professionals emphasis on wellness care in many schools o[nursing has crcaltrl rrurnv problems for health care institutions wherc patients arc gcilirrg oltlt.r and sickcr. As might be expcctcd, baccalaureate-prepzrrccl rrrrlscs rrrr,Emergence of Professional Nursing feel unprepared to provide acutc care. On the othcr hancl, clirritrrl sp.,Over the past decade, nurses in this country have sought to become cialists may leel well prepared for theirpositir.rns and nray lutli,,,p;,,rrecognized as health professionals. This has not been easy, as society tunity for full use of skills.awards professional status only to those groups that are recognized asprofessionals by virtue of advanced preparation and a body of knowledgethat is the unique basis for service. Nurses seek an independent as well Breakdown in Cornmunicationsas interdependent role as they make a strong plea for an increased voice There have been dramatic advances in medical knowleclgc rrrrtl rr,rvin decision making in health care delivery settings. techniqucs. The advent of antibiotics has helped to rout infectiorrs rlistrrst and many pcoplc are living longer and reaching the age in whiclr clrrrrrrit disease is morc prevalcnt. Highly sophisticated diagnostic ancl nrorri-Education for Nurses toring techniqucs, coupled with intensive surgical treatments aI unvAlthough associate degree programs continue to flourish in community agc, have crcated an cnvironment of machines such that human irrtt.r-colleges and diploma programs have not ceased to exist, it is increasingly action can bc avoided or misused. The purchase of new cquipnrcnI isapparent that graduate education for nurses is here to stay. New masters ever a bonc of contcntion as arguments go on over how scarcc lurrtlsand doctoral degree programs continue to develop. Baccalaureate ed- will bc allocat.ccl. Thc vcry complexity of the environment intclltrtsucation is considered by many schools of nursing to be the entry point with both thc tinrc :lnd placc of nclrmal conversalion.to professional practice. In addition, the American Nurses Associationproclaimed 1984 as the implementation date for requiring the B.S.N. The Joint Practice Commission Modelfor entry into professional practice. This proclamation was not widelyaccepted by the hospital industry, but the very existence of the statement Five 1actors havc corrtributed to divergent goals on the part of physiciarrsgave credence to the belief that advanced education in nursing is im- and nurscs, sr-rclr th:.rt in the 1980s it has becomc necessary agairr trrportant. emphasizc coopcratiorr arnd collaboration in decision making. Thc col- laborativc nroclcl clcvclopcd by the Joint Practice Commission is clc- pendcnt uporr llrc lirllowir-rg steps: (9):Quality Patient CareDirect patient care has been largely the provision of services to insti- Establishing ir crrrtlirliz.cd .joint praclice committee represcntirrgtutions and physicians. With the advent of interest in quality patient practicing nuls(s rrrrtl plrysicians, supported by administrationcare and patient-centered care, nurses are expected to play an ever-in- Introducirrg 1-rrirrrirry rrrrrsirrg, with registered nurses individually rc-creasing part in monitoring and evaluating quality of care. Emphasis sponsiblc lor- rrrrrsirrll tirrc within a collegial relationship wirh pliy-on care outcomes demands a look beyond chart audits and encourages sicians
  • 342 MovlNLi ultyoNt)l ltr ()t{r)rNAt( llll.( (tlll lr ()t ll/N,(,t llt t.Jt r.t 1 Schiller, poet and dramatist, dcclirrccl tlrat high comcdy is thc grc:rtcsl tttttttol lr,, l ttt;rllrt lt,,rtlr;ttl oll rvtv(t(, v(t(:t, l,:t,l oll:rr, llrrs of literary forms. The more comedy tcnds to be physical, thc lowcl it btnrtllt ,,1 r;r1,, is; the more it tends to be intellectual, verbal, concerned with thc plary lirrrrrr llrt.irlrrrrrtl;rrrtt,,1 llrtsttitntlottt olrsttr;tlitttts ott llrttrlrlttttol of ideas, the higher it is. George S. Kaufman once defined high c<-rmcdy cclrlcclv ovt.rlinr(, ()n(t:rrr rtirrlilv scc tlrirt trttrrttlV is lr rritlttrxrl tttttltt as a show that closed last Saturday. whicl-r evclv l)uul irrrtl rvonrlrr cart liucl slrclltr.llrtlrrolltttlt.,<ttl ol tottt Meredith (9) instructed us that true comedy is not contempt as is satirc cdy ancl tragcclv is sigrrilicant ancl clcar. (lortrrrlv is stt iotts lrttsirrtss. ll but seeks thoughtful laughter.It makes civilization humane by laugh- is also clear that courccly is rclativc, rt lltittttt ol o1rittiort. ing at humor. Vera Robinson (5) provides us with it gcttctic clclilritiorr. Slttvitrvs humor as any "communication wl-rich is pclccivccl [rv arr.v ol tlrt Pltlics Walpole made a telling distinction when he observed that life is a as humorous and leads to Iaughing, snriling, clr it lcclitrg ol ittttrtsttlltttl" tragedy to those who fecl, a comedy to those who think. (p. l0).Robinson notcs that within hcalth catrc scttings, rtlost ol tlrtlrrr Kronenberger (10) compared tragedy and comedy; both comedy and mor is spontaneous or situational in naturc, unlikc thc lbrrrral lttttttot tragedy are about human limitations and human failure. Tragedy is of literary work or the planned inclusion of j<-rkcs in spccchcs or-lccttttts. idealistic and says, "The pity of it." Comedy is skeptical and says, Humor as a communication that rcsults in ccrtain obscrvablc bcltirviot "The absurdity of it." Tragedy laments the flaws of humanity;comedy is an operational definition that scrvcs thc rcscarchers ncccl lirt rtrtrrs looks for them. In tragedy, humans aspire for more than they can urement. To the humor researcher, measuremcnt is thc liclcl ltt<r lr, achieve; in comedy, they pretend to it. Comedy is criticism. It does solved. Humor depends on so many cmotional, social, and irrttlltt lrr:rl not deny idealism but shows how far human beings fall short of it. faccts of human beings that it appears immunc to quantittltittltttitl:.t. Bergson (11) observed that comedy is based on our sense of the full, rich, spontaneous variety of human nature. When the human becomes nonhuman and acts mechanical, we laugh. Comedy is social. COMIC RESEARCH Freud (12) proposed that laughter is the surplus energy released when lear is appcased. Jokes release the anger or fear resulting from stress. Researchcrs who havc confrontcd the complcxilies ancl tlrt ittlttt t trl All jokes release bottled up anger or fear by presenting them in disguise ambiguity of the humor response have in the main producccl rltscr ipl rvt so that we can laugh at stress; the disguise protects us from direct studies, typologies, and functional analyses. Three primary lirci ol sltrtlv pers<rnal pain. We laugh for two reasons: (1) the catharsis of relief- have been ( 1 ) how funny a .lokc or situation is rated, ( 2) how.jokcs rr r igl r t ("thank God this has not happened to me"); and (2) the warding off bc classified into diffcrcnl typcs of humor, and (3) hor.v hunrotcutt ltt of suppressed anxiety-("by God, this might happen to me"). described in terms of its social, psychological, psychodvn;rnrir, irntl Grotjahn (13) refined the concept of comic distance. A joke is funny physiologic functions (17). Generally, thc litcralurc on thc positivt tlltt ls according to the efficiency of its disguise. The better the disguise, the of humor is based on personal expcricnccs, obscrvation, etncl scll-rtlroll better the joke. The disguise gives the audience the safety of comic (18). C<lser (19) obscrved thc joking rclationship as a status phcrrorrrtrr,rn distance, or protecting objectivity. in her study of humor in hospital settings. Othcrs havc tr-iccl cotttit pt irr Frye (14) speaks of mature comedy and comic grace. Comedy is de- ciples on for lit. Jackson (20) uscs the analogy o[ nurscs us clorvtts, lrtttl signed, not to condemn evil, but to ridicule a lack of self-knowledge. Paulos (8) applies malhematical logic and lzrws to unclcrstancl urrtl rrorl.l . . . The essential comic resolution . . . is an individual release which the structurc of jokes. is also a social reconciliation. The normal individual is freed from thc Research on thc relationship bctwccn humor ancl hcerlirrg lrirs rrol pr, bonds of . . . society, and a normal society is freed lrom the bonds duced the hard expcrimental cvidencc rcquirccl to convirrcc lltc sritnlilit imposed on it by . . . individuals. Comic grace is the grace of acceptancc. and mcdical community. Attcmpts to conncct lzruglrtcr to tltrprrxlrrt liorr A fundamental principle of comedy is to include rather than exclude, ol cndorphins or to thc activation of thc imnrunological svstcrrr irlt rrrrtltr to soften and reduce distance between people (15). wzry bv cltccrlrrl rrrttlicrrl ttscirtchcrs. Dr. Williarn [rr-v (2 l), ir psvtlrirrllist A cartoonist is a sit-down comic. Thc cartoonist Al Capp (16) has ob- itncl rescurtlrtr :rl l.orrur l.intll Iilrivcrsitv, is cur-rcnllv rortclrrt lirrl. tr served that wc laugh wlrcn wc fccl supcrior to thc comic Iigurc. Thc 1-rcrirrtcrrls llrrrl srt1. lo p11v1,1lr <ltlirrittplrvsi<llogitrrl lrlrrliorrsltip lrt morc scclllc orrc lccls, tlttrttotc r-cacl.y onc is to larrglr. So Clrarrlic Chap- twtrn lirrrl,lrltr :rrrtl llr,Itorltttliorrol tlrtccltolrrrtrirrts lry rlttnorrslllrltrrl. lin, llrt insllrrrl lrtirpptirltrl,llirvtrrs irll :r litlirr11 ()l sr(ulity. Ccrtainly, llrrrgltttrtllrt l. .rr lltr { n( ul;rlor V svsl(nr.
  • llrt.rcclrrirt,rrrt.rrls ol rtliirlrilitv;rrrtl v;rlitlily ittttl ttstol lttttttittt srrll.itc(s lrr llrrt;rrl lv{rlrrlltttttltttv, llttttilit (itor1lrMtrttlitlr(()) 1111r1r,itr tx1rr.rirrrcrrlirl lt.sc,alch nrc irrurrrtliltltollslaclcs. l-irtrt ltttcl l)ctttltttctl siztcl ir tlillrrtrrl ;r,.;xr I ol lttttnot: llttsrxiirl rtgrtllrloly lrrrrtliorr. lltr,vroleIrirvr rlcvclolrt:cl un instrumcrrI to itlcrrtily lrrd lrcasurc thc cottlttltttti- lhlrl llrttotttit:,1ritrl is;rsotlol sotiirltolrttlivtitntl sptirtgsirttotrtIiorrgirliotr skills usccl by providcrs witlr thcir paticnts. Thcir instrur-ncrtt is wltctttvtrnr(n w:r orrl ol ptrrl-lottiott-wltcllrcltlrcy arc plarrning short-llrc (lontmunication Preference Invcr-rtory, in which the willingncss o[ a sigtrtcrlly or lrlollirrg tltrrrcrricclly. Mcrcclith notccl thut htrmor, societallr(.ts()n to scnd or receive humorous responses when given othcr carclully hcalth, ancl llttsotiirl tt1r-rality ol rncn ancl wonrcn wcrc closely related.rltlirrccl choices is measured. The researcher claims to have developed The Frcnch wlitcr Hcrrri Bergson (ll) craftcd a cclcbratcd phrase inrr " rrrorlcratcly reliable, face valid, self-report measure of the degree to 1911 whcn hc attributed laughter to the mechanical encrusted on some-wlritlr consumers or physicians value the use of humor in physician- thing living. In other words, when humans become rigid, machinelike,;rrrticrrt communication" (17, p. 1224). Mindess has developed a Sense and repetitive, they become comic, since the essence of humanity is itsol l lr-rrnor lnventory similar to an IQ test (22). The instrument assesses flexibility of spirit.tlrttypc of humor one likes and the role it plays in ones personality. A well-known theory was developed by Freud in 1905 (12). ThroughMirrclcss premise is that if we understand who will laugh at what and jokes and witticism, a person vents his or her aggression or sexual anx-wlry, wc can learn more about our important differences. ieties in a disguised or playful manner. Max Eastman (23) emphasized ll.esczrrch on humor is wide and varied, cutting across academic dis- the relationship of humor and play as well as the requirement of antiplincs and engaging diverse and unlikely schools of thought. All dis- objective disengagement to appreciate humor. Eastman developed thet i p I i rres, however enthusiastic, face challenging methodological and derailment theory of humor. Humor is context dependent, that is, normalnt(ilsutctnent tasks. Students of humor have a lifelong career of im- events are derailed by the situation. Humorous events are not incon-ir1,.i rrl t i vc inquiry. gruous per se but become incongruous given their situation. Perhaps this theoretical insight is the origin of the popular situation comedies rampant in the television media.A COMIC HISTORY In 1964, Arthur Koestler compared the continuity of creative insights in humor with the creative insights of science and poetry: the logicalWc hzrvc seen that comedy defies definition, resists measurement, is a pattern of the creative process is the same in all three fields: creativityrrrlt tcr of opinion, is an ancient art enjoying a modern life-style. Humor consists in the discovery of hidden similarities, but the emotional climaterrpry lrc a contemporary phenomenon of inquiry, but it has a natural is different . . " the comic smile has a touch of aggressiveness, the sci-lristory that is instructive. The ancient conception of comedy was nar- entists reasoning by analogy is emotionally detached, i.e., neutral; thelowcr than ours, confined to farce, burlesque, and slapstick. This con- poetic image is sympathetic or admiring, inspired by a positive kind ofccption persisted until 1651, when the English philosopher Thomas emotion (24). Koestlers principle is that creative insight in all fieldsI lobbcs introduced a theory of laughter referred to as the superiority share the same logical patterns. Koestlers theory synthesized incon-or. clisparagement theory. A sense of satisfied superiority and self-sat- gruity theory with the psychological theory of humor. Laughter is theislirction are factors in many kinds of humor and play a prominent role discharge of emotional energy resulting from the "biociation" of twoirr sick and ethnic jokes. Superiority is the primitive base upon which incompatible frames of reference. Koestler has a disciple in John AllenIrlrrlor theory was developed. Paulos (8). In 1776, James Beattie identified incongruity as a comic principle. Paulos explores the operations and structures common to humor andlrrcongruity as oddness, or inappropriateness, was further developed in in the formal sciences of logic, mathematics, and linguistics. He developstlrc eighteenth and qineteenth centuries by the philosophers Schopen- a mathematical model of jokes using the mathematical theory of "ca-ltauer and Kant. Schopenhauer was so funny that countless adherents tastrophe." Paul<-rs exemplifies the universality of humor across disci-ro his pessimistic philosophy committed suicide. Kant in 1790 called plines and promises a humorous continuity in the age of informationattention to the elemcnt of surprise, the unexpectedness of incongruity: and its computer technology."laughter is an affection arising from a sudden deflation of a strained This chronology of one-liners is admittedly incomplete, but the com-cxpectation into nothing (8, p. 3)." Herbert Spencer and Charles Darwin mon ingredients o[ hum<.rr crnerge despite the different approaches ofobserved the physiological bases of laughter, laughter as a release of theorists of humor. An csscntial ingredient of humor is the juxtapositionenergy, an observation that influenced later theorists, in particular of two or more incongruous ways of viewing events, ideas, people, andFreud. their roles. For somcthirrg to be funny, some unusual, inappropriate or
  • (xl(l ttsl)(rl ()l il tttttst Itc pcrttivtrl ;rrrtl torrr1xrlctl Io tlrc rrolrrr. Arrolllcr 1lttlvltlcrlcc <tl ttttss;t11t t,ttttttlV, itlttl itt rvolkirrli lorvirrrl ir tglrt.si11rr 1l(ss(tllittl irrlr,rttlicttI ol ltutttot is Ilrt l)r()lxr l)syclt()l()gic:rl arrcl crnotiorral ell.titudc in scllirrlg rrgr r l)()rrl ol vitw irrttlligilrltlo lrollr lrrr.rr:rrrrl w()1lcp.tlittratc. Tltc prrrl-rctctrtotiorurl tlirrurlc is both surb.jcctivc and ob jcctivc Collierand llccliett (2.5) rrotttl llrrrl llris is ir grxrcl tirutlirr w()nrclr s llrnror:rrrtl, irr tlrc cnrr-cnt unclcrstunclirrg ol cornccl.y thcory, an unclclincd con- and a hard tirrrc lirl rrrtrrslrurnor. Arr illtrstruliorr is Stcvc M:rr.tin, a jrtl rrrt. popular malc corncdiarn, wlro is cloing ccrrncdy about thc fhilure of com- edy, about the persona hc scts lbrth. His comcdy is all form and style and no content. His sclf-deprccatory style is lunny and momentary, not.IIIIi GENDER GAP IN COMEDY the take-home comedy of insight and sclf-knowledge. Instead of an imitation of male comedy, humor by women is becomingWlrtrr wc rcvicw the historical development of comedy, the maleness of the comedy of friendship, of reacting with one another as colleaguestrrrcrly hits us like a pie in the face. comedy as the domain of males about aspirations and our anxieties, and our shared experienies. All co-is tvirlcrrccd in their numbers, in attitudes expressed, and in determining medians talk (and write) abour rhings they know well. Nursing admin-llrc wzr.y comic routines are done and who does them. Traditionally, istrators know the world of nursing, its culture, and its vocabulary. w()nrcn l.ravc been thc objects of the put-down; wife and mother-in-law Nursing administrators know the structure of care, the significance of jolics lrc thc stock and trade of disparagement humor. Women have an atmosphere of trust. Being or thinking funny has so much to do with lrttn sccn zls a community of fools. Jokes that degrade women (and men) trust, confidence, and intelligence that nursing administrators are in a stcrrr to corrclate with one of the personality characteristics called fortunate time and space not only to humanize but to humorize thc "trrrrglr p<.risc" in Mindess (22) typologies. Such people tend to be aloof practice of management. irrr<l lcl [rclicve that stereotypes of the opposite sex are true. A cartoon rlt;ricting a woman jacking up the wrong end of a car to fix a flat tire is orrl.y lunny if you really believe women are stupid. HOW TO BE A COMEDIAN (inrccly has been a field dominated by male thought and male themes irr rrrrrch thc same manner as the field of management. Both arenas are To humorize management in constmctive and procluctivt wlys rr.t;rrirr.s ll lrrsl wclcoming women. Women are proving that they can be bright, awareness, accumulation of comic knowlcdgc, ernrl tlrrPrrrgltssivt. rrurs rrsstrlivc, zrttractive, and funny. The phenomena of women going for tery of comic skills. A generous appreciati<ln ol corrrt.tlv, ils ltlalivt,rrir lrrrrglrs ancl recognition in all aspects of comedy-writing, cartooning, ture, and its rules is developed in indivicltrals ancl irr olgrrnizlliorrs lly prrrtlrrcirrg, and performing in movies and on stage-are no longer novel. the same process of developing and utilizirrg rr.w l<rrrwlctlgc irrrcl rrt.w(ollicr ancl Beckett (25) have examined the experiences of 17 women technology from other relevant ficlds. Curr-cntly, rrtrrsirrg aclrrrinistlltor-s lrrrrrrorists in a series of interviews to see how they live, to hear how are addressing the business of nursing, cstzrblishirrg thc ccorrt-rrlic ril- tlrtv tlrink, and to listen to their personal stories. The barriers come- tionality of practice, and intcgrating complcx inlbrmertion tcchnologytlitrrrrts lacc are familiar barriers to women in management: image into their professional practice. The arguments [<rr an cconomic frame- lrrirblcrns (thc difficulty of retaining their femininity while being funny); work for nursing practice, whether clinical or administrative practice,irt ctlltirrg attcntion (a nice girl does not draw attention to herself); and carries the urgency of survival. Similarly, if no other argument can beovclcorning the socialized fear of taking the spotlight away from men. made that will convince nursing adminisirators of the value of the comic Again, cquity is a common issue. Women humorists feel that they are perspective, humor as a conferment of survival skills, is the most com-Ioltccl ir-rto being better than men. Vocabulary and understanding pres- pelling.trrl clusivc barriers. There is a womens culture that men just do not Vera Robinson has developed guidelines for increasing a humor con-Itrrow about, a repetitive lament of nursing. The essence of comedy is science, identifying appropriate uses, and establishing a knowledge baselrrrrriliarity and surprise. one cannot laugh unless one knows what one for comedy and comic techniques for the health professional. Anotheris l:rrghing about. Male comedians do not ask, "Do you understand this?" survival manual for administrators is Carolyn L. Vashs book,The Burnt-lhcy scldom inquire, "Do you know what a carburetor is?" out Administrator, which is written with insight and humor (26). As- Worrrcrr humorists, once confined to a small and limited role, are now suming an informed student of the comic tradition, what possibilitiestrtirlirrg tlrc structure of humor and its content as well as performing are at hand for thc nursing administrator and his or her staff to stepit. llrt rrraturing of conrccly by womcn is more signilicantly evidcnccd outside thcmselves and thcir burcaucratic systcms, to see themselvesin tlrc incrcascd nunrbtrol comcdicnncs doing htrrlclr on issucs, in thc ancl thcir organizations lirm a c:onric pcrsl-rcctivc! Just as humor and
  • jokts lurvt:rl lr:r:,1 lrvo lrvtls ol ttrt:rttttrl,, orP-:rttiz.ltl.i()nlrl lll(()ry lr:rs lrvo l.:rrl1.lrirl11 rvrllr.,)lrr(r)rr. rttl,,ltls lrirrr or lrt.r irr lr sl,slr.rrr ol srr1rlr9rI lrrrtlItvtls ol (()n( (l)lrr:rlizi.rlion, rrolrrr:rlrvc lrntl tltscri1-ltivc, wlt:rl ()uglll l() r:rtt.llrtllrtr;rPtulr( lr,(.ol lrrrrrror lr1:lls llrr.pto;llt,irr lrrrirr, rrrrl llrt.lrt :rrrtl wlrirl lrt lrurlly is.llrt()r1:lurizirliorr:rl clrart iind i()b clcser-i;rtiorr pairl ill Ptoplt. lttto1rriztrtl, l:rrrlilrltr :rs t.vitltrrtt.ol :r posilivt.lrlr.lw<l har.rcly lrooks with which to lrcgirr plarcticirrg htrnr<-lr-. Wlrnt irr- lr:rlit,rrl cillc otlt(()lll((l)ittr(ls opltot ltrnily to tolltrltollrltwillr ltirlicrrls irr tlrcir.sights rrright cn)clgc ila humorist dcsigrrcd an organizationerl chart that own scll-rr.grrl:r I iorrlruly rcl-lccted organizational decision making, actual powcr ccl-rtcrs,irntl pattcrns of information flow! Is there a department of applicd hu-lu()r, a committee on utilization of humor, or a consultant on comcdy? THE PUNCH LINE ls t lrcrc a locus for maintaining an organizational sense of humor? Whatworrlcl a job description reveal about the reality of nursing if actual work At this time in this routine, a disquieting qucstion should be raised andpcrlirnr.rcd were described instead of work expected? Would a recognition resolved. Is there a comedy of management or a management of comedy?l)rogram change if humor or the ability to create laughter were among Is there a distinction here that makes a difference? A soviet diplomltt lrc critcria of achievement? How would a humor break effect the work was asked what in his mind was the difference between capitaliim andol committees? Would instruction or policy be followd more willingly communism. with a straight face he responded that in capitalism hu-il lorrnulated in a comic vocabulary? Would the graffiti of disenchant- mans exploit humans and in communism it is the other way around.rrrcnt that peppers the walls of a unit or department in crisis or under The alignment of management and comedy demonstrates two key char-tlrrcert change from rage to more accommodating slogans? If humor were acteristics of humor: opposition and relational reversal. opposition isItgitimized, what would happen to the relationship between manage- the articulation of contrasts: expectation versus surprise, the mechanicalrrrcnt and labor? Would communication failures persist if subject to versus the spiritual, superiority versus incompetence, balance versusr<lr.r.ric analysis? exaggeration. Reversal is cognitive restructuring that produces a change Thc folklore of an organization and the ambiguous context of organ- in perspective. It is the setting up of a premise, an expectation or aizational reality is a dazzling lode for the comedian. Humor ranges in process that suddenly shifts direction and meaning (for examplc, .thatr.r continuum from health to unhealthy. It is healthy when it deals with is not dirt in your soup; it is earth"). Like a relational reversal, a punirrrmcdiate issues and helps the individual or the organization handle forces one to perceive in quick succession two incongruities or unlikelyrcality. It is dysfunctional or unhealthy when it denies reality. sides of an idea. ln an entirely different context from that of the inherent absurdities comedy of management resides in the response to the dynamics ol organizational endeavors, humor has the potential for enriching -The of unruly oppositions common in administrative practice: p..dictabilityrrursing diagnostic and therapeutic practice. The American NursesAs- versus surprise, control versus freedom, stability versus chaos, fuilsociations Social Policy Statement defines nursing as "the diagnosis knowledge versus inevitable ignorance. comedy of management isand treatment of human responses to actual or potential health prob- keeping the people who dislike you from the people who are undecided.lcms" (27, p. 9). The document includes a partial list of human responses The management of comedy is exemplified in the dynamics of rela-that call for nursing intervention, such as self-care limitations, impaired tional rcvcrsal, in securing a new way of looking at the mundane to findfunctioning, and pain and discomfort. Laughter is a human response, the marvelous or beyond the marvelous to find the mundane. Throughinherent in humanness. It is also a functional ability amenable to nursing the management of comedy, human resources of imagination and crea-assessment and nursing treatment. Inability to laugh or to respond ap- tivity are liberated for invention and experimentation. Responding topropriately to the comic is a health problem. Recent research on the evcnts is the comedy o[ management, while shaping events L th"relationship of the right and left side of the brain promises diagnostic agement of comedy. -arr-criteria in brain-damaged patients such as in stroke. "Only when thebrains two hemispheres are working together can we appreciate themoral of a story, the meaning of metaphor, words describing emotion, SUMMARYand the punch lines of jokes" (28, p.7D. Utilizing the sense of the ridiculous has also been posited as a memory Humor is a distinct univcrsc of discourse with its own logic and its ownenhancing device; the more ridiculous the image created in terms of reason. constructivc hurnor integrates, combines into one view orassociation, the morc likcly the name, place, or event will be remem- framework, thc bcst ol two worlds: nursing and management. Humorbered. Laughter prcsupposes a system of shared values and beliefs. makes possiblc ncw c().rcctions between two clissimilar theorv and
  • (ioorll)1.:tr.li(.(t.tniv(lscs. rnirnitlt(ttlctlI is lltc coltsltttt livtlttttlttc:ttivt Il. lltrl",rrrr, ll lrtrtlllttrt. ,ltt l.(l()l/ llr,lllrtttrrttT. rtl llr,(ittrttr. Ntrv Yotl, (iootl conrtrlv crrliglttct)s ittlcl irrlirrlrrs tts itllotlt Mrrt rrrilllrrr, l)l Li.,sc,.,l hrr6rerrr r(s()ulr(.s.1;trr scll-c<-lrccpt arrrl ()ur ()lgllllizrrliorrlrl c()r)ccpt. A cclnlic 1-rct sllectivc 12. lilrrrtl, S..lol.t.s llttllrtir lcllrliorr lo lltttttttonst iotts itt.l . Slllrt lr,v,,t1,, //r, Cotrrltltlt l.st<l1rt1r,r1rrtl Wtttks ttl Sigtrrtrtrtl ltnrtrl- l.otttlotl: llttl;11111 Ittr:,It,lcls an organizzltion l()wlll(l gl(lttcliIw:.lrcncSS cll its strcrlgtl-r arrrcl 1961.w(irkncsses and allows lul ()rgi.rnizutiort to lcspond to onc cl[tl-rc n-rost 13. Grotjahn, Martin. Bcyontl l,uughtcr: A l)s-v<lttxtttttlvtitttl Altltrttttrlt lrt llrtttrttr you havcl)()wcrlul human drivcs: thc urgc [o tly sontcthing ncw. Whcn New York: McGraw-Hill, 1966.Ir lrirrnmer in hand, you look lor nails. whcn you hervc a comic pLr- 14. Frye, N. Thc Structurc of comccly in S. IJunrtll, Ld. l"il,ltl ()trrtt (tttttrltts1tt.ctivc, you look for new ways to rcspgncl etnd cxprcss creativity. New York: New American Libr:rry, l95tl. 15. Frye, N. Z/ze Anatomy of Criticisnt. Plirrtctorr: It itrttlott Iittitrt,ilr lr,,,, 1956.STUDY QUESTIONS 16. Capp,A.Thecomedyof CharlicClrapl:rrr. Alltttrtic lllrttttlrlt. lrl,ttr,rr. l,"11 17. Linn, L.S. and DeMalleo, M.R. Ilttttrot luttl olltrt (()ttttttltrt{.rlrort lrtrlrlr ttr r, in physician-patient encountcls. Mttli, rtl (ttt,, l()lJ l, ./( 1.), l." l l. lllI . What value does humor have on your personal and professional life? 18 osterlandHHumor: Ascri<tttsltPltto:rtlt l()|;lli(lll ;tlr Niltrrr"ii lt cember, 1983, I 3(12), 46-47 Examine what makes you laugh. Do you initiate and create humor? . 19. Coser, R.L. Some social functiorts ol lirttllltlct lltnrt,ttt llrlrtttrttt.. ltt"tt ! 2. What do you mean when you say someone has a sense of humor? 17 1-182. Can you specify or quantify your definition of a sense of humor? 20. Jackson, M. The nurse as clown: Thc corrrit s;rrr il rrr nur,rrl llt, ltrr,rtr irt .,3. Select an organization with which you are familiar and analyze it April, 1980, 53(4), t2. according to a comic perspective. What kind of humor is character- 21 . Fry, W.F. Sweel Madness: A Study ol llturrrtr. Irrlo Allo, ( A l.r rlr, lr . 1963. istically expressed? What patterns of joking relationships characterize 22. Mindess, H. Paper presented at the Fourth lntcrtuttiotutl ( orrlt t cttr , ott l ltt the organization? How does the organization utilize comic framework mor. Tel Aviv, June, 1984. and techniques to accomplish organizational work or goals? How 23. Eastman , M. Enjoyment of Laughter. New York: Sinlorr & i 1111s11 1 , lt) {tr much fun or playfulness is tolerated or sanctioned by the organiza- 24. Koestler, A. The Act of Creatiort. London: Hutchinsorr, 1961. tion? 25. Collier, D. and Beckett, K. Spare Ribs: Women in the Hunttsr /Ji^:. Ntrv Yor k: St. Martins, 1980. 26. Vash, C.The Burnt-out Administratiorz. New York: Springer, 19U0.REFERENCES 27. American Nurses Association. Nursing: A Social Policy Statenreril. Kittrsits City, MO: American Nurses Association, 1980. 28. Gardner, H. How the split brain gets a joke. Psychology Todav, FcbttrirtY, 1. Blanchard , K. The One Minute Manager New York: Berkley, 1982 1981.15(2),74. 2. Ven in ga, R. T he H uman Side of H ealth Administrafion. New Jersey : Prentice- lllll, 1982. 3. Don:rbcdi an, A. The Definition of Quality and Approaches to Its Assessment. Vol. l. Ann Arbor: Health Administration Press, 1980. 4. Cun]n]ings, H.J. The importance of not being earnest in the arts, sciences, ancl prc,fJssions. Address delivered at the Second International Conference on Hut.ntir. Los Angeles: August 1979 5. Rcrbirrscrn, Y. Humor and the Health Professional. New Jersey: Slack, 1977. 6. Cousir.rs, N. Anatomy of an illness (as perceived by the patient). New England Journal ol. Medicine, December 23, 1976, 295(26) 1458 7. Hyers, C.fhe Comic Vision and the Christian Failh. New York: Pilgrim Press, l98l. 8. Paulos, J.A. Mathematics and Huntor. Chicago: University of Chicago Press, 1980. (). Meredith, C. Ap fl.s.say 6n Comedy. New York: Scribners, 1918. 10. Kronenbcrgcr, 1.. llttlhread ol laLrghter. New York: Knopf, 1952
  • 25 niltr,lll,., .r ,,,ll,rl)ot ,tlt{)lt :.llr lt llt;tl llt( 5(l)iu;u( r( r rrrrr^,r,,1 .,t rurtlttltr,;rlr()r ;u( n() lotrl.tt ttrtltttirrl,lrrl. Wrllrrrr llris lrttt t1rlrott,;rtoltt .sioturl nllrs( s ;rs:,uln( h.v lt;rtlttslrrlr ;rosiliotts lttttl lrtltt lit t , lrrrtt:rllv, acltttirtisltltivtlv, ol lrollr:rs rvtll lts ltltrlt.lltis rrrrlrrlll(nl(nl rr(l1irl(:, The lTursing Imperative: thc gucst or visitol lirtrrlty rrrltirt 1:rtirrlittsttlirrg,s:rntl llrtl:rt k ol tttrlsirtlq scrvice involvcntcrtt ir-r tltc tcaclrirrg ol slrtrltttls. Nursc administrators in scl-vicc arrrl cclrrtirliorr pl:rv rr trrrit;rtttoltirr Integf,atirg Practice, developing this conccpt and crcertirrg llrc crrvilorrrrrcrrt in wlriclr pnrlts sional practicc can occur and cnclur-c. In or-clcl t(r lurrctiorr irr tlris rrrrit;rrt leadcrship role, nurse administrators rnust ltavc a bctlcr urtcletstuttrlinli o[ integrated models and collaboration within ancl bcyorrcl rrur-sirrg. llrtrr Education, must also be a better understanding olthc unlbrtunzrtc scpuratiorr ol nursing education and services over the late ninctce nth zrncl c:rrly twcrr- and Research tieth centurics. AN HISTORICAL PERSPECTIVE The idea o[ integration of education and practice has existcd sirrct tlrc The purpose of this chapter is to summarize the major concepts development of nursing schools in 1873 (l ,2). Early schools ol rrtrlsiul,, of professional nursing administration within a framework of lrrte- were hospital based, and nurses were trained through apprcntictslrip, gration and collaboration. Nursing service and nursing education with littlc emphasis on formal education. Nearly all schools olnrrrsittg can,no longer exist separately. Together they blend uid brrlld o rvere owncd and controlled by the hospitals they served. Students uve lt quality research to bring harmony in the practice setting. Nurse used for service to maintain low costs. Early schools were desigrrccl to Administrators hold the key to professio.rul it"g.ution a"nd must function in much the same way as religious orders, with the hospital be the leaders in this effort. on completion ofihis chapter, the being the training ccnter for educational and practice activities (3). Thcrc reader will be able to: was much confusion as to their purpose: service or education. Dillcr- 1. Describe the historical development of the separation of nurs- ences in the rolcs of the nursing student and of the graduate nursc wcrc ing service and nursing education. not clearly dcfined. 2. State reasons for the need to intcgrate service and education. By 1923, the need for self-directed, independent schools of nursing 3. List critcria for integrated models for professional nursing. was identificd. Thc Goldmark report stressed the need to establish uni- 4. Describe models for integrating nursing service, research, and versity-bascd schools of nursing (4). The dual role of the hospital school education- of providing education and scrvice was viewed as detrimental to thc 5. Justify collaborative practice within nursing as the first step needs of paticnts and students. Furthermore, the training of nurses was in achieving a nursing communitv. considercd a scrious cducational business that required direction by 6. Describe an approach to collaborative practice that includes those who wcrc committed to quality nursing education. nursing, medicine, and administration. Throughout thc ncxt four decades, there occurred a gradual transition 7. summarize the major concepts inherent in professional nurs- from hospital-bascd to univcrsity- and college-based schools of nursing. ing administration. Concomitant with this changc was a dramatic decrease in faculty in- volvement in dircct scrvicc in hospitals. Although the primary purposcs of universities arc tcaching, rcscarch, and service, the service componcnlThe relationship between nursing service and nursing education became deemphasiz.ccl. As fzrculty moved away from practice, nursir-rg hasmoved full cycle and is now back on a trajectory of iniegration within service personncl nrovccl aw:ry from education. In the process of devel-a conccptual flramework of "nursing community." The conlept oping the strong rcscarclr lircus so important in quality nursing edu- of nursingcommunity develops from the highest order of collaboration within cation, many faculty clriltccl uway lrom problems related to direct carc.352 tr
  • ln tlrc tirlly l9(r()s, sotttttrttrsirrl, lt;rtltrs lrtglrr lo st.riously tlrrt.sliorr l lr,,rryilrrrizirliott;rllrttrl (l((rr,l()n rrr;rhrrl,:.ltlt(ltttr.,ol lltt1rt ;rtlttt:tlthc scperrarLiort itttcl bcgirn to cltvist :rppr olrrlrts lirl ltirrttgrirtirrg rrtu sirrg lirrli:, lr;rvtrlilttl tlltt ls orr lltttrltttl lo,vlritlr ttltttltliotntl rtttsstottspractice and cducatiorr. Notctl irritiirlivcs lrttlrtprrrglanls ut lltr[Jni- cirtt lrt lrt lticvccl.versity of Florida, Casc Wcstcrn Rcscrvc Urrivcrsity, Univcrsit.y ol Roch- Exccllcncc irr rrrrlsirrg prirt litt irr lrr:rlllt rlrttstllirrpis lltt ilitlrlts ntrrsrrl.ester, and Rush-Prcsbyterian-St. Lukcs Mcdical Ccntcr (5). t:rlucnl iorr. These programs have shown grcat promisc, but scvcral pcrsistcntdifficulties hinder implementation in some settings. Doctorally pre- These assumptions, whilc ncccssary lirt ptrrlrssiorurl ptittlirt, ;rlso l,rt tttpared faculty hesitate to assume leadcrship roles in practice. Lack of the basis for dcvel<-rping organiz.arti<.rnal rrtoclcl$ tltirt allow lor rrrttl losltragreement about academic preparation for nurses interferes with the integration of nursing cducation zrr-rcl se:rViicc. Altlrorrglr ir v:rrirly olprofessional integrated models. Nationwide, the deficit of nurses pre- models can providc this, the ultimatc goal is qualit.y tttttsirtg t:ttt lltrrrlt;,11pared for leadership roles interferes with selection of nursing assignment an integration of administration, cducation, rcsc;rrch, nrtcl clittitlrl pr:rtpatterns approporate for specific integrated models. Integrated models tice.are not accepted by all nurses, and, indeed, crises are brewing in nursing Though marriages o[ service and academia are coming ittltt vttl.rttt irtthat demand the most creative thinking by nursing leaders. the form of born-again models (20 to 30 years ago, deans wcrc clitcclors of nursing), the criteria are similar. The following conccptual liarrrrc"volli adapted from Christmans work on centers of excellence in nur-sittg strl gests potential criteria for integrated models (6,7).NEED FOR INTEGRATION OF SERVICEAND EDUCATION Criteria for Integrated ModelsProfessional nursing practice emphasizes interdependence and collegial Complete Opportunity fbr Practicerelationships betwcen schools of nursing and clinical practice settings.The distinction between faculty and nursing service personnel in this Educators are pracLitioners, practitioners arc cducators, arrtl it v:u irllrelationship becomes diminished because all are participating in mul- of opportunities exist for joint appointments. Shared resportsibililitstiple aspects of practice. Practitioners in educational and clinical practice are assumed, and research, both individual and interdisciplinar.y, is rtttsettings must be active participants at all levels of policy formulation expected behavior. Administration is recognized as a legitimzttc ct.rttt-and implementation in both the educational and clinical settings. Such ponent of professional nursing.professional accountability for all aspects of practice by all participantsis essential. Appropriateness for size of I nstitution In addition to professional accountability, mature professional practice and Schctol of Nursingrequires the acceptance of the following assumptions: In some scttings, thc dean of the school of nursing may be the dircctor Clinical nursing is central to all other aspects of the profession of nurs- of nursing. In <-rthcr scttings, it may be appropriate to have an asst-rciu tr ing, thus forming the unifying base for administration education, re- dean for cliniczrl practice. Top-level administrative responsibilitics in search, and practice. practice and cduc;rtion are assumed by the best and most appropriatcly prepared nurscs. Professional nursing is practiced in all settings, including acute, long- tcrm, and home care seltings. In these various settings, nursing care is based on the most advanced O p en C omnt unic u I i <t n B e lween nursing knowledge. Nursing Seruice untl Etluctttion Nursing is responsible for nursing administration education, praclice, Open communication is rr-raintained through joint appointments ancl and research. shared committcc or tnsk lbrcc responsibilities. Joint positions arc cnr- The relationship between a school of nursing and a practice setting cial to maintarinintl opcn conrnrunication, and nurses in these positions fosters a mutually productive environment that enhances the tripartite are the viablc lirrkagc. lior cxamplc, curriculum and research revicw missions: education, practice, and research. committees, forrrrcrly consiclcrcd the total prerogative of schools ol
  • 11tsi1p,, llrvt,tttr;.sirrgstrvitt;rrrtl l;rtrrllvrtttttllttls, lot llttvltt,()ll(illl(l It:r..lr1l lt(.1llr, Al ,rrrt.t.rltrtrrtir, llttot 1.lrtttu:tliolt:tl tttotlt1, ( ll;ll,l( lilthc sutttc irt :trr iltltgtltlttl tttrttlt1. izt.tl lry llrt. :rlr:,or plrolr ol ;rrrlr)nonr()us rt ltrtolr. ol ttttt:tll|l ;llltl rlr|;rtI pt(1ls 1l lrlrsirr1, 11,1,r Ilrt. rrrttlit lrllV rlotrritr;tlttl ."y:.lttlt, Att r)l)l)r,:.ll( tr.cpcl isr.lr;rllrtlr.rrzt.tl lrvllrtirrltg,rirtiottol stltoolst,l ttltt,.tlll, lrl(l lllll.Ability to Be Rceiliz.etl in u Vurietv ing scpvitts inlo tr rrrrilitrl slrrrtlrttt lot lltt ptovisiott ol ttttt,llll {,ll(of Heeilth Care Settings and nursing cclttr.lrliorr. lltlwtt:rt llttstl,ivrt trll(ttt(:;;tt, ttlrtlllplrolltttBecause of the close involvement with the dclivery o[ patient care, faculty organizati<-rnal structurlcs itt wlriclr rttttsirtl,, plt.rvitlts t lirrit lrl t;tl,, ttlwith joint appointments are able to be more realistic in assignment of ucation, and managcmcnt ol sclviccs. Wltrlrvtt ()t lrltttizitltottltl tottltrlpatients for student experience. All models portray the teacher as a par- prevails, nursing contends with rrrultiplturr1lror ilv sysltttts :rrr(l rf.ll(:.ticipant in acute, long-term, or home care rather than as a visitor to a related to the direction and scopc ol pritt lit t.patient care setting. Variationsformodelsof intcgrationcxisI itr llrtrtirl rv,,l l<l ;rtttl ott lltt drawing board. As indicated prcviously, Cnsc Wtsltt lt l{tsttv. llrriyrt sity, Rush-Presbyterian-St. Lukcs Mcclical Ocrtltr, itrrtl llr,lJrrivrtrtltParticipation in Policy Making at the of Rochester present established unilication tloclcls. Otlttt (l{) lrrlstrrlttlExecutive Level a taxonomy for integrated modcls at thc Fall Corrlirtttttol tllt Mitlrvt".lThe size and type of institution dictate the nature of governance; how- Alliance for Nursing in September 1980. fhis tltxorloltty Itpttstttl. rt progression of develoPment:ever, successful implementation of any model requires the participationof the dean or director at the executive level. This includes but is notlimited to voting membership on the institution and school of nursing 1. Nightingale model: historical hospital training tlroclcl willt tto ot ganized external educationexecutive boards. In academic centers, nursing by-laws are shared acrosseducation and service. 2. Medicalmodel:currentstateoftheart; structurcriitttttrlsittl,ttt:tltlt the medical organization 3. Collaborative model: characterized by consultativc itlt1l t tp,(l l rtt t l s i t rComparable Rewards for Education, selected roles and at selected levels of institutions; instittrliorr sPtt ilitPractice, and Research 4. Affiliative model: based on the "associated with" collccl)t; lorrrrrl irrBecause of the tripartite mission of most teaching hospitals, nursing shared services and multihospital systemshomes, and home health care agencies, the successful integrated model 5. Independent faculty practice model: a specific mutant ol tlr,litltl orrallows for comparable rewards for education, practice, and research ac- the edge of the movement with realignment of roles and cttttttrl list:rltivities. This includes promotion, merit rewards, and public recognition issucs. 6. Transition model: undefined conceptually and operatiorrrtllv, llrtPromotion of I nterdisciPlinarY conversational model of integration without firm conlnlitlttttrl lrtCollqboration any of fhc invc-rlvcd members; goal clear, but process for acltitvttrrttrl unclcarThe success of any integrated model depends heavily upon the accept-ance and support of other health professionals. Nurses, physicians, and Othcr modcl vzrriations could potentially be established arotttttl:hospital administrators must collaboratively define and implement anintegrated model appropriate for each particular institution 1. Contract lbr nursing services by clinically expert faculty (for cxarrrlrl,, gerontologiczrl or pcdiatric specialists) 2. Unrcin-rburscd ad.juncl appointments in the practice setting MODELS OF INTEGRATION 3. Rcscarch lbcilitatit-rn by nurse administrators The mid-1970s signaled the beginning of a time of revolutionary change 4. Collaborativc rcscarrch involving participants from practice and ctl ucation in the organization and operations of departments of nursing and their relationships with schools of nursing. To grasp the magnitude and scope 5. Cqllarborzrtivc sclrolarrly cfforts among researchers, clinicians, antl of these changcs, one has only to recognize two concurrent yet con- c<lucatots
  • 6. Slrlrlctl ltlrclting lrv lirttrllv ;rrrtl t lirrit:rl plirt lilionrrs l)tlur ot rlit rt lot , s, ltool l)rt cr lor ol rrttt.ittl itt7. lntcgratiottol lrosl:ritnl Ittttsirrlistrvictsr,vilhnrrr-sirrghor-ncaurrl horrrc ol rrrrrsirryi :ln;t( ill(, ltoilr,, ot Iottp, ltt ttt t ;rt t carc scrviccs irrslilrrliorr8. Allcrnating appointmcnls by tclnr in rrursing practicc zrnd cducertior-r Assisl:rnl <lc:rrr lirr Assisl:tttl rlir tt lot lor9. Shared nursing consultation within and across multih<ispital systcms nllrsrng p|aclrcc trtn sirrl,, ;rr;rrl ir t Assistant clc:rn lirr Assistrtrrl tlit tt lor lor The extent to which integration occurs depends primarily on thc crea- nursing cclucatiorr ctlttt:tliott:rl slr vir r"tivity and flexibility of the nurse administrators in both education and Assistant dcan fbr Assisllrrrl tlit tr lot lot rcsearch r-csciu t lrservice. Sharing common mission, philosophy, and goal statements is Slr urcd utttt rr t i t I ces :the first step in collaboration within nursing and the development of a Exccutive c<-runcilnursing community within a geographic area. Curriculum committcc Rescarch review Infbrmzrtion systemsCOLLABORATIVE PRACTICE WITHIN NURSING Clinical policies and proceduresIn the final analysis, it is unreasonable to talk about joint or collaborative Departmeti directors: Assistan I <: I itri ttt Ipractice with physicians if there is no collaboration within nursing. The directors:integrated models proposed by Grace (8) essentially are designed for rrrrlsirrl,academic centers. However, integration (internal collaboration) can and Mcdicai-surgical fuedi..t lSur-gical ttrtr :i rr1should occur in any setting where professional nursing is practiced. Allnursing divisions have, at a minimum, practice and quality assurance Ped i at ri c- ma te rn a I f Pediarr i. rrr rr1committees or councils. Is this not the first level of integration? Is this lMatcrrral nur nrl,.not an opportunity for faculty involvement? All schools of nursing have fPsychiatr it Psychiatric-community health { Commlrnitv rrrr.lcurriculum committees. Are these not opportunities for service involve-ment? The education of students should be a high priority for nurse [ .mb,.,l"t,,rv (:u (administrators, and opportunities for clinical practice and research FIGURE 25.1 Collaborative nursing model.should be available for nursing students. Figure 25.1 depicts a collab-orative nursing model, freestanding from medical structure, that could thc physician and the nurse. Today, the relationship has changccl clrl-optimize communication between and among educators and practi- matically as care has bccome more complex and there is strong sLrl)l)()rltioners. for multidisciplinary patient-centered carc. The collaborative model could be modified to meet the needs of any In todays world, there secms to be a lack of opportunity fbr irrtcr-practice setting in acute, home, or long-term care. It builds on trust, personal understanding. Many more nurses are ready lo do battlc ovtrmutual respect, and pride in professional nursing. Although the same real or perceived nonrecognition. Whcre once the alliancc ofrlcclicirrtperson could be in the designated positions, this is not necessary. In a and nursing was strong, therc is increasing evidcnce o[ a bonding [rc-collaborative approach, two or more nurses can work together to achieve twecn administration and medicine, much to the dissatisfaction nrrclcommon goals related to excellence in practice, education, and research. concern of nurses. Small irritations become major incidcnts, ancl it is not unusual for nursing strikes to occur. Interpersonal relaticlnships alt important, and much more attention is devoted to joint or collabclrzrt ivtAN APPROACH TO INTERDISCIPLINARY practice in most health care settings.COLLABORATIVE PRACTICE Betwcen 1978 and 1981, the National Joint Practice Commissiorr ol- fered lcrur diffcrcnt but typical hospitals the opportunity to demonstratcNot long ago, the relationship bctween physicians and nurses was clear- how to succcsslullv altcr thc physician-nurse relationship with resultirrgcut. Nurses understood thcir place in thc world, and physicians were benelits to paticr-rts, nLuscs, physiciarns, and the hospital from cstab-captains clf thc hcalth carc 1cam. Thc tcam consistccl o[ two persons: lishing.joint prracticc (9). llrt rorrrnrission wers supported by the Americar
  • tvl(r |(, lil lr|t, t til tI(t|lt/t.r tli:rrrs lixrrs orr llrtsulvivill ol pt,11,lt:urtl llrtit irttittrclts:ur(l vrlLlcs li)r g:rttizlrliott lt, ,trlrltt,tt lt t, rl ttt Wirslrirrglorr, l).(., r,vlrit,lr s(.r v(s irs lr (.1(,1p.tltlrlirrlg willr tlrt(()nlcnl an(l ((rlrl(l ol llrtir cnvil-onnrcr)[s. ittglrotrs.lo1 1111 lrrrrrror 1t()v(.11(.11. Alr<lrrg l91rrt.s rrrrr[.r.slrr<lV:rrr. lrsv- llrrrror ciln l)c uscd colrslluctivtlv lo irrllucncc hunrarn bcharvior- irt cltolol,rt:rl llttrtt tts ol ltttttrot, llrtslrapitrg l)()wcl ol corrrit.slr.ips, stirrrcl-lrt:rlllr scrvicc organizzrtions. Irr pullicrrlar, nursing administrertors, likc LIP c()lll((lv, llrtlrrrlv lool, cirttsttuctiorr arrcl ilrrplicalions gl ctlrrric arlclt,rrrrttlilrrrs, can bc bcarcrs of a spccial kind of wisdom and grarcc: thc clisparagtrrrtnl lrrrrrror, tlrilcllcns hunror., arrcl tlrc corrrccl.y ol stylcs 9frvistlorrr lo sccr thc humor of our condition and the gracc to crcatc thc humorists such as Rabclais, Chaplin, and Richar.d pryor.t orrrit vtrsi<lrr. Apprcciating humor, even recognizing it, requircs human All of thc abovc cxarmples illustrate thc rurngc ernd dcpth of the humorslills ol tlrc lrighcst order. So does managing enterprises o[ human ser- revolution. The promise of the comic viewpoint in thc affairs of peoplevit t. and their organizations is a sudden insight, a lresh and accommo.l.tirrg change in viewpoint, an ability to see things in a new way, as Thoreau would say, to affect the "quality of the day." Beyonci each day, the im_ portance of the comic vision in our time is amplified by the unparalleledSIATI1 OF THE COMIC ART knowledge and technological power availabll to us for dehumanizing and destroying as well as benefiting one another.llrcrc is wiclcsprczrd ignorance among scientists and professionals oforrl lrrrnror hcritagc and the potential for the postive use of the comicI r ;rtlil iorr. Irr tcrcst in the serious study of humor by scholars, educators, THE NATURE OF COMEDY:.t itrrtists, arrcl thcrapists is a lairly new phenomenon that has only re-ttrrlly taplurccl popular altcntion. Cummings (4) notes that the pioneers The plea for the comic vision begins with understan<ling the nature ofin tltvtloping constructive use of humor in therapy in the treatment o[ comedy and an appreciation of the rules. Finding a universal definiti<_rnlttrrrtkrl chilclrcn, alcoholics, and drug addicts have been greeted by a of comedy is as difficult as finding a universal definition of nursing. ourrrr:riority ol tlrcir profcssional colleagues with a lack of enthsiasm not authorities on comedy speak from a heritage accumulated over thi pasttlissiruillrr to that demonstrated by many members of the medical several thousand years. No one <lf the following observations tells theproltssiorr whcn fcw innovators in that field insisted that nutrition be whole story; neither do all of them together; none of them, you willrtt o1r11i7L11 ars an irnporlant factor in physical and emotional well-being. observe, is good for much of a laugh: Ittttntly, inrrovations in the teaching field have intentionally dem-,rrslr:rlctl llrc usc ol-humor in textbooks to enhance learning, not a new Plato first noted that the genius of comedy and tragedy were the same:rrlt;r, sirrtt llrc Talmud instructs its readers to "begin a lesson with hu- a true artist in tragedy was also an artist in comedy.rr()r()us illrrsilzrtions." Vera M. Robinson (5) was the first nurse to leg- Aristotle reflected the attitude of the classical writers who consideredilirrriztlrrrrrror as a fruitful concept and tool in communication and in- comedy base and ignoble. comic heroes were smaller than life. Au-Itr vcntirrn with clients in Humor and the Health Profbssional. Norman diences looked up to tragic heroes and looked down on comic heroes.( r rr rsirrs iut iclc "Anatomy of an lllness" in the New England Journal of /rltlit itrr(6) stirrcd immediate and persistent controversy in the medical [n Roman comedy, the characters who are comic are from real life, are comrnon people. The emphasis is on the physical, on social prob-rv,,rl<1.llrc ptrbliczrtion o[ his book by the same title became popular lems, and on the community setting of the -lty. Ro-a., .o*"dyIrttrrrlrrrc, with its mcssage that human beings possess remarkable tablished that catastrophe in comedy is never permanent. Thcrc arc "r_l)()w(t s ol hcaling borh ol the body and mind. Cousins use of humor to those whom we laugh at and those whom we liugh with.tnlr:rrrtt his sclf-hcaling has become a modern legend. (orrrccly has lwrl csscntial ingredients: incongruity and surprise. Sur- satire results from moral indignation. It seeks to reform or at leastpr ist irrrcl irrcorrgluity are exemplified in the unlikely perspectives o[ expose vice and stupidity by attacking it with sarcasm, wit, irony, orlrvo strrclcnts olcomedy: Conrad Hyers and John Allen Paulos. Conrad ridiculc. It is not always fun or funny. There are basically two cate- llvtrs (7) prcscnts an cngaging interpretation of the religious dimensions gorics: Horatiun ancl Juvcnzrlian. The satirc o[ Horacc prescnts follyr rl I rr rr gl r t cr, hu rnor, and comedy in C omic Vision and the Christian F ait h. and lcts il btits ()wn w()rst cncmy through zrccllratc rcproduction,.lolrn Alltrr Paulos (8) has comprchcnsively studied the formal propcrtics only srrbtlv txrr1ig,tr:rtt,rl. llrc s:,rtirc o[Juvcnal lttlcks lbily full tilt;ol lrrrrrrrrl lry rnzrtlrclnltical anerlyscs in Mathcmatics and Humor. Thc its conlrnrpl :rrr<l iurll(t ;u (. rrntlisgrrisctl antl ovcr.t.rrlrit;rrily ol lrtrrrror is sttrr in llrc clivcrsity oIstrrclirs currcntly unclcr thc M<rlitrt"s pltv lrtttttll. rv;r lr;11tt,rl trs ir1rrr9r.:rl lrrrtl lrllrslrlrt,rrr1;trs wlrcprrrrrlrrtlllr ol llrtWollislr,rlr l.ibrary on Wollrl llrttttot, a nonprolit ot- llc ltll:rt ktrl lltl r t,,.,,1 llrr.;tl(. l)V rlr;li<.li1g llrt,rrr irr r.irlir.rrlgrrs grrist.s.
  • l.ll{ M()vtN(; til;,y()Nt)ililioRDlNArtY|,0. llcnolicl, J.Q. litlrics in nursing practice and education. Nursing outkx*, .lrrly/August 1983, 31(4), 210*215.I L Arrrc;iczrn Nurscs Association. Code for Nurses with Interpretive Statements. K:rrrsirs City, Mo.: American NursesAssociation, 1976.12. Arrrcrican Hospital Association. Patients BiU of Rights. Chicago: American I losl.rital Association, 1970.I l. Marrrlrrzr, J.P. Ethics and medical technology. Michigan Hospitals, April 1983, /e(4), I l-13. The Comedy1.1. t)irvis, A.J. Helping staff address ethical dilemmas. Journal ofNursing A I t i s t ra t it.rn, February 1982, I 2(2), 9-13. trr r r i of Mana$ement Marjorie M. Jackson The purpose of this chapter is to call attention to an unnoticed relationship between comedy and management. Examination of the relationship will not make you laugh, but a comic outcome may be achieved: a restructuring of your perception of comedy and management. This chapter develops the thesis that the qualitics inherent in good management are similar to those of good comedy. On completion of this chapter, the reader will be able to: t. Discuss comedy and its relevance to management. 2. Argue for the constructive use of humor in influencing human behavior in health organizations. 3. Appreciate humor as a human skill of the highest order. 4. Discuss the history of comedy. 5. Relate comic perspective to creativity. During the past decade, there has been a virtual explosion of information in the field of management, rangi4g from the popular and brief One Minute Manager by Kenneth Blanchard (1) to Robert L. Veningas (2) The Human Side of Health Administration to the scholarly conceptual- izations of The Definition of Quality and Approaches to its Assessment by Avedis Donabedian (3). This same decade has seen a parallel emergence of comedy in literature, theater, research, and the information media. Current confcrcnccs on humor and laughter are playing to full houses across thc cotrntry, just zrs conferences on managcment thrive and pro- lilcrertc. llowrvrrrlisplrrrrltthc two arcnas appczrr, thcy sharc a basic thcrrrc: ltow pto1rlc lrcltirvt, bollr as incliviclurals ancl as nrcmbcrs olor- garrizirliorrs. M:ttr;r1,rts;rttrl totttt<li:rtts h:tvc nttrch itt cotntttort. M:rnttgcrs lixus,rrr llrt,tuvtr;rl ol llrtutllrutizlrliorr, rurtttcly, on irttllttrvin13 plo- tlrrt livil, (n1iil rir1, ,1ii;rlil, ;rtrrl tttltrt irrp, tosls lltrrrrrpilr Ptogrlt. (orttt- I l()
  • ti:trlt.j I Aldl).1 lvll ll(,lN(;lllA( ll( l ,l lllNl,:: t/l16 M()vrN(,Br,()Nl) lttt,.ol{t)tNAttItoliticerl isstrts irrclr-rdc constrictit.rrr ol rtutsing roles, dccrcasc in tlrc 7. (i.lrl.,rrrrtir. I llrrr r..rlrr.rllon lrro:rrlcrrirtl. lror;pilrrl :(lvt((5 rvlt;tl ttl.tl.ts /rrtrnrbcrs ol nur-sing staff, community nursing centers, and national S(rt:(: llrt,|11111". l){ ( {lrrl}(l l. l)tl,l, 5o(-l l), (rlt, 70 Ihcarlth insurance. 8. Ktr1:r1ilr:rrr, S.(i. Notrlr:rrltlt,,nlrl itvtttttt: tlivtrtili,:tliott l,rt 1ttiltl llttsltitttls, Dct.tilrlrt.r l, l()8.1, 5r(.lt),75,7U 81. llcalth promotion, disease prevenlion, and continuity of care havc 9. LaBirr, C. tlrinl l)ttttt, llcitttlttr.sLtn(nl Lcgi.slttlitttt /(), .S( ,1t( {.! ttl Nrtrsts: Airsstrrncd new importance in health care due to price competition and Report ol ChangL:s itt Stutt Ilcaltlr Irrsururt<t /,r,ttt.s. Kltttslts (iity, Mo.: At.tlcricanttor.romic factors. Nursing administration has key roles to play in plan- Nurses Association, 1983.ning ernd implementing services in all three of these areas. 10" Kahn, H.S. and orris, P. The erlcrging rrrlc ol sirl:rliccl plrysiciitns: an or- Knowlcdge of ethics is essential for the nurse administrator dealing ganizational proposal.Joarnals of.Publit tlutltlt /<r/icv, Scptcnrbcr 1982,3(3),witlr thc four areas of health care ethics: (1) clinical, (2) allocation of 284-293.scarcc resources, (3) human experimentation, and (4) health policy. 11. Ginzberg, E. The economics of hcalth carc zrnd thc luturc oI nursing.JournalMcchanisms for dealing with ethical dilemmas and supporling staff in- of Nursing Administration, March 1981, / 1(3), 28-32.r:ludc a decision process, informal discussion groups, counseling, staff 12. DeMaio, D.J. Health services for children: a descriptive analysis of an urban program, in L.H. Aiken, ed., Heakh Policy emd Nursing Practice. Kansas city,clcvclopment programs, consultation, and ethics rounds. Mo.: American Academy of Nursing, 1981. 13. Miller, M.K. anci Stokes, C.S. Health status, health resources, and consol- idated structural parameters: implications for public health care policySTUDY QUESTIONS Journal of Health and Social Behavior, September 1978 19(3),263-279 14. Lange, N.M. Nurse-managed centers: will they thrive? AmericanJournal ofl. Dcscribe some current and emerging settings in which nursing Nursing, September 1983, 83(9), 1290-1293. administration is and will be practiced. 15. McClure, W. National health insurance and HMOs.NursingAuilooft, January2. Discuss the impact, actual or potential, on nursing of one economic, 1973, 21(t), 4448. onc social, and one political issue. 16. chaska, N.L. The Nursing Profession: A Time to speak. New York: McGraw- Hill, 1983.3. How do health promotion and disease prevention differ? 17. Brubakcr, B.H. Health promotion: a linguistic analysis. Advances in Nursing4. Define continuity of care. Science, April 1983,5(3), l-14..5. Dcfine health care ethics. 1g. Gilbert, R.N. competition spurs ambulatory choice. Hospitals, May 16, 1983, s7(10),67-68.6. Why is it important for a nurse administrator to be knowledgeable Bealty, S.R., ed. Continuity ofCare: The Hospital and the Community. New lg. about ethics? York: Grune & Stratton, 1980.7. _Dcscribe one mechanism for dealing with ethical dilemmas. 20. Crittenclen, F.J. Discharge Planning for Heahh Care Facilitie-s" Bowie, Mcl: Brady, 1983. 21 . Somers, A.R. The geriatric imperative Hospitals, May 1, 1983, -59(9) 17 8l 22. McKeehan, K.M. Conccptual framework for discharge pl:rnning, irr K.M. McKeehan, ed., Continuing Care- St. Louis: Mosby, 1981 23. Orem, D.E. Nursing: Concepts of-Prttctice. New York: McGraw-llill, lr7 I lrrstilrrlc o[ Medicine. Nursing and Nursing Education: Public Policys and 24. Joseph, L.S. Self-care and the nursing process. The NursingClitti,, rtl Nrt tlr Iriwtlt, At:lions. Washington, D.C.: National Acadcmy Press, 1983. America, March 1980, 15(1), 131-143. Sr lrlrl i t t, J.T. Swing beds. H ospitals, Novemb er 1 6, 1 982, 5 6(22), 67 25. Levin, L.S. Self-care in health: potentials and pitlalls. Wttrltl ll,ttlrlt I ttt ttttl r -7 2. M<rlitz, P. Health care in correctional facilities: a nursing challenge. Nursing 1981, 2(2), t77-r84. O tt t lult, April 1982, 30(4), 253-259. 26. Natitrnal Commission on Nursing. Nursing in Trunsilirttr: lll,t,l,1" l,tr itt cessful OrganiZtttional Change. Chicago: American Hosp i l l l Asst x t l tr )r r. l t : )11 Davis, C.K., Oakley, D., and Sochalski, J.A. Leadership lbr cxpatncling nursing inl.lucnce on health policy. Journal ofNursing Administration, Jzrnuary 1982, 27. Westbury, S.A. Ethics and hospital decision makirrg. l1 iclttl.,ttt lltt"1trtl t 2(t), ts-21. April 1983, /9(4), ll 13. 5 Mor-row, H. Thc funclamcntal influcnce o[ political, social, and cconoruie 28. Vcatt.lr. lL-M. I)elirritiorrs ol lilcancl clcatlr: shotrltl tltttt lrr( ()rr,i,1 n, rrr Iirct<rrs <rn hcalth :rncl l-rc::rlth car-c. Inlentaliona.l Nursing Revieu,, Novcrnltcr/ M.W. Slrrrrv rrrrtl A.li,. l)orrtlt.rir, ttls., I)tlitrittg llrrrttrtrr 1,r/,. Arrrr Atlr,r , Nlr l)rtcnrlrcl 1982, 29(6), l 113 l tl6. Ilt;rltlr Arlrrrirri"lt,tliott Itt ss, I()lll- (t l)rtvrs, (.K. Nrrlsirrli lrrrrl llrtlr.rrltlr cirltcltlxrlts, lrttrtga:lltc.lotuttttl ttl 2(). I):rri... A I .rrrrlAr,.lr,rr .M l l:tltitttl l)ihtrtttrtt.sttrttl Nttt.,ttrl, Ir,t,ltrr, ,1,,l Nttr sitt1l St lt,,lttt s/r17r, Srrrrrrrrtr l()tl .l, / 5( l), 67 N,,rrr.rll,, ( rrrrrr r|l1r1, lrrr ( rttlttlt( trrlls, lt)l{l
  • r r/ (r i( r rr,(5 rnrs (ln(tttltlit lt;t (l(lt;tl(()V(l llt("s(x iill svsl(tlt ol tlclrlll l. Wlr;rt lt.t 1,, , ll lr ill ll{(l tt r rrtlltl ltt ltltt ll((l ll1)lll lll( l):l:11 Ilrtlt:tviot ." A:, lrtirlllr (;u( :,(lIrrr;r, lrttorrrt nr()r( s()l)llislicirtrrl irr ttiltrrl lo llrr,,tlll,llllll Istrtltlrirr1l ()ut llr(tltatlr protcss, nurs(s iu(llcccl witlr rnor-c nrrcl rrrorc 2. Wlr:rt tl, t,tr,,r t(.n((.;ur(l (()nrr()lr stltsttlr,tttlrrttl itt lltt;rttsetlI sit-l)itlicrtts rvltostlttirtls illc l)elrlirrl, lrttt wlt()sc btttins att-c clcacl.llrcy ar-c rllrli()rr,] lrr tlris tliltttrtttir, wltlrl ttralics scllsc lotevetytllttilrvolvccl ?in lacl. cudilvcls. Ilowcvcr, clcciclirrg to call ar body dying or dcad is cs- 3. Wlrlt ultllrtpl,lrlrlrltltttttlc (()llsc(lllcll(t:s 9l tlttlt acti.,rr? (29)scntially making a moral, lcgal, or political dccision about how a bodyshould be treated. There are important questions about shifting from In addition to lerciliterting thc discussion ol thcsc qucstions the nurseacute curative care to comfort hospice care and whcre this carc should administrator should haie knowledgc o[ ethics so as to bring a broadbe provided. base of thinking to the resolution of ethical dilemmas Nurse administrators are now and will continue to serve on ethics Some ethicaidilemmas can be addressed before a crisis arises, for admin-and hospice committees wherein decisions are made about death and example, dealing with "do not resuscitate" orders. The nurselife. When is a fetus alive, and when is a body dead? There may be no istrator is in a key position to facilitate the establishment of a mechanismsingle point at which death occurs. We may decide to remove organs to resolve this kind of clinical dilemma. when a mechanism is in place,for transplant when the brain is destroyed, read the will when the hcart the nurse administrator has the responsibility to monitor the effective-stops, and begin mourning at some other point (28). .r"rs of the mechanism, for example, a committee a panel of experts The issue of defining death is only one issue encountered in balancing or legal counsel. Another key responsibility of the nurse administratorknowledge from the sciences with ethical decision-making. Although is to Iacilitate the establishment of u t.tppott system for nurses who dealethics will not provide instant solutions for complex moral-technical withethicaldilemmasasdailyroutine.ThesupportSystemmayincludeproblems, ethics does provide frameworks for dealing with ethical di- nurse ethicist such mechanisms as informai discussion groups lead by alemmas and issues (30). o, oth", knowledgeable professional, individual or group counscling pro- provided by a mentat heilth professional, and staff development andionsultation provi^ded by a clinical nursing specialist wilh ;;;r knowledge of ethics.DEALING WITH ETHICAL DILEMMAS Rnothe*r mechanism to assist nursing staff in dealing with ethical di- lemmas is the use of ethics rounds, in which the clinical aspects of aIn dealing with ethical dilemmas or assisting nursing staff with them, .rr" ,i"a are the basis for an organized discussion of the ethical di- or casesthe nurse administrator can turn to some general sources of information i"--u and possible solutions. Hypothetical cases, casc histories, of ethicsand direction. The American NursesAssociation Code for Nurses (31) ;;;", .ur" -uy be used for ethlis rounds. Since the purposeprovides a basis for self-regulation in nursing. The requirements of the must be rounds is to reason through a case study ethically, the_leadercode can serve as one resource in dealing with questions of unethical a knowledgeable nursing idrnittittrator, clinical specialist, or someonebehavior of registered nurses. The American Hospital Association Bill from anotf,er field, such as philosophy or religion (34) .of Rights (32) is not an ethical code but could provide useful information Whatever mechanisms are establithe,t fo. the nursing division to deal con-for discussions about ethical dilemmas. Other sources of direction mav with ethical dilemmas, the nurse administrator must demonstratebe found in the approaches suggested by Mamana (33): cern and caring for the nursing staff by listening to their concerns, being worklng with thlem and others to solve the ethical dilemmas, andl. Peer review mechanisms using quality assurance committees an advocate for quality patient care2. Controls on health care technology by institutions, for example, the prohibition of heart transplants3. Hospital ethics committees to revicw new and existing technologies SUMMARY and thcir impact on humans4. Rationing system fcrr resources controlled by federal or local health In current and emerging practice settings, many economic social and planning agencies. p"riir*r issues affc.l ,iuising. Major economic issues include federal and third- i.orro-i. policy, the cc<,rnomic base of acute care hospitals,structure of Making decisions or choiccs of an ethical nature can be facilitated by party reimburscmcnt lbr nursing. Social issues include theusing the following qucstions: ityS.iu empl.yn-rc.rt uncl thc increase in the number of physicians.
  • .1 M()lN(,lil (rlillr.rrrrt lrvrls, lor t.xlrrrplc, r rlu sirrl,, l1.,tttt., lrclltll tttitittltttlttttt ol- lo llrt,r,rrlt.rl, r ni, lrt ,,1 .., 11 t;u(t()l(s lot lxrlitttls lts lrlrt I ol ltttlrlttttttrlittlglrrlirilti()tt, ltrlslritt:, or- hontc cllI ( l)11,l.l itIIl. lltttorr, t;rl ol r orrlrrrutlV ol tlttc. llrrrs, tlrc gcriatlic ernd cost-corrtuirrrrrcnt intpcr-attivcs o1thc 1980s ltilvc1,,rr.:rtlv cpr"rtributcd to the ncw emphasis in hospitarl administraltion artcltlr.. lrtialtLr czlre industry in general on functional indcpendcncc rathcl- ETIIICS ANI)llllr NLJRSE ADMINISTRATORtllrn ctrlc. Prevcntion of disease is emphasized at all ages, and pelticntt.rlrrrrrtion prclgrams and departments have become part o[ many hos- Nursing is in trarrsition (26) and rapidly undcrgoir-rg chzrnge. Techno- logical advanccs, changing attitudes of paticnts and hezrlth care profes-lrit:rl-lxrscd human resources departments. In addition, there is common,,g,re.rrrcnt among hcalth professionals that public financing should bc sionals, government regulations, and other internal and external pres-irnlrirr f ially distributed among diverse services rather than primarily to sures are creating changes that cannot be ignorcd within the profession.Irt rrlc curc. This will involve transfer of some resources from acute carc Computers, CAT scanners, and invasive techniques that require extensive lo prirnary and long-term care. medical care are coupled with nuclear energy possibilities to create an llr1 goarl clf functi<tnal independence, rather than cure , for patients environment the world has never seen. The nuclear revolution is here,.l,,,r,,,,rcls zr changc in thinking on the part of health professionals. Con- and the benefits for changing the work of the nurse are as dramatic as tirrrrity gl cerre and discharge planning are processes, not end points. those of electricity in rural America. Ilotlr proccsscs involve the patient and a team of individuals from various Nursing will have time to be creative, time to evaluate ethical issues, tlist iplincs working together to facilitate the transition of the patient time to consider the quality of life. Work in institutions will be done Ir<rrrr orrc cnvironment to another (22). These environments are usually differently, and more people will be able to spend less time in acutc lroslrilals, nursing homes, or the patients community home care. More nursing time and expertise will be spent in home care, am- llccausc patient participation is a cardinal principle of continuity of bulatory care, health education, and health promotion. Nurse admin-tl lc, t hc concept of self-care is very fitting for incorporation into a nurs- istrators will evolve a vision of nursing within a total health perspc-ctive. irrg pr-actice setting. By embnacing the self-care framework, nursing is As technology has become increasingly advanced and as nursing has ;rlrlt. to lbcus attention on assisting patients in self-care practices and changed, ethical issues have been raised about life and death and the orr irrcrcasing self-care abilities through education. Based on the work quality of life and death. Nurse administrators also continue to face oI ( )r.crrr (23), Joseph stresses the importance of human agency and self- such ethical dilemmas as unethical behavior of professionals, with- (.r( irllcncy. Human agency is the knowledge, power, or ability of a holding information from patients, and employee insubordination be- and cause of conscience. Rapid technological developments and financial l)r.r.s()p to act, including cognitive knowledge, affective feelings, psycltorn11tor development. Self-care agency is the ability of a person to constraints have made ethics a major concern of all health service ad- irr ir iatc and perform health activities for himself or herself in main- ministrators. lirirrirrg li[c, health, and well-be ine. Q4). According to Westbury, "Ethics is the application of a persons values l.cvin (25) has become one of the most outspoken proponents of self- in decision situations. These values are derived from the individuals clrc in this decade. Health profcssionals, according to Levin, are so rarely total life experience, including family upbringing, religious training, rvillirrg to trust people t<-r make decisions about their own health that education, social contacts, employment experiences, and other influ- tlrt.y harvc dcveloped a ncgative veiw of peoples role in health. The health ences " (26 , p . 7) . Health care ethics are ethics applied to the health sci- .stablishment hars cncouraged the growth of a "serviced society" in ences. Health care ethics concern what is right or wrong or what ought wlriclr hcalth professionals seek to provide a service for every need and to be done in a health science or care situation that requires a moral {o slimulartc a nccd lor every service" Health Services have emerged as decision. Four areas are addressed by health care ethics: (1) clinical, (2) irrr incltrstry with values, operational styles, and plans for expansion Iikc allocation of scarce resources, (3) human experimentation, and (4) health lrry othcr inclustry. A recent rise in public awareness of the limits ol policy. Thc purposc <-rf health care ethics is to provide approaches for r(,soulccs in hcalth has added to the interest in self-care. Self-care is systcm<rticillly rcasoning through an cthical dilcmma that arises when ttrtirirrly plrt o[ continuity of care, wherein people function on thcir mcrrarl clairrrs corrllict. A clilcmma may bc vicwcd zrs (l ) a dilficult prob- owrr ltclrlll in hcalth promotion and disease prevention in such roles als lcm tlral s((nrs lo lrirvt no sirtislitctory soluli<ln <tr (2) a sitr-ration in- IrtirItIr rrnintcnarnce, sclf-diagnosis, self-medication and sel[-trcatmcnt, volvirrg lr < lroi, t lrtlrvtttr tt1tr:rlly urtclcsititltle lrltclrrativcs (27). rrrrrl ltirrticipation in prolissional carc. Thcsc tolcs zrrc carricd ottt irr Wlrtrr is il ;r;)l)r,lrr r,rlr l, sloP ltt:.rtittg tct-t:tirt irrclivitlrttrls as il wc ..r,ll1l13rrrti1;rr with hclrltlr prrrltssionals. Nursirtg sttvicc:s c:rn conttibtrtt Irltl lr p:rr lir ll.rr .rl rrl rllrr,:rl ;rrrrl ltglrl tltrlits lor.vlrtrl llttttt,) Vrlrltlr
  • l)r()nr()liott irrrtl rlistrrst l)rcvcrlliorr, llrtst l(rnrs lt:rvc rtot lrtett clcrrt lv rtpl pcrlr.rp. rrr prtlrlr, lr,;rlllr tttttsittlt,. (tttttttl ptltt litt stllittl,s, tspttlelinrcl ()rconsisl(lrtl.y usccl. Irr gerrrrirl, tlrtcortccpt o[ hcarltlr pnrntotiorr ciallv lr, nl(.(.ut. ,,r,llrrr1i.., rrr:rv rrol lrrrvtllltttsrtrtttts lol ot lr,orrlol irrl-is lrtalth carc ainrccl at growth ancl inrprovcn)cnt in wcll-bcirrg. Discasc plcrrrtrrlirrlt lr,.;rlllr prorrroliotr lrrtl tottltl itttteitstlltttotttcttt ol cliscirscprtvcrrtlon is a scparate concept and rc{crs t<l health carc providc(l to p1cvcrrtiorr irr llrt.pr ;rt litt.ol nulsos tltrotrgh strrall pnrjccts. liclrcxzttttplc,prrrtcct {rom or defend against diseasc (17). disclrargt.tl pirtit.nls r"villr lirrrriliar historics ol spccilic cliscatscs could be [Jrrtil rcccntly, hcalth promotion and disease prevcntion havc bccn ;r givcn litcratln-c or rcllr-ri.rls to appropriatc counscling agcncics; or ansrrrirll scgr-r.rcnt of the health care industry. Howevcr, currcnt cconomic injury prcvcntion plOgram could be dcvclopccl arnd irnplcmentcd for bothlrrt lors ;rnd pricc competition arc directly affecling the dcvelopment ol patients and employees. These examples als<,r contribute to increasingsclviccs barscd on thcsc concepts, primarily under ambulatory carc. Gil- the implementation of the concept of continuity o[ care, which should bcr-t clclincs ambulatory care facilities and organizations as those that be a part of all nursing services.l"rruviclc homc hcalth care, outpatienl rehabilitation and therapy, pre-vcntivc hcalth and fitness, hospice, diagnostic, and therapeutic serviccson an outpaticnt basis. The importance of the relationship betwecnlrtalth promotion and ambulatory care is based partially on thc follow- CONTINUITY OF CAREirrg: Continuity of care means that care is provided throughout time, froml. Ncw tcchnologies that increasc the possibility of giving care on an setting to setting and across the wellness-illness continuum. The concept or-rtpaticnt basis of continuity of care also encompasses the goal of coordinated and un-2. Insurance coverage cxpanded to include ambulatory care interrupted services as well as comprehensive care, including hcalth promotion, disease prevention, acute care, rehabilitation, custodial care,3. Rcimbursement based on cost efficiency and the resultant encour- and terminal care. The major thrust of continuity of care is prevcntion, agcment for hospitals to use lcss costly alternatives whether it is prevention of chronic disease through health promotion4. Private entrepreneurs opening ambulatory care facilities. (18) programs or prevention of rehospitalization (19). Much of the earlier emphasis of continuity of care was on referral from the hospital to public For the nursing administrator, knowledgc of the concepts of health health nursing or visiting nurses. This thrust is now included in thepr-omotion and discase prevention will become morc important as in- process of discharge planning that was mandated in 1972 Medicare andcrczrscd emphasis is placed on developing new programs in these areas. Medicaid amendments (Public Law 92-603) for hospitals, skilled nursingSincc thesc are areas ofnursing cxpertise, nurses should be included in facilities, and home health agencies (20). Although discharge planningkcy positions in implementing the new and expandcd programs of hcalth has been a component of quality nursing care and continuity of care,promotion and disease prcvention. Although therc will be compctition inpatient settings may still not be organized to consistently meet thewith nursing for positions in new programs, nursing administrators can patients and familys needs upon discharge. A renewed interest in con-bc prcpared to prcsent sound ralionale for why nurscs arc best employed tinuity of care has resulted from several changes in society and the healthirr many of the positions whcre onc-to-onc counseling and group guidance care field.rrlc provided, for example: A monumental increase in the number of older people has created what Somers (21) describes as the geriatric imperative. This imperativel. Nurses are knowlcdgeable about health and illness so can makc ap- has created new health care problems that demand health care policies propriatc asscssmcnls and referrals of prcsumably wcll individuals. that recognize prevention of disease and poslponing or controlling2. Nurscs usc a comprehensive view of clients and thus can be morc chronic conditions. Maintaining quality o[ life in thc later ycars is dc- cllcctivc. pendent upon the availability of ambulatory, acute, and long-tcrm czlrer3. Nrrrscs arc cost cflcctive because they can function in various phascs serviccs. ol hc;rlth promotion and disease prevcntion. Thc total rrrrrnbcl ol rorrrrnunity hospitals is cxpcctccl to shrink liorrr i,rbout 6,(XX) to 5,(XX), rrntl ol (lrc tcmarining nttnrbcr, -55 ttl 60 pcrcctll tll( Altlrotrglr hcalth promoti<-rn zrncl discase prcventi<-ln have bccn intcgrerl cxpcctctl lo joirr rrrrrlti irrslilrrliorurli.urangcnl(rrls(21). Mtrltilt<lspitlrlpirlls ol rrrrr-sirrg, 1-r-:rclicttrrvirortrt-tcnts havc not always cncour:rgccl clr- iyti.lng(nr(nls t:rrr lr, lror iuorrl:rl tttorltls lirrkirrlr, lwo ot tttott ltosltilltls:rllowtrl nuls(s lo irtlttlrurlrlv irrclrrcle thc conct1lls irr tl.rcir practicc, cx- ()t v(t lit:rl rrr,,, l,l, lrnktnl ,t lroslril:rl tuvillt ottt ()t ttl()t( irrstilrtliolts ol
  • l2tl M()vrN(, iltryoNt)tHItoRDINAI{y r trtrt,t Nl ANt) l,.Ml,.l{(,lN(,1l{A( ll( l.5l l llN(, ll)rnay not lcalizc a spccific physicians lack of qualifications. Nursc ucl- tt.1rl ol llrt t otrrrrrrlnly ulustrtll crttlrrr.vlts ittltotltlt,tl ott lltt ttitliottttlrrrinistrators may have somc influence in this area by being involvccl in lcvcl irr tlrr. lorrrr ol lt1rsl:rtiorr llrirI wotrlrl lllorv llrttlclivcry rtl ttittt-sctting qualifications for positions that relate to nursing serviccs. bursablt rrrrr sirr1, s(t vr( rs lo rrlrpt o1lti:.rt( ttlls(l vccl ot ttttclttsct vccl pop- Arr incrcase in the number of physicians will also decrease thc likc- ulatiorrs.llris rrrttlrlrrrisrrr rvoulcl allow palicnt ltopttlitliorrs clircct atcccsslilroocl of third-party reimbursement for nurses in expanded practicc to nursir-rg strvitts willrotrt tltc usc o[ atr intcttncclilrry, sLlch as a phy-lolcs as long as costs must be contained. Income protection is also thc sician. Thc ccntcrs wotrlcl plovidc out-ol-hospital scrviccs consistcnt withrrur.jor reason that physicians may oppose nursings efforts to changc provisions o[ thc statc liccnsing authority. Altlr<-rugh thc idca of nurse-rrrrrsirrg practice acts to include more expanded and independent rolcs managed centers is not ncw, there wcrc only 63 opcrarting in thc United( I r). States in 1983 (14). The increase in the numbcr olccnters that could occur with the necessary financial legislation could dramatically increase access to nursing care. Nurse administrators will bc needed to assist inIDOLITICAL ISSUES the development and operation of community nursing centers, as well as to be active in the legislative process that will create part of the fi-ln lrlclition to the opposition that will come from physicians for ex- nancial base upon which the centers will operate.pirrrrlccl nursing roles in nursing practice acts, there may be attempts National health insurance has been discussed in the United Stateslo irrlr<-rclucc legiSlation to restrict the role of nurses so that physicians since at least thc l92Os, but serious activity to adopt a national healthwill lravc more opportunity to expand their roles into areas of health insurance plan or system has been absent in the last several years. Ovcrprrrrnrotion and prevention. [n one past difficult economic period, the a decade ago, several plans introduced in congress covered a variety o[(ircat Dcpression, the American Academy of Pediatrics promoted the funding possibilities as well as benefits. However, there were criticismse xpar.rdcd role of the physician in well-child supervision. [n the Division of all plans that did not adequately address three major health carcol (llrild Hygiene of the Board of Health of the City of Newark, the num- issues: distribution ofhealth resources, quality ofcare, and cost controlbtrol physicians was doubled during this time period even though the (15). What might be the effects on nursing and nursing services of atlltctivcncss of nurses in reducing infant mortality had been demon- national health insurance plan? The nurse administrator must becomeslnrlr.tl in that agency since 1913 (12). aware of the potential effects of a national health insurance plan on llrt ntrrsc administrator must be alert and attuned to factors in the nursing service and become involved in forums to inform nurses aboutsocitty and political environment that would result in inappropriate the advantages and disadvantages of such a plan.torrslriclion of nursing practice. Being involved in the American NursesAssociation and in specialty nursing organizations, such as the Societylirr Ntrrsing Service Administrators and multidisciplinary organizations, HEALTH PROMOTION AND DISEASE PREVENTIONis onc <-r[thc best avenues lor rcceiving information about legislative:rrrrl political issues. Florence Nightingale established the importance for nursing of health lhc incrcase in the numbcr of physicians may have some other long- promotion and disease prevcntion with her emphasis on the restorationlcrrrr cllccts if thc nun-rbcr clf nurscs is reduccd in hcalth care agencics. and preservation ofhealth and the prevention of disease. She identifiedAs pointcd out in a str-rcly by Millcr and Stokcs (13), the only health that the basic principles inherent in nursing and health are the samer(sorlrcc that hars merdc an elpparcnt dilfcrencc in infant mortality ancl (16).irll(-scx acl.justccl dcath ratcs wzrs the increasc in nurses per capita. As Today, the concepls of health promotion and disease prevention areotlrtr hczrlth scr-vicc lcsourccs incrcascd, such as hospital laciIities ancl cqually, if not more, important, since many diseases and conditions re-plrysicians, cithcr r-ro cllcct occurrcd or mortzrlity rzrtcs incrcasccl. Nurs- sult from Iifc-style or behavior, for example, smoking, alcoholism, andirrg ncccls lo corrtinuc to concluct studics to documcnt suctr rcl:rti<-rnships rnalnutrion. In orclcr to continue to extcnd the li[c span, science andlrrrtl lo gain grcertcr ptrblicity cll such str-rclics. Thc nursc adnrinistrzrtor lrczrlth czrrtnrrrsl corrttrrlr:rlc on how to facilitatc lifc-stylc changes andis torrlinrtotrsly chnllcrrgtrl lo havc strclr clata to pr-cscnt whcr-r plarnr-rirrg l)rcvcnt cl islrbilit,. 1lris lirliorralc is part of thc busis for thc incrcasedlrntl <ltrisiolls:rr(Io lrtttlrtlrirllottl trsc ol tcsorrtcts witlrin tlrc hr:trltlr irrtclcs{ irr llrtst;u(irs ol lrr:rlllr tlrrc. llowcvct, lltc irttct-cst is not totally(:ll ( :ll,(ll(V. llllrrislit, lrlrrrl ;rl.,, tcl;rlttl lo lltrcltsirts ol lrtlrltlt cltttttg(tlcics to lrvo ollrtrlopirs llrrrl ;rrtirr llttpolitit:rl :u(n;r irr(rttrtst-ntrrurlltrl ittct t:tst I lr,rr r ( ( trtt( 1,r,l. ;ttt<l s()ttt ((s.or(()nunlnrilY rrrrr:,nrlr lnl(r.:rrr<l rr:rlion:rl lrr:rlllt irrsrrt:trrct.llrttorr Altlr,,rrllr nr.rrr Irul,t;tln,;ur(l sctvitts ltlttlittt lttl lorvltttl lrt:rlllr
  • ((tn:ur(l rnlrrrsl irr tonlirrrrill, ol t:ur, lrrrl lrrlrlllr t.lrr-tlrgt,rrtit.s lr;rvr. (l)(lli,t l,r,lr lr Ilttllrrlr,rltrttl ttttrls; lo rltltrnrirrt llrrly;rrltrrrl trrix 9lttol itlw:tys lltttt ot1r,:rttiztcl lo lrllorv or(ttr()r.llilll(.ir L()nlirrtrit.y 6l c:rtt, slltll, ;rtr,l 1,, lrrr{ , ,i r{rtl, ;rtttl Ptovirltsllrll tltvrloPrrrtrrl lol llrt lrorrrcsysltttt lirrltaticrrts.lltis Itrrtl lrlorrtis l(lrs()n cnoLlgll lol rrrrr-scs to ltc- lrtirlllr t:rrt. :l,rll Alllr,,rrllr ;r rlrs(^lrtlrrrirrislurlor.rvlro is lirror,vlr,rlgcirblct otttt rltrtclt motc oricntccl lowitlrl woll<irrg togcthcr in cliflcrcnt scttintlr.i itt ltotttt lrtrrlllr ,;rr,:lrorrltl lrrlrirercl to lrcarl tlrtsr.rvicc, llrc rrtrrsc ercl-rrntl lowurcl clcvcloping modcls lbr-lrcalth carc delivcry that cmphasiz.c Ittittistlttlot ol ;rn ;rllilr;rlttl inlrlticrrt sclvicc shor-rlcl contirruc to supportpr irrtiprlcs ol continuity of care. zrrrd Lrc upprrrprirrItly irrvolvccl in planrring aetivitics. Arr rrrrslublc cconomic base for acute care hospitals has rcsultecl in Anothcl rrur.j,rrrorrt.rrrric issuc fbr nursilrg is that ol third-party reim-llrtir tlivcr-silying, thal is, broadening their mix of products or serviccs. burscment fbr nr-rrsing services. In thc latc 1970s, nursing organizations llris tlivcrsilication is coming about because of the need for more incomc, began working to have state legislation introduccd and passed to require sirrtt tlrc clcrlrand for inpatient care is growing very slowly and hospitals hcalth insurers to directly reimburse nurscs for services provided. As of rr|trrrrtlcll)ressure to contain and reduce their costs (7). Thus, acute mid-1983, 14 states had passed laws mandating third-party reimburse- r;rrt lrosPitals arc sccking ways to decrease their dependence on patient ment for registered nurses or specific nurse groups, such as nurse mid- ( iil( r(v(nLrc. A hospital with less dependence on patient-related revenue wives, nurse practitioners, nurse anesthetists, and psychiatric nurse is,rr rr sor.rrrclcr [inancial base because it does not have to cut services specialists (9). with prospective reimbursement and pressure from the rvlrtrr rru.ior third-party payers withdraw support (8).In the future, hos- nursing profession for nursing services to be separated from room and lritlrls will lacc cvcn more financial pressures as they experience an in- board, third-party reimbursement for inpatient nursing services may ( r(irs(irr thc acuity levcl of patients while third-party payers will step not be a distant reality. rrp cllirlts to contain hospital costs (7). What changes for nurse administrators will occur with third-party srrrrt cxar-nplcs <-rf diversification that hospitals have already under- reimbursement for nursing services? A greater knowledge of revenuc t;rli,trr irrcluclc buying and operating apartment buildings; making other forecasting, budgeting, and budget monitoring will be necessary as thc |t:tl cslutc invcstmcnts; manufacturing hospital linens; leasing hospital fiscal systems become more complex. The nurse administrator requircs spltc lo nor-rhcalth businesses, such as banks and fast food restaurants; such knowledge, not to perform calculations, but to work with the fi- Ptrlting rcstaurants ;rrrrl (8). Although diversification into areas where nancial management staff of the health care facility. Nursing has rarely llrt lr.sPital lacks cxpcrtise is not recommended, there are numerous been made accountable for delivering a specific amount of services, ex- rrrcirs irr wlrich h<-rspitals havc not made use of the expertise on the staff, cept perhaps in such agencies as visiting nurse associations. The ability I,r ,xiurrplc, cxpansion of ambulalory nutritional services for the elderly to accurately predict revenue is still not well established for nursing (/). l)ivtrsilication is a process in which the nurse administrator should services. In the future, this will become important to hospitals and other lrt irrv.lvttl irr planning and developing areas for the expansion of nurs- agencies that may have decreased revenue bases and shrinking paticnt rrrl. srrviccs. For cxample, classes for ambulatory patients and com- numbers. rrrrrrrilv rrrcrrrbcrs cern providc nurses with creative practice opportunitieslr. rvtll lrs irrc:rczrscr hospital revenue. ll,rrrc lrcaltl-r carc is an important area of diversification for hospitals SOCIAL ISSUES:rrrrl ont irr wlrich nursing should play a maior role. The importance of Irrrrrtlrtallh cerrc lbr hospitals lies in the strategy of extending the hos- The change in the structure of physician employment is a major socialPilrrls splrclc ol irrllucncc to activities that may lead patients to seek issue that will no doubt have an impact on nursing. The point has nowlrrsPilirl scr-viccs irr tl-rc luture. "By linking both prehospital and post- been reached where salaried physicians constitute approximately one-lr,sPitlrl scrviccs to thc traditional inpatient services of a hospital, hos- half of all active physicians in the Unitcd states (10). In addition toPilirls rrol orrly errc mccting new community needs but also are sccuring physicians holding salaried positions, the number of physicians is proj-t rrrlrrrl ovcl thcir inpatient utilization by organizing both entry and ccted to increasc lrom 175 per 100,000 population to 240 pcr 100,000txir li<rrr rlrc hospital" (7,p.70).In addition, hospitals will have difficulty population by tlrc crcl .f thc I980s (11). Both of thcsc facts mean morei n I (rln I ly I i rrtrncing capital needs, with cost-containment measurcs compctitiorr willr rrrrrsirrg lirl pzrticnts zrnd, thus, lor nroncy and jobs.lr.in11 irrrPlcrrcntcd. As a result, hospitals are looking to less capital- Many posiliorrs rrorv.lrtltl lrv rrur-sc 1cl ntir-ristrut11r-s urrcl ltLtrsc rniddleirrltnsivc invcstments, such as home health care programs. l-llzlllitgcts ttt:ty ltt,(,rn(;rllt;rt livr to plrysiciarrs wlto iurLrrrnltlc to fincl lrr tltvcloping homc health carc programs, the nurse administrator. ,tttlll,,vttt,trl ilr ,lrt r I lr,rlt( ttl {:u( iu(:ls. l:vtrt llt,,rt1lt lrlrvsit i:tns lturvslr,rrlrl takc thc lcad in part of the planning proccss. Nursing has thc Ittll lttt1rr;rlili,tl l,,r rrr.rrr .rrlrrrrrrislurlivt;rosiliorrs, intlivitlrrlrls rvlro lrirt
  • 324 MovING BEYoND THE oRDINARY (III{I{IiN,I.AND EMLR(;IN(, PRACTICE SETTINGS 325 For inpatient settings, the wide rangc of opportunity for administrative An analysis ol luctors tlrat inl-ribit improvcmcnt of the health stzrtuspractice varies from the small rural hospital to the large multihospital of the poor populatiorr ol thc United Statcs would probably rcvcal sittr-system. In the small mral hospital under new swing bed reimbursement ilar, if not the samc, rcsults. Nurse administrators must bc knorvlcclgtregulations, patients will range from acute care to intermediate care to able about the economic, social and political factors that affect hcaltlrlong-term care, depending upon the needs of the community (2). Such care and must work to change those factors for better health carc lirra setting requires a nurse administrator with different clinical knowledge all.than that of the nurse administrator functioning at the corporate level Nursing in the United States is subject to all the economic, social,in a multihospital system in a large urban area. and political forces that shape and change any society. The currcrtt arrtl Approximately one-half million men, women, and youths are in pris- emerging effects on nursing of several major issuesare discussccl irrons, jails, or detention centers in the United States today (3). Nurses this chapter.In analyzing the reasons for the impact of thcsc issues otthave a unique and difficult position in correctional systems. On one nursing, a direction emerges for anticipatory actions.to be takcn.hand, they are health care providers whose focus is on health care ser-vices. On the other hand, they are corrections officers monitoring securityand public safety. Nurse administrators have key roles in developing ECONOMIC ISSUESand managing nursing services in correctional institutions. On the national level, Davis and colleagues (4) stress the need for nurse Over the last several years, our society has been bombarded with stvtr rrladministrators to enlarge their role in health policy making by increasing major economic fluxes that have conlributed to major shifts in tlrirrliirrltheir potential legislalive expertise and activity. Until recently, nurses about how to finance health care, or, more appropriately titlccl, siclints.have relied on a small cadre of pcople to influence legislative policy care. Inflation and high unemployment have had major eflccts ort llttdevelopment. In order to increase nursings effectiveness in competing cost and use of health care. The idea that health care costs Irttsl lrtfor scarce resources, the number of politically active nurse administra- brought under control has long been discussed but has hacl ir pr(irl(l tors will have to increase. Political power can best be generated by the number of advocates and been the target of more actions sinct t llt ,, ,,t t leadership in nursing. Nurse administrators are in key leadership roles omy of the United States worscned during the 1970s ancl car-lv l()ll()s to affect policy issues at the local, state, and national levels. Economic policy and strategy changes on the federal lcvcl zrllict rrtrr s In the United Statcs, as well as internationally, the determinants of ing in very direct ways. One change that occurred in thc carly l()tt()s health are rooted in political, social, and economic realities (5). Poverty was a shift in federal spending from human resources to dcltrrst. lrr and lack of education are the outstanding inhibitors for health in the 1982 alone, a 25 percent cut was made in public health grants to llrt developing countries. One should not be surprised that the same factors states (6). A second and related major change in federal policy wits llrt exist to a lesser degree in the United States. Of interest to nurse ad- shift to a prospective reimbursement system for hospital cetrc. Tltc irrr ministrators is the result of a Wolld Health Organization analysis of pact on nursing of this system is not yet totally clcar, but it rtury lrt the factors that were inhibiting improvement in the health status of the speculated what this major shift from fcdcral funding ol hcerltlr,.:rrt worlds poor populations in the 1970s. This analysis shows that increas- means to nursing. ing resources for the health sector did not improve health slatus for thc The change in fedcral funding for hospital carc crc:rtcs itrt rrrrsllrltlt following reasons, among many: economic base for acute care hospitals. Sincc m<;st nurses rttc crttplovtrl in short-term, acute care hospitals, thc unstablc ccclnomic bnstrvill, ol course, affect the nursing cornponenl of hospitals. ln sotrtc ittslltttt t,,1. Limited national resources were largely devoted to curative, urban, decreased hospital rcvenue will mean a dccrcasc in thc sizc <ll tltc rrrrlsinl hospital-based services, which wcre inaccessible to the rural poor. staff. For somc hospilals, this will incrcasc strcss on thc trtttsirrlq slrrll,2. The greatest need for health care was for simple, preventivc and pr<-r- sincc not all lrrsl-ritirls w(rc aclequatcly stallccl bclirrc pr1)sl)((livtttitrr rnotive services that did n<-rt require highly trained pcrsonncl with burscmcttl. sophisticated equiPmcnt. Will :r rltrrtlrstirr rrrrr:,rrr1r sllll ancl shor-ttr-lerrgtlts ol st:ry ltsrrll irr3. The scrvices reqtrirccl particip:rtiort ol tlrc pcoplc Itsspirtitlrl lr;rrlrirry" lltr:i:.:rttrttiitl issttt, lrt<:rttstp:rlitrrlsrvill trccrl4. Strr:c.tsslirl lrtttrirrrrrt.rrl ol lrrr inttglltl.tl itpllttxtt lr to lltaltll cilrc l(- trtottlt:rt lrnll,, ur)l lr",,, rl lltt;rttlo lrttlist lrrrr1trl:rs s(,()u:rs 1ro:,silrlr. rltrir-ttl roopttrrliorr lrorrr o{lrtt stt lot s,lot ,x:tttt;rl,,lr1,ritrrlltttt:,1lttll lltc rrcttl lor r,rrlrrrnrl ,1 r;ur t. lrlso:rPl)lu(nl rvltttt l,roliirrl.:tl :r Ito lic rvotli.r,, trltt,;tli,tt, ittt<l r,tt i;rl rvtll:rtt s;rtrlivtttitnliilr,{ ur{ t!l ,,1|tlt Nttt.t"lt;tt,t;tl,;tYr.,l(trr()ttf,ll:tlttltrrlt
  • lo rttlvr)r l vrllrirr llrtir ()t ,:uu/ rlrorr:rlrvot li,lrl:rttlrrrtl proltssiorlrlsvs Itll.lst/.( tttr rrr I ,, ,,,t.tIttns. Nol otrlv is rvotli-ot ittrltrl 1io:,sip slrrrttl irl n(lw()ll( nlr(lilr,,.s lizirrli llt, , rp( tt( rrr { ,rrrrl nl(l(tsl:rrrtlirrli ol ,llrr,rr- (;1r ri.(11(,.lt.t.lrrr1,..wlriclr (x(ur()v(r lrttrtlt, lrll(t v()r l, (lr orr rvttl<trttls brrl so is irrrlxrlllrrrl ol isollrllorr,;rrrrl lrl,rrrroll r,tll(.sl((.nt tvltt.tr< iu(.(.t l)t()lit(,:rr, rs:,1:rllr,rl otittsirlr: irtlolrrurtiorr.llrrrrtrglr rrtl,vorkirrg, lrlliarrccs arc clcvclol)(cl, (()n- clistottr:r1,,1I Irr,rlIr,.r., rrr,rrr or lr.rrrrizlrIiorr.nccti()ns nlaclc, ilncl conc:clns ail((1. Wlrilc it uray lrot l)c car.;v t() guill Ntlr,volliirrltt<;ttitts:t tottttttilnrcrrl lxrsttl orr prrrlt.ssiorlrl r.orrr;rt.ltlrtt.,cntry to ccrtzrin nctworks or to srrbcltrc llclings oldiscomli)ll as ll ncw rclinbililv,lrrrtl t rttlilrilitv. OColnror. ll.ltly ;loirrls ()ul llr:rl rrt.lrvor.lismcmbcr in somc groups, the nursc administrator must sL^ck zrcccss t() 1lr<-lviclcsltggtsliorrs,tliltctiort,guidarrcc,trrrtl sul)l)()t l,rrol solrrliorrs"(1r.thc most inllucntial networks in the health care organizal,ion. 40). Clarity atttcl lrortcsty bascd on what ()nc can ol ltrirrrotlrtrol urlr:rl Nurses, in particular, encounter difficulty moving out oI thcir sphcrc clnc nccds lronl othcrs is vital to succcss{irl nctworkirrg. lrr:rrltlitiorr, inof comfort. This is in part due to the traditional separation of the nursc cotporating cross-gender and variei prolcssior-rtl1 ,.1rr.*",rtati1;rr itr prrr,:,and the physician socially and professionally within hcalth care scttings nctworking systems will greally enhancc and cxperncl tlrc likclilrrxrtl eland the lack of assertivencss that continues to be part of thc subscrvient achieving professional goals.role of traditional nursing service. Nurse administrators have opportunities to network withir-r tl.rcir. lot.irl, Particularly relevant to nurse managers is the contention of Warihay state, and national spheres of influence in nursing. This can bc act.orrr-(5) that in some organizations where few women enjoy the career benefits plished through professional organizations and groups <-rr sirrply byof upper management, developing a new womens network may be pre- making contact with others in the professional nursc and hcalth crrlr.mature. The women in need of support may far outnumber those avail- management community. one reason nurses arc never invited to clcblrlt.able to give it. In addition, limiting sources of support to femalcs would or report important hcalth issues-as are physicians and othcr hcrrltlrtend to narrow career mobility. Thus, any man or woman in ones or- care specialists-is that they lack professional networking skills. Ntrr.st.sganization who will bc an ally and is supportive of womcn and men can also establish important weak ties across professions. For cxarrrplt.,and their achievement perspective warrants inclusion in a network. they can network with journalists concerning womens health isrrr..r, the problems of aging, or clarifying the media-imposed image ol pr.,lt.s sional nursing?PROFESSIONAL NETWORKING when one needs the assistance and support of others, others oltcn li:t.l the same way. when individuals come together with mutual intcrcsrs The importance of networking in achieving professional goals has been and concerns, a network is created. It is unnecessary to endurc scll, dcmonstrated in academe (18,27).Data indicate that a linkage exists imposed isolation from peers and colleagues. among career success, inclusion in ones profession, and networking ac- tivities. Successful nurse academicians report that involvement in professional networks is critical in establishing successful career pat- SUMMARY terns. Nursing colleagucs occupying prestigious positions as journal rcfcrees, There are varying degrees of assistance identified as positivc lorccs irrpublishers, grant reviewers, and officers of professional nursing organ- the development of a satisfying carcer. Mentorship is one aspccr oftlrt. izations and groups are invaluable sources of professional support for patron system of support nurscs are encouraged to adopt. Nursc lrtl- the nurse academician. Networking among academicians is a time-hon- ministrators are vulnerable to the barricrs women in the workplzrcc crr-ored institution. Cranc (32) calls such unstructured arrangements "in- counter as they attempl to move into the higher echelons of powcr arrtlvisible collegcs." The dissemination of knowledge is the underlying pur- influence within health care organizati<-rns. There is evidenceio supp()r.tpose of such networks. Academicians network about thcir interests, the view that thc assistance o[ a respected, influential person can bc rrprojects, successess, and each other. These contacts form a valuable link critical factor in promoting succcssful career endeavors.among colleagues within the community of scholars. until greater numbcrs ol nurscs achicve positions of authority in hcalt lr Nurse administrators must provide similar access to each other as care organizations, thcy rnust sllpport cach other and recognize thc r.rccclwell as senior and junior managers within the health care system. Peutz for cross-gender mcnt,r-protigc In addition to sponsorslrip,(19) and OConnor (33) provide a comprehensive overview of the art of ^[liliations. nurses in leadership posiliorrs c()ntilct thcir peers and colleagues throughnetworking. They discuss attitudes, skills, and behaviors pertinent to networks. There arc clalir t() sr.rpl)ort thc link between networking, in-the development of a network culture in nursing, These authors em- clusion in a professiorr, rrrr<l (luccr satisfaction and success. The intli-
  • Itis or lrtr pl ultrsioturl sl;rlrn t 10. l):rllorr. (, W . Ilr,,rrrp,,orr. l., ;rrrtl Irit t., l{.1.. 1lrr, lorrr :l:r1,,t.s ol Prolcssiorr;rloyrttrttrl - (rrr((r:,: ,t ttrrt lrroli ;tl ;tttlottttltll((lly lrtrrltssiotttls. ()tgttti;.ttlittttttl l)1, il(untl , Srrrrilrrr.t lt)/1 ,(/ll, 19 42. ll. lllitlisrrrr, l:, ll.(ltrltllrrxxl rttttl Stxicly.2rrcl ccl. Ncw Yolh: Noltorr & Conrparry, lrrt., l()hl.Sllrl)Y QUIISTIONS 12. Blackbrrrrr, l{.1., (lurplrrarr, D.W., and Czrrncrt.rrr, S.M. Clorrirrg in academe. Reseanlt itr lliglrtr fitlucalion, 1981, /5(4), 315-327.l. (r itirirlly analyz.e thc aclvantagcs and disadvantagcs olmcnlor-pro- 13. Zuckerman, G. Scientific Elite: Nobel Laureales in the Ilnited Slates. New It1iti r-clalirlrrships in a hcalth care setting. York: Thc Free Press, 1977.2. l)tvt,lop a rolc clcscription of thc nurse administrator as a mcntor | 4. Halcomb, R. Mentors and the successful woman. Across the Board, February :urtl rrs ir prot6gi. t980, r7Q), r3-r8. l. ltlr.rrtily various pcoplc within a health care setting most appropriatc 15. Epstein, C.F.WomansPlace. Berkeley,Calif.: Universityof CaliforniaPress, 1970. l() nrcnlol- al ltLlrsc administrator. 16. Hennig, M. and Jardim, A. The Managerial Woman. Garden City, N.Y.:1. llvlrlrrirlt tlrc nrcntoring strengths and weaknesses of each potential Doubleday, 1977. rrr(nl()t iclcnti[icd in qucstion 3, above. 17. Sheehy, G. Passages. New York: Dutton, 1974.5 wlrirt is tlrc nr-rrsir-rg administrators role in creating and legitimating 18. Cameron, S.M. and Blackburn, R.T. Sponsorship and academic career suc- ;r posilivc cnvironmcnt for mentoring and networking? cess. J ournal of Il igher Education, April I 98 1, 52(4), 369-377 .(r. l)rirrv ull il contract between mentor and prot6gi explicating the terms 19. Puetz, B.E. Networking for Nurses. Rockville, Md.: Aspen Systems Corpo- ration,1983. ol llrt rclarti<-rnship and the responsibilities of each. 20. Felton, G. On women, networks, patronage, and sponsorship.Image, March7. (r it itall.v cvaluatc the place of role modeling on the support contin- 1978, t0(3), s8-s9. lrun) Its it rclatcs to the nurse administrator. 21 . Halsey, S. Role Theory: Perspectives for Health Care Profbssion a/s. New York: Appleton-Century-Crofts, 197 8. 22. Spitzer, R. The nurse in the corporate world. Supervisor Narse, April 1981, t 2(4), 2r*24 .Itl!ITERIINCES 23. Atwood, A.H. The mentor in clinical practice. Nursing Outlook, November 1979, 27(tt), 7 t4-7 t7 . l. lltrrrrig, M. ar.rd Jardim, A. Women exccutives in the old-bov network. psy- 24. Hall, R.M. and Sandler, B.R. Academic Mentoring for Women Students and ,1t,ilt,11t l ttJttv, August 1977, t08),76-81 . Faculty: A New Look at an OldWay to Get Ahead. Washington, D.C.: Asso- ciation of American Colleges, 1983. .1 . l.rrrrclig, F.J., Clcments, G.R, and Perkins, D.S. Everyone who makes it has l nrcnt()r. Han,ard Business Ret,iew, April 1978, 56(4), 89-1Ol . 25. Moore, K.M. The role of mentors in developing leaders for academe. Edu- cational Record, Winter 1982, 63(l) , 22-28. l. l{.rlrt, G. Much ado about mentors. Haward Business Reviev,, January 1979, 57(t), t4 16,20,24-28. 26. Hart, L.B. Moving Up: Women and Leafurshzp. New York: AMACOM, 1980.,1. (<xrk, M. Is the mentor relationship primarily a malc cxperience? personnel 27. Buchanan, C. An investigation and analysis of the prevalence and effect of Atltrrittistrator, November 1980, 24(11), 82-84, 86. sponsorship in the academic career development of nurses. Unpublished doctoral dissertation. Ann Arbor, Mi.: University of Michigan, 1984.5. Walihay, P. The climb to thc top: is thc network the route for women? per- .sorrttel Adtninistrator, April 1980, 51(4), 55-60. 28. Aldrich, H. Organizational sets, action sets and networks: making the most of simplicity. Draft paper. Ithaca, N.Y.: Cornell University, 1976.6. Martin, N.H. and Strauss, A.L. Patterns of mobility within industrial or- g:rrrizations, in B.G. Glaser, Ed. Organizational Careers: A Sourcebook for 29. Granovetter, M.S. The strength of weak ties. American Journal of Sociolog,, lltetn1,. Chicago: Aldine, 1968. June 1973, 78(6), 1360-1379.7. Kanter, R.M. Men cmdWonten of the Corporation. New York: Basic Books, 30. Kleiman , C. Womens Networks. New York: Ballantine, 1980. t977. 31. Josefowitz, N. Paths to Power. Reading, Mass.: Addison-Wesley, 1980.ll.Lcvinson, D.J., Darrow, C.N., Klcin, E.B., Levinson, M.H., and McKee, B. 32. Crane, D. Invisible College.s. Chicago: University of Chicago Press, 1972. The Seasons ofa Mans trfe. Ncw York: Knopf , 1978. 33. OConnor, A.B. Ingredients for successful networking. Joumal of Nursing9. Shapiro, E.C., Haseltine, F.P., and Rowe, M.p. Moving up: role models, Administraticrn, Decembe r 1982, I 2(12), 36-40. me.ntors, and the "patron svstcm." Sloan Managentent Riviiu,, Spring 197g. 19(3), pp. 51-58
  • 22 MAlaKlll lN(, Mitrkrlitt1, ts;r rlr:,. rl,ltrrtllrrl tttit[rlcs otgirttizirliotrs lo itltrrlilv lrrrrrurrr welnts lttttl tttttls itt ottltt lo itclticvc org:tttizitliotutl golrls:urrl olr;ttlivts. It intplies lrcirrg scrrsitivt: Io artcl satislyirrg irrcliviclrrirls ntttls:rrrtl r,vrrrrls Marketing Nursing through tltc proccss ol cxcltangc. lt involvcs iclcrrtilyirrtrr, plotlrrtts lltat are viewcd as capable of satisfying a lrrrrrralr want, rrccrl , or txtlurrrgc. Kotler (l) states that exchange requircs tlrc lbllowirrg iliorrs: Services corrcl l. There are two parties. 2. Each party has something that may bc <-r[value to thc othcr. 3. Each party is capable of communication and delivery. The purpose of this chapter- is to provide an introducti<.rn to prin- 4. Each party is free to accept or rcjcct thc offer. (p. 20) ciples of marketing that will enable the nurse administrator to in- tegrate marketing concepts into nursing administrative practice On completion of this chapter, the readir will be able If these conditions exist, there is potential for exchange. Whether ex- toi l.Formulate a definition of marketing and health care marketing change occurs is dependent upon whether the exchange will leave both management. parties better off than before. Exchange is referred to as a value-crealing 2. critically analyze the diffcrences among three management process because the act of exchange brings both parties something of philosophies, the product concepr, the -selling .""."ii, value. the marketing concept. ."a A market is a place of potential exchanges, or trade. Marketing is 3. Describe marketing information and research. working within the context of a market to actualize potential cxchangcs 4. Describe the issues related to price setting, promotion, and in order to satisfy human needs and wants. Coping with exchangc pro- competition in health care marketing. cesses requires considerable deftness. Organizations must dcmonstrzr tc 5 Identify and critically evaluate marf,eting strategies for the expertise in managing exchange processes. They need to attracl resourccs nurse administrator. from specific market arenas, change them into useful products, and trarclc them in other market arenas. Kotler defines marketing managcmcnt 1rs "analysis, planning, implementation, and control of programs dcsigrrctl The influence of such factors as escalating health care to create, build, and maintain mutually beneficial exchangcs ancl lr- costs and con- sumerism have resulted in significant chairges in health lationships with target markets for the purpose of achieving orgarrizrr- care deliuery. In order to reduce expenditures, hospitals h-ave ."rp;;l;J-wirh tional objectives. It relics on a disciplined analysis of the needs, wants, incen_ ti-ves to bring costs down. For exampre hospitals perceptions, and preferences of target and intermediary markcts tls t lrt norn offer a broad range of services geared to ambulato.y.ui". The federal ,yr,"roip.orp".tiu" basis for effective product design, pricing, communicalion, ancl clistli- reimbursement based,on diagnosis-related groups bution (p.22). ronC.l provides incentives for hospitals to control expendiirres(see "ri. cri.p,". rol. Simarily, Cooper (2) defines health carc marketing managcrncnt as The advent of wellness and primaiy care programs is "the process of understanding the needs and wants of a target ntarktt. a challenge tohospitals because such programs extend ttt"io.!itut,, Its purpose is to provide a viewpoint from which to integrate thc nccrls t.uaiiiorral roresas a provider of inpatient and emergency services. and the wants o[ a targct market. Another purpose is to provide ar vicw- These programs arebased on the premise that the .unJ.,-". or client point frcrnr whiclr lo itttcgrate the analysis, planning, implemcntatiorr has a choice as towhether, when, and where to seek hcalth care. In initiating (or orgarniziltiorr), lrrcl control o[ thc health care delivery systems. 1lrc health pro-motion and primary care programs, h<lspitals must attrJct output o[thc lrtrrlllr tllc rrurrkcting proccss is the development ol tlrc clicntsthe use of such scrviccs tt-tr""gh the ussof a marketi.rg-uipr,ru.h tr_l nrcilns to salislv orl;rt ilit:rltcxclrarngcs bctwecn health care providcr-s tuhcalth calc rlclivcr.y. zrncl thc tatgtl In:rrlirl(s)" (pP. j-4).3t0
  • MARKEIING MANAGIjMIINl Il llL()SOPItlES ol1:,:rttiz:rll()n {l .,.,1{111.,o llr;rl il tltlivtts lltttlt:itttl ltvtl ol q;tlisl;ttliott ntol t tlltt I rttlr :rtrrl clltt itrrl ly lltlrrr ils t otttptl ilot s. ltl itttPltrrrllll :l lrl;llkttilr11 itPllrrrltcll :ttt ttlllttltz:tlitt tttttsl ll:tvt ;tMarketing managemcnt is thc clclibcraLc cllbrt to achicvc outct.rntcs withtarget markets. It is inperative that organiz.ations formulatc philoso- stratcgit lrl:rrr ol rrr;rlkt.lirrli rcscatch Io tlctcrrttittr:ttt<l ltllttttpl lo slrlislyphies to direct their marketing endcavors. Marketing activitics nccd t<-r 1dclinctl st.l ol rvtrrrls ol :r talgct gr-oup.llrtolglrrtizltliott tttttsl ttlsobe administered according to a concept of responsible markcting prac- rccognizc that activitics lclatcd dircctly or inclir-cctly to llrt l:rrgtl tttitt ktltices. Three alternative concepts can assist organizations in their mar- musl be locutcd undcr:rn integratcd nralkct cottltrrl. ()oo1rtl (.1) rroltsketing activity: the product concept, the selling concept, and thc mar- that the succcss of the hcalth care systcm irr satislying tltc clicrrt ttsttllsketing concept. in repeated usage, support for the Systcm (vclltrrttccr sctviccs, ttltl t rrls, positive word-of-mouth publicity), and clicnt loyzrlty. All ol llrcsc ttsttlls contribute to the satisfaction of the systems goals.Product Concept Implementing the marketing concept starts with asccrtaining cxislirrllThe product concept is a management orientation that assumes that or potential consumer needs, followed by planning a coordinatccl scl olconsumers will desire those products thal are good and reasonably services and programs to serve those needs and wants. Thc scrviccs:rrrtlpriced. Such products require minimal marketing strategies to achieve programs are aimed at generating consumcr satisfaction as thc stitttttlttssatisfactory sales and profits. In health care, the consumer, who is usually to satisfyin g organizational goals.the physician, will respond favorably to good products (or services) and Drucker (4) contrasts selling and marketing by emphasiz.irrg llrrrlfacilities; therefore, minimal marketing strategies are required to ensure "selling and marketing are antithetical rather than synonymolls ()r(v(nsullicicnt utilization. complimentary. There will always, one can assume, be ncccl lirt sottt. Both profit and nonprofil organizations can operate according to a selling. But the aim of marketing is to make selling supcrl lttorrs." lltproduct concept. A classic example of the failure of this concept is the stresses that "the aim of marketing is to know and understittttl tlrt t tr:-dcmisc of the railroad industry, whose managernent was so convinced tomer so well that the product or service fits him and sells itscll. lrltrllv,it had a superior form of transportation that it underserved its customers. marketing should result in a customer who is ready to buy. All tlrrrtThc railroad industry ignored the challenges of the efficient service of should be needed is to make the product or service availablc, i.c., ktp,.islit sthc airlincs and the trucking industrys capacity to pick up and deliver rather than salesmanship, and statistical distribution rathcr Iltittt ptrrdoor to door. motion" (pp.6a-65). Marketing challenges health care organizations to be respctnsivc Itt why patients or clients seek or avoid care: their wants, needs, attittrtlcs,Selling Concept and perceptions of the risks versus the benefits of various sctviccs.The selling concept is a management orientation that assumes that uti- MacStravic (5) points out that "in addition to marketing compctctttt,lizers will usually not purchase enough of the organizations products however, the hospital must adopt a marketing perspective: an ztwltl(ll(ssunless they are approached with a considerable selling and promotional of and sensitivity to the exchange relationships it depends on li1- ils vtrvventure. The major focus of this concept is obtaining sufficient sales for existence" (p. 59).an organizations products. This concept is based on the assumption The first step in this process is to identify the markct, thc inclivitlrr;rlsthat customers will buy again, but even if they do not, a sufficient num- who might exchange something they have that the orgernizertion tltsittsber of other customers will buy the product. This practice has many for something they want that the organization possesscs. In tlris ptottss,disadvantages, particularly when customer satisfaction is secondary to important attributes of each party are identified. Thc ncxt sltp is loselling the product or service. divide the market into homogenous, distinctivc groups in otclct lo t rrl tivate separatc stratcgics for each onc. Specilic <-rpportunitics arrtl lri;,lr probability cxclrangcs witlr various market scgmcnts atc tlrcn iclcrrtilittl.Marketing Concept Thc [inal stc1.r is to tltcitltwhicl-r of thosc crppol-tr.uritics to tatgcl lotThe marketing concept is a management orientation that accepts that spccilic acliort rrtrtl rvltltl t tsttlls atrc clcsirccl .the key task of the organization or system is to ascertain the needs, wants, Thc rrrlrrlit.linl: ( ()n( (l)l rs ;rtrrlitrrllrllv sigrrilitlrnl irr rtttlsirtg [rttttttsrand values of a targct markel or markets. The objective is 1o modify thc rrlusc url lrrinislr;rlor r, rrrusl lrtto1,rtiz:ttrt ol tlrc txtltitttlltttl:rliorrsltiPs
  • witlrilr tltc ttltttcxl ol tlrc lrt:rltlr or 1i;rtrizirli()ns cxl(t lrirl rrrrrl irrttrnirl 2. Act ts:rlrrlrt t nr,rl.rlrrrrrrl rtrtrsl lrt ;rlrlt lo irlcttl rlt, r lro:,rtt .r1ttttttlrcnvirclnnrcnts. rvillrirr llrt ,,r, r,rll rrr;rt li,l ;rrrtl tlltt tivtlv ltrt tts ttt:ttlr,lttt1, tllolls orr I ltost st;, ln(r rl, 3. Srrltstirrrli:rlrililt,: tlrtst1.rrtrrls rttttst lttlitt1-1ttttottlllr or strllititrrllvNURSING MARKET ARENA impotlirrrl to tttct il llrr tirrrc itncl cost ol st1-rittltlt:tlltttliotl. Within the nursing division, the target market arcnas arc thc membcrs It is di[[icult to implcrlcnt markct scgrlcl]taliorr sttaltgics wlttrt lltc of the organization and the client or service population. other internal target segment is not clcarly identifiablc with thc 1ropttlitlott. ltrl tx- constituents may include the governing board, employees of other de- ample, a health promotion program may bc clcvcloltccl to sctcctl l)()lcll- partments, physicians, and voluntecrs. External environments includc tial diabetics, clinics may be establishcd in strattcgic loczttiorls,:ttttl ir clients, community, visitors, suppliers, regulators, supporters, profes- pricing policy may be determincd. Howcvcr, inlbrrring indiviclu:,rls wlto sional associations, and colleagues in other organizations. could benefit from early diagnosis and pcrsuading thcm to usc thc scr- The exchange relationships in nursing are fundamentally unstable, vices may be difficult.since the value of what is exchanged tends to change. Alward (6) em-phasizes that in certain transactions the nurse executive represents the MANAGEMENT TOOLShospital organization in exchanges with nursc staff; in others, he or sheis the spokesperson for the nursing division in exchanges with the hos- Marketing Information and Researchpital. In the hospital, the organization exchanges such things as salary,fringe benefits, social rewards, and a sense of accomplishment and re- The nurse administrator must identify actual and potential mztrkcls irrrtlsponsibility for the staff nurses effort, loyalty, and support of organi- institute a two-way flow of communication with all markcts itt ottlttzartional objectives. Clients exchange money, approval, and a sense of to determine the elements that are valued by each segment ittttl rvlr;rlsatislaction for nursing services, relief of pain and anxiety, and re- each wishes to exchange. Marketing data, such as the needs, wtutts, rrnrlsumption ol a particular level of functioning. values of the market, should be systematically reviewed ancl itttrtlvz.tl Thc physician exchanges client referrals for a workplace, prestige, in- by the health care organization. When this initial process is corrrplttttl,flucncc, and many conveniences. In a hospital setting, physicians are strategies are devised for each segment. To do this, the orgatlizrtliotrprimarily responsible flor admitting patients and providing medical carc systematically collects and analyzes data from which to mzrkc politv(writing orders for treatment and medications). Nurses generally ad- decisions regarding consumer prcferences in the market.minister those ordcrs along with performing autonomous nursing ac- The nurse administrator needs to be intimately involved in lbrcclstirrg,tivities. Patient satisfaction is directly rclated to the attentiveness and volume and frequency of demands lor nursing services, pcrccptitlrrs olcapabilities of the nursing staff. clients about the organization and its health care services, ancl potcrlt ial demand for new services that are required by the clienl, physician, arrtl nursing staff. He or she must recognize nursing as a potential rcvclltl(-Market Segmentation generating service, projecting the numbers and typcs of nutsittg ptt- sonnel that are needed to meet these demands.Every market consists of consumers with different needs, preferences, Flexner and Berkowitz (8) present a conceptual flramcwork lor trrltrltttand responses. Thus, no one approach will satisfy all consumers. Each oriented health services planning thal shows that the csscntial lirrli irrsegment of the market requires its own services, marketing strategies, such planning is between research on consumers and plzrnning ettttl t,rttand goals. trol by management. The authors identify thrce phascs in this l)r(x(ss For a health care organization it is important to identify whethcr er The first two conccrnecl the rcsearch program, and thc thircl cottttt rrsdistinct group of individuals would or might use a particular scrvicc il planni ng, i nr plc rncn tzr t iott, itnd evaluaticln.the need arose. Lovelock (7) identifies three criteria for the developmcntof meaningful market segments: Phasc [ : tttt it, .S/trlir.s Qr rttl i1. Measurability: it must bc p<-rssiblc to obtain inlbrmation on thc s1rc- liilsl,rrrirrr;r1,.(nr(nl ;rllrtttPls lo tltlctntittc wlrirt litclots:rllcct tlrtrtllr- ci[ic chalactcristics <ll intcrcsl. tiorrslrilr l)(.1v((n llrl,rl:url/irliorr:rrrrl ils torrsrtttttrs. ()rrlrlitlrlivttt
  • l)Nl) I lll ()lil)lNilllY tulAl{Kl llN(,NlllislN(,:l.liVl{I:. 17s(:ll1ll lttltttir;ttts ltrc trsctl irr llris plr;rstol irrvcstigatiorr to iclcrrtily tht: r,llilizlrliorr, t(rr!n{", ;rrrrl , of,lr., ( onslnrttrtortt;lliirrrctlrrrtl strlisltrcliorr,c.rltttl ol tlrtplolrlcrrt in c;ualil:rlivrltrnrs. Onc such tcchrriqr-rc is tltc urrcl hclrl{lt orrlt ()nr(i A Ilolirnu is nrolt liktly to lrtsuttrsslrrl witlr l Iocr-rs-gxrr-rp cliscussicln, fbr wlriclr a l-c[)lcscntativc group cll actual or nrarkctirrg rtpptrr:rt lr lrtt;urst rr ntottitotittg systcttr is clcsigrrtrl spccilicall.y potcrrtial uscrs is brought togethcr. A subjcct is introduced by a mod- lbr carclr st1,r,rrrtrrl ol t orrsrrrrrcrs lrtlilc inrltlcrrrcnt:rtiorr [rcgirrs.trirtor, who gcnerates discussion through a few selected "focusing" Plans irtcorpolirling tlre rcsults ol rcscarclr arc lbrntulzrtcd and im-tlrrcslions. The purpose is to elicit emotional and subjectivc statements plemented, thcir- r"csr-rlts alc cvaluatcd. As progrant outputs arc obscrved regarclir-rg thc participantspreferences about the topics under discussion.flrcscr stt-rl-cmcnts are analyzed in order to identify the components and measured against the plans, nbw problcms arrisc, crcating a need o[ for additional information. llrc rcscarch problem that seem worthy of more exact measurement. Clarke and Shyavitz (10) suggest that markct rcscarch should typically A sccond rcsearch technique is the individual depth interview, which be done with the assistance of or by external consultants with expertise is rrsc [o clerrify issues raised in the focus-group discussion. The decision in the area of market research. Since such research must be objective,rraking or rcasoning of the participants is probed on a one-to-one basis it is important that it be carried out in an unbiased manner. It is difficulttlrnrtrglr strrrcturcd, predominantly open-ended questions. The responses for the internal staff of any organization to be objective and unbiasediut anerlyzcd to furthcr clarify the issues. in the way they ask questions of clients. Also, confusing market research A third tcchnique, the nominal group, or Delphi technique, is used with promotion activities in an attempt to "sell," or promote, the or-whcn group consensus is desired. A highly structured format is used to ganization is less likely to occur if market research professionals arerrrirrirnizc group interaction and help the group reach creative or judg- consulted. These researchers realize that the purpose of market researchrntrrlirl clccisions. In a study of nursing shortages, Wandelt, Pierce, and is for the health care organi zation to become educated about its market,wirklowson (9) utilized the norninal group technique at a conference of while the puryose of promotion is to educate the market about the healthlrtulth carc cxperls. Thcy generated over 150 suggestions for attracting care organization.nluscs back into the work force. Marketing Strategiesl)l ttt.st, I I : Quantitative Sludies(-)rr:rrrlitativc or descriptive studies are conducted to identify consumer In the implementation phase of a marketing plan, the organization should translate marketing research information into strategies andst1|rrtrrts in the health care marketplace so that forecasts can be made tactics. An important element that must be considered when developingirlroLrl thcir futurc behavior. The behavior and demographic character- market strategies is planning the marketing mix, represented by theisli.s,l thc consumers are then assessed. These profiles indicate who four Ps: product (service), place, promotion, and price. The decisiontonrpliscs thc markct and who provides services to the segments within regarding the combination of the various elements-which can be com-it . M rrclr of tl-rc data needed for descriptive studies can be obtained from bined in several ways and coordinated in a systematic way to reachsccorrclarry sourccs both intcrnal and external to the organization: pre- targets-is an integral part of marketing strategies. Ireland (11) em-vi,rrs rcscirrch studics, discharge or case-mix records, and so forth. Data phasizes that success in understanding and applying the marketing mixrrrry lrt: collcctcd through carefully selected survey instruments such as to a given market "lies in developing a thorough understanding of ther r rlr i lccl qucstionnaircs, telephone intcrviews, and personal interviews. people in the market so that the right producl can be afforded at rheAllcl collcction, thc data are analyzed so that patterns of association or right time in the right place supported by the right promotional effort"rtllrliorrship among variablcs can be determined. (p. 2s8). Il rtt.st I I I : Ilunning, Implementation, Cost and Pricingtttrrl liyulttulirsrt The determinzrtiorr ofpr-icc in health care institutions is one of the mostln tlrtlirral pl.rasc, thc results of data collection are translaled int<-r fca- contplcx ar-t:as ol irtlrrrirristruticln. Thc dircct and indircct expenses gen-silrlt pxrgr-aurs. Thc inlormation procured in the qualitativc and quarr-r- crarllyrclattrl tolrspctilit tosl ccntcrdonclllbrm;rnaccuratcindicatorlilirlivt ;rlurscs olthc rcscauch is uscd to devisc program stratcgics arrrcl ol thc ittltutl tosl ol ptovirlirrg rrrrrl rrrarintairring llrcstsclviccs. Markinglltt lits. (ri lrlia fotcvitluitlirrg progrzrr-rr inrplcrrrtrrlution arrc outlirrcrl . tltittgts ttlr itt trt t,., ,r1 )( l lo l(X) ptrrtrrt lirr clilgrroslic scr-viccs is rrlirt txlrrrrplc, l)r()l-lr:ur tllirlivtntss is nrclsrrlttl lry irrralysis ol scrvitt c()ttttlt()tt lrtrtt ltt,ttt lt,,ptlirl, Itrit irrlq plirtlitts rrt,.t1 l9 lrtlctv:rlrtitlttl
  • rrr rrrUr( (.(lilil,lt)t( ;iltil (.()lill)(.lllt,(. 1il lll(. lllill.l((.1 plzrcc. l;otcxittttPlt, lrtirlllt t lrtt;r,,(r( l(s slrorrltl .1.v,.1,,1r rr plit.irrll slr.rrr. ;rtrltlttt I lurtl rt, rlr,rtr rl ,rllt tlrttlcs. lltt lttlr)t nt:rtt()n or.,,( rnrr.rr( (r rlrr,1, turc th:rt r-cttcct.s,r,",,,i.,,r.:,,,.,,,,*i;;;";;,1:iil,,lil,:llii,i,,,lli lrt llrrstrl ,,tt tllr.rl i rrr,unr(r:, tt,ttl lo littorv. trators must bc cogttizatrtt ol llrttorrrpltxiry of lirct1;r.s irrv11lvgcl irr rlt.- l)tontolr()r rrr,,lr,,;rrlvttlisirrg,, scllirrll, ;rrrtl Prrlrlit rtllrliotrs. ln ir tcrmining thc c<_lst o[ nur-sirrg l.cvcltu(, cclltcrs. hcaltlr (lu(s(llrrrl,, prorrroliorr:rl lrctivitits rrstrlrlly irrclrrtlticltrrlilical-ior-r Kotler (12) notes that an.rganizertion must dcciclc, in erttcrpting t, ol sctviccs, lor txrrtnplt, ttlrrtrtticlrtal scrvicts. llospillrls rrrttl lo bc t-trorc ascertain a price or pricing policy, the objcctive that it is trying r, aggrcssivc in tlrcir aclvcltisirrg clfbrts. l)trlrlitrrliorrs :rrrtl n(ws lelcases achievc. He describes four different pricing poli.l". prolit rnaxin-rizatigl, are most cffcctivc whcn dcsigncd withirr thc corrttxt ol lr lolal h<-rspital cost recovery, market incentivization, and markct disinccntivization. marketing plan. Recruitment of nursing stall is lrlso lrrr (xanrplc of a The profit maximization policy dictates that an organization set its pricc promotional activity. Recruiters publicizc thcir lgcrrcy by clistributing to yield thc largest possible revenue. cost recovery involvcs setting . promotional brochures, participating in prolcssiorrnl rrrtct ings, and ad- price that would cover costs. An organization adopis the market incen- vertising in professional journals. In the prescnt hcaltlr cill-c itr-cna, com- tivization policy when it seeks to attract the greatest number of cus- petition is evident for the attraction of consumers in thc markctplace. tomers in the shortest possible time; relatively low prices are set in order tstimulate the growth of the markct or capture a,large share of it. Thc Competition opposite is true of market disincentivization, in whlch pricing is un- dcrtaken with the objective of discouraging pcople frompurchlsing a In health care, competition is geared toward demand, which restricts, particular product or service. For example, the theory behind high glv- the dollars coming into the health system. The assumption is that con- ernment taxes on cigarettcs and liqur is to discourage people from uiing sumers are involved in making different choices depending on their par- thosc products. ticular needs. Some spcnd additional dollars in order to have more ser- Kotler further notes that pricing models applicd in practice tend to vices. Through control of costs and prices, providers such as physicians bc based on unclear objcctives and take a limiied ,riewtf pricing prob- compete for clients. There is bargaining with providers over prices by lems. Thcy tend to base pricc on factors such as cost, demand, an-dcom- such groups as businesses and labor unions. It is assumed that cost con- petition. when an organization is considering a price change-whether tainment results through market forces and consumer choice. a pricc increase to take advantage of a strong demand oi a pricc re- Congress has been involved in several procompetition measures aimed duction to stimulate demand-the action is certain to affeci buyers, at reducing health care costs. These proposals provide consumers withcompctitors, distributors, and suppliers. The success of a change dcpends incentives to decrease unwarranted use of health care and to select thcon how the parties respond. Any price change carries great risks. most cost-effective health care plans. The attempt is to reduce the dc- Simon (13) stresses thar the grearest limitation faclng hospitals in ductions employers can claim for medical benefits, which would cn-developing competitive pricing policies may be rhird_iarty paycrs. courage them to choosc less costly health insurance programs. Thc pro-Third-party payers limit the ability of health .u." p.oui.lers to price posals also advocate an increase in cost sharing through deductiblcsservices competitively, since pcnalties may be imposed when prices are and copayments, which would be included in plans for the employccl and Medicare and Medicaid recipients. An interesting poinl is that thcreduced.In general, reimbursement formulas tend to penalize a hospital proposals are recommending counting part of the employer-paid healthwhen,cost or pricing reductions are implemented. bu.h cost savingswould not be reflectcd in consumers insurance premiums. A reduction insurance premium as income, taxable to the worker, which would cn- courage employees to be more cost conscious. Griffith (14) stresscs "tlrertin cost to the public can be negatively received if the consumer feelsthat a price reduction indicates i"cut-ratc" pricing of services, reflecting without direct third-party reimbursement for all licensed professiorrarlpoorcr quality. The organization shoulcl move a*iy from excessive con- providers, entry into the health carc is restricted and true compctition is impossible. Physicians and hospitals arc the major recipients of djrcctstraints and be ablc to reflect the realities of the marketplace. A market-orientcd pricing system that allows hospitals to morl closely match third-party reimbursement in thc current system" (p.26D.priccs and costs is needed. Restraint-of-tradc activitics in professional practice in the health carrc system for the purpose of stilling compctition is being increasingly questioned. The Supremc Court r-ulcd thal the "learned professions" alcPromotion subject to antitrust law.fhc court confirmed that the professions arr-c subject to the restrictions ()n nl()n()poly and unfair methods of compc-Promotional activities arc a strategic parl of a markeling campaign.Prspective clicnts need to bc knowledgcable regarding tf,c scrvice or tition cited antitrust slulrrtts irnc[ casc law. The American Medical As- sociation supported lcgislltiorr lo pn-rhibit the Federal Trade Commissior.r
  • irrvtrligatinli Itslr;rirrl ,rl ltittlt:rtlivilics irt lltr.Ptoltssiorts.(1,l() lrorrr rrgr..tls, prt.lt.r,.rr, r,1, ;rlrl Irr,l lrplrotts ol ;toltltliitl ttstt s ol rrrtl sittll stt vtttllrc prrrposrrl lo txcrrlrl prolt:,srorr;rls ltotrt tlrc jtrrisclitliott ol tlrtlrl( :rswt,lllrsl(..llrr.r;rp;rlrrlilicsol tltr.rtrplrrrrizltliottltttttttl llttrlttttlttttlwirs l:rlrlcrl orr llrtScrralc lloor irr l)trrtrlrctl9tl2.lltis isstrc is tt()t y(l lirr. strvit.t.s. Slr;rlrprrcs ;rr r tltltrtttirrtcl lirl cttclt ttlitt litl stlitttctlt, goalsscttlcrl arrcl will c()r)tiltLlc to lrc ckbatecl . a6rl 9[.jt.tlivr.s;rrr. lolrrrrrlrrlctl, rrrrtl trtnrlictirrg ltllrrrs lrlc itrtlllcrtlcntccl fhc Amcrican NurscsAssociatiott (15), in its legislativc prioritics lbr alcl cvalrratt.tl . Mlrrltt.lirrg, is a nrarrlzlgclltclrt clisciplirlc atttd nrust bc rcc- l9B0-1982, listed "definition o[ nursings interest in the devcloping <lgnizccl by tlrc ttttt sc ;lcllrlitlistrzrtor as such in orclcr to achicvc thc high-tornpctition in the health care industry" (p. 2). Nursings intcrcst in- cst quality of nursing carc within thc prolcssional practicc of nursingcltrclcs incrcasing Iegislative visibility, achieving third-party reimbursc- :rdministration.rrcnt, and interpreting the nurses role in preventive care, geriatric care,and c<-rnsumer education. A preferred provider organization (PPO) has been described as thc: STUDY QUESTIONS rl<-rst powerful marketing tool that providers can utilize. It is an ar- r:.rngcment or negotiation between a third-party payer and a provider. l. What are the similarities between marketing management and health Pancls, providers, or third-party administrators offer a benefit packagc care marketing management? to cmployers. A PPO is designed for the purpose of establishing con- 2. Describe the rationale for using the marketing concept as opposed tr:rctual relationships among all parties. to the product or the selling concept in the health care delivery sys- PPOs negotiate provider fees and other cost-saving benefits Providers tem. rcccive a certain volume of patients and rapid turnaround in claims 3. What are the major differences between marketing information andpr.ryment. Characteristics include formation of a panel of providers (hos- marketing research?pitals or physicians), negotiated fee schedules in which services are dis- 4. Analyze the impact of issues related to price setting, promotion, andcounted from 5 to 20 percent, a commitment to utilization review meth- competition within nursing administrative practiceods of quality assurance, and flexibility in the choice of provider with 5. Identify and critically evaluate marketing strategies you would utilizca linancial incentive to use the preferred provider. Recent legislation to address the issues mentioned in question 6, above passed in California allows insurance companies to contract with hos- pitals and physicians in both preferred and exclusive provider arrange- rncnts ( l6). Physician competition will also increase as the oversupply of physi- REFERENCEScians expected to occur in 1990 becomes a reality. Friedman (17) predictsthat nurse practitioners will be at risk: "The major effect will be on 1. Kotler, P. Marketing Management Analysis, Planning, and Control,4th ed.nurse practitioners, who have done the most to take over health as- Englewood Cliffs, N.J: Prentice-Hall, 1980.scssment and counseling" (p. 121). 2. Cooper, P.D. What is health care marketing? in P.D. Cooper, ed., Health care Uaikettng Issues andTrends. Germantown, Md.: Aspen Systems Corporation, Marketing competition will directly affect the health care industry. 1979.As McNerny (18) eloquently states, "For every force, there will be a 3. Cooper, P.D. and Robinson, L.D.HealthCare MarketingManag,ement: ACasecountervailing force. Progress will be evolutionary, through competition, Approach. Germantown, Md.: Aspen Systems Corporation , 1982voluntary efforts, and regulation." 4. Drucker, P.F. Management Tasks, Responsibilities, Practices. New York: Har- per & Row Publishers, 1973. 5. MacStravic, R.E. Should hospitals market? Hospital Progress, August 1977,SUMMARY 58(8), s6-s9, 82. 6. Alward, R.R. A marketing appr<-rach to nursing administration, part l. TheNurse administrators must understand marketing principles, techniques, Journal of Nursing Adninistratiott, March 1983, I 3(3), 9-12and tools and be able to develop marketing strategies to survive in to- 7. Lovelock, c.H. conccpts ancl stratcgics for marketers, in P.D. Cooper, ed" Health Care MarketiLrgl.ssrrr,,s atrdfrcntls. Germantown, Md.: Aspen Systemsdays economy. Such strategies should be devised to meet competition Corporation, 1979.and increase nursings influence in the health care sector within the 8. Flexner, W.A. and Bcrkowitz, 11.N. Markcting research in health servicesrealm of professional nursing practice. - prr""i"g a model. Pttltlittltttltlr llLlxtrls, November/December 1979,94(6), By utilizing a market model, the nurse administrator can analyze 503-5 I 3.
  • ( ,tr I rt I I 1.. ) t) W:rrrtltll, M A,Ircrrt, I.M., iur(l wr(lrl()v:,orr, lt.l{. Wlry rrrrrst.s lt.rrvtrrutsirrl, :rtttl rvlrltlt;ttt lrttlottt:tltottl rl .lttrrttttttt.l()utrtttl rtl Nut.tnl,.llrrrrr;rr.V 198 l, , ttt ).1) // . (llrrlit, I{.N.lrrcl Slr.yavitz, L. Miu litlirr1. inlirr.trration trnd rcsczrr.ch: rralrrablc trrtrls lirr nriuragcrs. Ileulth LurL lvltttttrllt,nt(nl RevieM, wintcr l98l , 6( l), 73 7,/. 23 lt lr.lrrrrtl, R.c. Marrkcting: a new opportunity for hospital f.1). (ixrlrcr, ccl., Heahh Care Marketing Issues andTrends. Germaniown, Mcl.: Aslrtr r Systcrns Corporati on, 197 9. mzrnagcr-ncnt, in Current and trrnerging l) lrr rtlt r , l. Murltctirtg fbr Nonprofit organizations, 2d ed. Engrcwood cliffs,I N..l .: l)rtrrticc-Hall, 1982. Si.rr.rr, .l .K. Markct.ing the community hospital: a tool for the beleaguercd 1. Practice Settings :rtlrrrirrisl.rrlr,. Hcalth Care Management Review, Spring 1978,3(2),ll_23.t,l (;r illitlr, ll. conrpctition in hcalth care. Nursing outlook, September/october ()tr t I , l / (5 ), 262-265 . Arrt r itirrr Nulscs Association. Legislative priorities for 198o-1982 biennum. llrrlrrrlrlislrccl papcr. Kansas city, Mo.: American NursesAssociation, 19g1. The purpose of this chapter is to discuss current and emerging pr,actice settings for nurse administrators and to address some spe-l( l.,tlrrtr, K. c,mpctition: getling a fix on ppos. I1osplra1s, November 16, t()t31, 5rr(22), -59 66. cific current issues relaled to economics, society, politics, ethics,l/ f ;r ittlrrurrr, Il. Doctor, thc patient will see you now. Hospitals, Scptembcr and health. Although issues constantly change, nurse administra- lh, r()8t,.55(lB), 117 127. tors require mechanisms by which they can be informed of theI ,l Mt Ne W. Tcstimony on S. 1968, the Health Incentives Reform Act, to the changing issues and forums in which the issues can be opcnly clis- v, Srrlrt.rrrrrrittcc ,rr Hcalth, committee on Finance, u.S. Senate, March cussed. On completion of this chapter, the reader will be able to: 19, l ()t{o 1. Attain an increased awareness of the multiple settings in which nursing administration can and will be practiced. 2. Discuss the actual or potential impact on nursing of major economic, social, or political issues. 3. Describe differences between health promotion and disease prevention and their relationship to continuity of care. 4. Define ethics as the concept relates to health care. 5. Describe a process for dealing with ethical issues. The professional practice of nursing administration is carried out in a variety of settings where the opportunities for leadership at all levels of administration have never been greater. Nurscs have always valued the whole person and from early times stressed the importance of the wellness-illness continuum. Patient-centered care and continuity of care are not new concepts in professional nursing; thus, the sudden awareness of these concepts by other health professionals is refreshing. professional nursing administration is practiced in mzrny settings-in fact, wherever prolcssional nr-rrsing is parrt o[ health care dclivery. Thcsc include am- bulatory, acrrtc, lr,rrrr, urrcl long-tcrm care scttir-rgs. Thc nursc aclmin- istrator is lrlso lorrrr<l irt tottsullltion agcncics, sclrools o[ nursing,:rnd var-it.rtrs g()v(r nnr(nl I,:,irirs lrr tlrc policy,nral<ing lr.vcl.lhc l9g3 In- slilrrlt ol M,rli, irr, l{r;ror r (l) t.x;rirrrtls llrt list ol pr.:rtlitr, st,Irings l9 irrtltrtltlrt;rlllr nr:u!rl{ n.ur{ torl,:rrriz;rligrrs, slrrtlt.rrl lrt:rlllt st.r.vit.t,s, lrrrtl totttltltx pltt:.r, r.rrr.,,1|r,,,, I tl
  • Blarckltu;rr, (llrrrprrr:rrr, rrrrtl (:un(rorr (ll)tltstlilrtlllis 1,roolrrill!l l)lr)- ottI ol lorrrr, .rrrrl llr, tnrPnr l;rtttt: ol lltr ttttttlot irr llrr lttolt:..torr;rl liltcessascloning.llrcrrrtrrlolllrslriorr:. llrtptoltigiirrlrisolltct owtlitttirgt ol tlrc l)r olt1,1,rr t ;rll poltrtl ilrl prolrltrrrs irr l lrr l riirtl.and likeness. This stylc t-rl grrronrirrlr ()((urs irr tlrc prcpillLlti()lr ol sci- It is lrv virlrrt ol ils inl(nsily :-rrtcl lircus llrrrt lltt nr(nl()r ptolt1ir ;rlentists. The novice scientist minrics Ilrc rrirslcr irr ways tlrzrt bcncIit thc filiatiorr is tlrtlrtsl rtttlltotl lirr gloontirtg llttr.ttc le:ttl.ts; lrv tl: vtr v n;rcontinuity of scientific excellence. It is oltcri tluor-rgh thc cmimcncc ol turc, rrrcrrtorirrg curr lrc botlr valucd ancl Ici.rlccl . [Jnltss nr(nlr)r irr1i,:rrrtlthe mentor that the work of the prot6g6 is rccognizcd. especizrlly cross-gcndcr mcntoring, is a lcgitinrntc:illu( lnr(vrllrrrr ;rrr Zuckermans (13) study of the Nobel laureates provides cvidencc o[ organization, both men and women are rcluctzrnt lo risli ils lr;rzlrrrl:,.the valuable link between bright young scientists and their eminent However, in spite of the risks, cross-gender mcntoling ltrs lr,rrr :rr,sponsors. The socialization of the next generation of prize winners is cessful. Women have reported enormous benelit frclrrr llrtil rvor h rvillrthe unofficial domain of the laureates in science. It is understood that male mentors (16-18).the work of science is passed from one generation to the next. It is ac- A less intense, less personal relationship has benefits ars wcll. Mtrrtor :,cepted that a laureate will guide and promote the successful achieve- and prot6g6s can adjust theirexpectati<lns of each other by rrutinl:.rrrrrrr;,ments of the next generation of Nobel prize winners only a professional interest in the relationship. Such a modilicrl vtr si.rr of the more intense prototype can be effective in sponsoring cflbrt s ( I u ).WOMEN AND MENTORS MENTORING NURSESWomen need mentors at two crucial points in their lives: during theearly stages of career development and during the final thrust to the The barriers and attitudes concerning the role of women in the workplacetop (14). St.rdi"r of women in top-level management positions indicate are concentrated in nursing. In addition to overcoming the barriers cre-that they had help from a mentor, usually a male boss (1). In contrast, ated by cross-gender mentoring already mentioned, nurses must over-women who failed to establish upwardly mobile carecr patterns were come the stereotype attributed to their profession. The attitude thatwithout sponsors and other support relationships (7). There are some nurses should be content with traditional nursing roles and leave theimportant considerations for women who engage in mentor-prot6g6 re- task of comprehensive health and fiscal planning and management tolationships with men. those best suited-namely, hospital administrators and physicians-is Cross-gender mentoring-as exists between a male mentor and a fe- a major barrier. This perception, commonly held by men in health caremale prot6g6-is discouraged by some authorities (8). stereotyping is management, is often shared by nurses (19).cited as one barrier that influences the relationship negatively. It is be- Another common attitude is that nurses are educated to provide ser-Iieved that commonly held attitudes about women may interfere with vice. They are not expected to provide meaningful management directionthe effectiveness of the mentor: "she is bright but not committed," "she for an institution. The nursing profession itsclf is ambivalent aboutis too pretty to be committed to a career," "she will get married, get nursing administrative roles in health care organizations. This ambi-pregnant, and leave." valence is manifested by confusion about the best arrangement of clinical Another barrier involves thc perception of peers and colleagues. Men and management components in graduate programs preparing nurseand women fear being linked to illicit relationships in the workplace. administrators. Nursing staff in health care settings are not supportiveMentor-prot6g6 affiliations can fall victim to the faulty perceptions of of nurse administrators who cannot demonstrate clinical practice skills,others, resulting in severc damagc to reputations and careers. Organi- but thcy also cxpcct the administrator to possess lhe necessary skills tozations can remedy this potential threat by a willingncss to recognize access power and credibility in thc higher echelons of managementthe mentor-prot6g6 relationship as a positive and sound force in the within the institution.preparation of leadership skills. This in turn is beneficial to the organ- These attitudes constitutc abarricr that thwarts the desire and progress ization. Generation continuity and homogeneity of leadership is the of the nurse administrator who is capable of assuming greater respon-prized objective of most organizations (2). sibility and career divcrsity. Although same-gender mentoring is ad- The final barrier in cross-gender mentoring is the fear of the mentor- vocated for both men ancl wonrcn and would seem to alleviate thc prob- marital triad (15). The intensity of the relationship can be disruptive lems and attitudes inl-rcrcnt in nrcntor-prot696 relationships, thc when marital partners are not clear about the intent and purpose of the dilemma posed by thc crrrploynrcnt of too few women in the upper ech- prot6g6s relationship to the mentor. Working late, an occasional trip elons of management is lr rtlrlily. Women, and especially nurses, are l.-
  • lllE R()Ll1 ()Ij MliNl()ltS ANI) Sl()NS()ltS uunt N/tr rrl,r t, llr, ttro,1 ttlrn,{ ;ltt(l 1r;rlrr tt;tlt:.ltt ttl;tllolt:lttlr lrtt lltt (()ltlultlr lort;rl ,, 1,, ltorr,;r"(ll;rllott,;rtttl llll:,1 ;ll..lt;lt;ltlttt:,litqolMcntclrsl-rip lras rtccivtrl irrtrrirsrrl irlltrrliorr irs irrr irrtlrollrtnI r:lcrntttl tltis rtllrlr,,rr,,lrrp Nt l r,, llrt,.1){)n},(}r rtl:rlrorrsltip, tltlirrttl ltttl)l)r)t lt(in career dcvcloprrrcrrt. lt lras lrttrr tspctiirlly populirrizcc[ irt [rr-rsincss bltt trot porvtl lrrl rrr lrllt.. ol t:rtttt rttlvltttttttttttl.llris rtllrltott:.lttp lrttrl"literature as thc mcans to a slrcccsslr-rl clinrb up thc corporatc laclclcr to bc crrtourirl,nrl,, tor rolrollrlirrl., rtttrl cottlitltrrtt lrrriltlrrrl,. ttt tt;tltttt(l-5). Men, womcn arc told, h<lld thc kcy to succcss in thcir choscn oc- Guidcs, tlrc rrexl posiliorr on lltc tor tlitttttutt,lttltt liott lo slttt irrtltvi,ltt;rl,cupations and professions because they are compctitivc, politically wise, Thcy oftcn pt-r-rviclc lrclltlr-rl irtlt-rlnrirlion lborrt tltrsvsltttr, pitl;rll. t,,and help each other via the "old boys network." Further, if women arc avoid, and standarrd nornts ol lrclravior. (itriclts rttr ttstutllt ;trlttttttt:lt:tto succeed, they must be socialized into this network. This "tuning-in" tive assistants or exccutivc sccrctzu-ics. Tlrcy itlso ltttttliotr rts l:tltlttlrtt .process for both men and women is accomplished with the assistancc who control access to the elitc in an clr-gar-rizittiotr. l.lsl ot t lltt((,nlnurlnrof mentors, or sponsors. is the relationship bctween pccrs: pccr pals. Pccts slutttittlot ttt;tltottol Researchers interested in organizational behavior have identified the mutual interest, Serve aS a sounding bozrrcl lblottt :tttollttt , rll)l){tr Imentor phenomenon. The distinguishing function of the mentor is to one another, and generally develop rclzrtionsltips tlrll lrtlp <,tr. ,rtr)llr( laccess power and influence for the prot6g6. "A major influence deter- grow, progress, and succecd in carccr cnclcavclts.mining who moves and how far is the action of the sponsor. When the Daltcln, Thompson, and Price (10) adv:rncc it nlgclcl ttl tlrtt,t ()rf;rrrsponsor rises, the prot6g6 moves with him. Which career lines are chosen ization consisting of four stagcs: apprcnticc, cclllcagrrt, llr(rrlot , :ttttlor available often depends on the action of a sponsor" (6, p. 203). sponsor. Thc apprentice stage is a dcpcndcnt rclettit.rrslrill tlrlrl ittvolvt". Kanter (7) describes an informal pattern of selection observed in her l lcarning experiences. The collegial slagc supports ittclt1-tttt<1,rrt t lr,study of a complex business organization. Individuals in the fast lane mentor is involved in helping the apprenticc. Thc sp()rls()ris:trt ttttltwere affiliated with a sponsor who served as influential and powerful vidual involved in the direction of an organization tlrxrtrglr polit r,, llvpconduits for their prot6g6s. Men and women who moved up without mulation and the promotion of key people.sponsorship were often stalled at some point in their career and deniedadmission to the inner circles of upwardly mobile elites. Sponsors notonly prepare their prot6g6s for upward mobility but also influence how CHARACTERISTICS OF MENTORS AND MENTORthey are received by those in higher echelons. RELATIONSHIPS Typically, mentors are highly placed in an organization. Thcy art trsrtrrllyWHAT IS A MENTOR? associated with the most powerful and infiuential pcoplc. I;tcc;trtrrllv they are men, simply bccause women are not in the highcr nlilllllS(lll(lllThe term sponsor reached popularity in the i960s and early 1970s. Today, echelons in most organizations. Sometimes a mentor has morc tltlttt otttthe commonly accepted term is mentor. Sponsor, mentor, and role model prot6g6 within the organization.are often used interchangeably, but most would agree that mentoring Levinson (8) describes thc relationship between mentor ancl ptoltilttis reserved for a relationship that is more special, intense, and enduring as a love relationship, intense, not scxual. It often occurs natutally;rrrtlthan that implied by modeling (8). spontaneously. The expcrience is dcscribed as similar to falling irr lovt It has been suggested that role modeling is not effective in helping in that it cannot be arranged or mandated. Many prot6g6s dcscribc tlrtirwomen acquire reputations of influence and power. The strategies used mentors as father figures, wisc, loyal, trustworthy, and protcctivc.by those who have achieved success may not be relevant to succeeding A comparison can bc madc bctwcen mentoring and Ericksorls ( I l)generations of women. Searching for the role model who encompasses generativity stage of dcve lopn-rcnt. Human beings reach a stagc in tlrtirall the attributes associated with success is discouraged. Instead, a com- development that requircs thcru to give others the benefit of thcir lilt"sbination of models may be more appropriate. This provides the novice experiences. It is thc proccss o[pzrssing lrom one generation to anollttran opportunity to choose the traits he or she wishes to emulate and to the values, standards, ancl ncltttts clfthe former generation.reject others. Ideally, a similar proccss occurs bctween mentor and protelgd. Mcrrtot A patron system that embraces a continuum of support is proposed passes to prot6g6 valucs arrcl stunclards that maintain continuity antlby Shapiro, Haseltine, and Rowe (9). Mentor and peer pals are the two stability of leadership withirr tlrc organization. The mentor prepares tht end points, with sponsor and guide as internal positions on the contin- next generation of lcarclcrs.
  • 2lMentorshipand NetworksCatherine BuchancLn The purpose of this chapter is to prcsent the nature, charactcristics, and consequenccs of mentorship and networking and their appli- cation to the practice of nursing administration. On completion of this chaptcr, the rcader will be ablc to: l. Dcscribe the importance of a mentor relationship in thc de- velopment of a successful carcer in nursing administration. 2. Cite the paradoxical naturc inherent in cross-gender mentor- protdgd relationships. 3. Construct a viable continuum of support for thc nurse ad- ministrator, making use o[ sponsorship and networking. 4. Discuss the limitations of rolc modeling as a strategy for ad- vancing a career in nursing administration. 5. Formulate a definition of mentoring. 6. Explain the theory supporting the career advantage of par- ticipating in networks. 7. Analyze the relationship betwecn networking and career dc- vclopment issucs in nursing administration.Without qucstion, women cntering ficlds and professions that are tra-ditionally male dominated are encouragcd to enter under thc aegis o[a mcntor. Prolessionals in predominantly female occupations often donot consider the importance of a mentor rcl;rtionship in the devclopmentof a successful career. This is particularly truc of nurses who occupyadministrative positions in health carc organizations. A powerful andinfluential pcrson within arr orgarnizntion acting as mentor or sponsorcan be a key growth factor irr providing thc protig6 visibility, credibility,and acceptance. 295
  • l(1. ( rulin, l. l)t lrrtttittittll tosls ol rur.rrli strvitts ptr l)lt(). Nttt.sitry, Itltttt (tt-!ut(,tt. Alrr rl ll)tl.l, l.l(l), l6 ,llI l. l,rrvtntltro, l{. Nrrrse lrrtltrorrl: ,vlr;rl (iur wc ltalrr? .lottrttul rtl Ntrr.sittl., Atltttitti.slrtttiorr, Novcrnbcr/l)cctrrrlrer l9fll, //(ll lrrrcl l2), 17 23. PAIIVI12. Serrrrt.jcrrs, A.D. lltrrrr<)ut in nlusing,: Wlrut it is urrcl lrcrw to pl-cvcrrt it. Nrrrsirrg Adtnirtislraliott Quurterly, Fall 19U2, 7(l), 12-19.ll. l,cvirrson,H.Asinineattitudestowardmotivation.HarvardBusittessReviaw, .l anuerry/February 197 3, 5 I (10), 7 O-7 6.l-1. l.cvirrson, H. What nursing administrators say about RIMs ernd DRGs. Anrarican Joumal of Nursing, October 1983, 83(10), 1466-1467 , 1484. Moving Beyond15. (ioldon, G.K. M<ltivating staff: a look at assumptions. Journal of Nursing Arlrrt inistration, November 1982, I 2(ll), 27-28.16. Kcplcr, T.L. Mastering the people skilIs. Journal of Nursing Administration, Novcmbcr 1980, 1 0(ll), 15-20. the Ordinary17. .loincr, C., Johnson, V., Chapman, J.8., and Corkrean, M. The motivating 1r<rtcntial in nursing specialties.Journalof NursingAdministration, February 1982, t2(2),26-30.lil. Ilackrran,J.R.andOldham,G.R.Devel<lpmentofthejobdiagnosticsurvey. .lountal ofApplied Psychology, April 1975, 60(2), 159-170.19. .lohnston, S. The use of the Rines model in differentiating professional and t cch n ical practice. N urs ing and H ealth C are, September I 982, 3(7 ), 37 4-37 9 .20. Clark, M.D. Performance appraisal. Nursing Management, October 1982, /.1(r0),27-29.2 I . Courrcil, J.D. and Plachy, R.J. Performance appraisal is not enough.Iournal ol N ursing Administratiorz, October 1980, 10(10), 20-26.I]IBLIOGRAPHYll.incs, A.R. Dcvelopment <lf objectives: program level/course and unit, in Prep- urutiort of-Associate Degree Graduates. New York: National League for Nursing, 1977.
  • Iterlirrrrra rrcc |tln lrlri ng silitirlitttt lool, , ,ttt lrtovttlr ;t ltitttttwrlt li llt ttttlrsttt ittg ltt,tlttt livilV.Orgarrizlrtiorral lrrrtttirttisrtr ((,n((rlrs lrrrrnurr irrlclt:st, vullrcs, itrrcl tlrc Jtllt srrlisl:rr lr{)n.ur(l,r trr,rlrv;rling tnvitottttttttl irrtlirclors lltirt totrllilt-dignity ol hltttti.ttt [rcirrgs.lltr.lrrtrtrirrrist lrclicvcs thart hurnans:-uc c()nt- tltc l() ptorlttt livtlv. ltt lot tturnte pllrrrrilrg is irn in)l)()t liutl tnrrgizirrgplex, harvc shilting ncccls, lrrcl stlivc lirr pclllction. Accolclir-rg to Clerrk arplrroaclr irr clcalirrg witlr low productivity.(20), power should bc cxcrciscd tlrr-ourgh ct-rllaboratit-rn and rcason rathcrthan imposed by coercion ancl lcar. Pcrformancc appraisal processescan be constructive means for humanistic staff dcvclopment. Quality STUDY QUESTIONSperformance evaluation of staff is done for, not to, staff. Discontent and restlessness will soon develop in a person unless the 1. Define productivity and discuss the factors that influence it in nursing.individual is doing what he or she individually is fitted for. This Mas- 2. Describe the symptoms of low productivity.lovian guide for management is the basis of performance planning ap- 3. Explain resistance to productivity measures and the rationale forpraisal. Performance planning, with follow-up appraisal, is a cooperative them.venture between the nursing administrator and the employee based on 4. What can be done about nonnursing tasks?a genuine concern for each others success (21). Properly used, the systemcncourages employee parlicipation and goal achievement. 5. What recent developments have provided the major impetus to measure and increase nursing productivity? Performance planning is a way of enhancing communication betweenthe nursing administrator and the employee. Praise and helpful criticism 6. Describe the factors that influence motivation and describe how mo-can become a regularly scheduled part of evaluation meetings. Such tivation theories can be used to increase motivation.meetings can also serve as valuable opportunities for the nursing ad- 7. Discuss the implications of differentiating the roles and performanceministrator to learn more about employees, to assess how they have of professional and technical nurses. Is this important?changed, improved, or corrected their performance. It is also an op- 8. Name some productivity measurement tools useful lor nurses in im-portunity to cooperatively plan future direction and encourage individ- plementing DRGs and discuss their application.ual growth. Individual employees differ in growth needs; astute nurseadministrators recognize those individuals early on who have a desireto move forward. It is easier to fan a glowing flame of interest than totry to find a cinder in the ashes of discontent. REFERENCES Any type of performance improvement system is meaningless unlessthe nurse administrator has a sincere commitment to the constructive l. Bennett, A.C. Productivity and the Quality of Work Life in Hospitals. Chicago:use of such a system. Management by objectives can be a meaningless American Hospital Association, 1983.paper exercise if it generates nonachievable objectives that are demor- 2. Rosten, L. Passions and Prejudices. New York: McGraw-Hill, 1978.alizing and inhumane. On the other hand, realistic objectives can be 3. Skinner, W. Big hat, no cattle: managing human resources, part 1. Jountalthe focus of the well-motivated, creative energies of nursing staff and of Nursing Administration, July/August 1982, 12(7 and 8),27-29.middle managers. Quality performance appraisal can contribute to a 4. Glaser, E.M. Productivity Gains ThroughWorklife Improvemenls. New York:productive environment. Harcourt Brace Jovanovich, 1976. 5. Hanson, R.L. Managing human resources. Joumal of Nursing Administration, December 1982 , I 2(12) , 17 -23 . 6. Grant, S.E., Bellinger, A.D., and Sweda, B.L. Measuring productivity rhroughSUMMARY patient classification. Nursing Administration Quarterly, Spring 1982, 6(3), 77-83.Although productivity has not often been a concern of nursing, the cur- 7. Easley, C. and Storfjell, J. Easley-Storljell Instruments forWorkload Analysis.rent emphasis on cost containment has given it high priority for nursing Ann Arbor, Mi.: University ol Michigan, 1979.administrators. Because nurse administrators have not necessarily had 8. Henninger, D. and Dailey, C. Mcasr-rr-ing nursing workload in an outpatientcontrol of nursing resources, both they and individual nurses have had department. Jounteilof.NursitrllAdtrrirtislreilion, September 1983, 13(9),20- 23.little incentive to control costs and increase productivity. Productivity is delincd quantitarively and qualitatively. Patient clas- 9. Grimaldi,P.L.andMichclctti,.l .A. l{lMs:rnd thecostof nursingcare. Nursing Management, Deccmbcl 1982, / l( l2), 12-22. L
  • lltt: r,vrtli,l tttttsittl,:(lvl(( l:,;t(I(,rrr;,lisltrtl lltrotrplt llltltttttrlrtt tlt lltt:rtrst lltr ,rt, lr,rllr ttttltrtt l;tttl lo llttrqrr;tllll ol ;r;tlitttl t:ttt;llltl ttttl:,t:" lrc1t. As rttttsts nr()v(ul) llrt:rrlntittrslt:tli,,,tllrtltltr, llrtrtis ltss lt..tl worli lirrt., li;ulrrrtlo rrltltztPtoltssiott:tl ttttts.s:r((()l(ltlrli lo tlrtir ttl to function at tlrtltclrrrictrl lrr,r1, lrrrl llttlt(ltllittistlill()l llltlsl ltcv(ll()s( rrtirtiorr irrrtl rr;tttlt:trs llrtlilst g,ltltl tvil irr llrtlrt;rlllr tltttrvotl,l. sighl ol thc tccIrrical clcrrrirrrtls tlrrrl rrrtrsl [tc ttte t. (]tttlcltt tltttsittg ptlrt l.)xpt.t tirrp ltxr rrrrrrlr ol ltt lrrritltllv pttpittttl utrrs(s is lltt stt otttl 1.rt:rltsl tiJe is highly tcchnical, in kccpirrg lvitlr rrroclclrt tillcs. Altlror-rgh tlre Irrnlaclv.llrtrtisrrorrrrrsing,sltotlirgtlotlrtv,.itrsl lrslrot l:rp,titrottt Iltittlt human body hr,s not changcd, thc nntur-c o{ trczttmcnts hlts chltngccl as ing arbotrt rrl ilizlrl iott ol Itttt sirll,!, tcs()ttl((s. socicty has bccomc increasingly computcrized alld mcch3ni7.ccl. Jqhnston (19) slatrs llrat tlrcrc is a gtcirl rtttrl to clurilv llrtrlilltr Joincr (17) suggests fhat job enrichmcnt can incrcasc thc p6tcntial cntiation bctwccn tcclrnicarl arncl pt.<-rlcssir-rttal tttusirtg tolts. ( it ltrltrlrlr:- for work sarisfaction and hclp administrators attracl and kccp a high- of two-, three-, [our-, ztncl {ivc-ycar nut-sirtg pl()gtltllts itll:rtttlilrilrltlor quality nursing staff. Although job cnrichment can be viewcd as part the same licensc. Nursing administrirtors lrirc tltcrt.t to clo tlttsittttt tvot l, of th"-".r".gizing function, it must be remembered that not all nurscs at the same starting salary. Using tl-rc Rincs n-roclcl, Joltttslotr ltslrrl llr. want enriched jobs: jobs that are high in skill varicty, task idcntity, task hypothesis that nurses differ in thcir usc of the nursing l)r1)((ss lrt t ot rltttl, significance, aulonomy, and feedback. At differcnt timcs and in diffcrent to their educational.preparation. The dcgrcc and nonclcglc( Illllsts (lil ycars, indiviclual nurses vary in growlh needs and in their intcrcst in fered in several categories. The major implications cll tlrtsltttlv rv,t, their jobs. that: Haikman and Oldham (18) havc idcntilied fivc corc job dimcnsions that could contribute to job satisfaction in nursing. These are useful for l. Unnecessary duplication of effort exists bctween thc two litottps ,rl the nursing administrator in identifying jobs that havc low motivating nurses. potcnlial: 2. The team nursing assignment pattern lends itself to tllc ttstol lrrt.. calaureate nurses as team leaders. l. Skill varietv: to which job challenges the individual tl-re dcgree 3. Primary nursing patterns could utilize the baccalaureattc tlllts( its 2. Task identity: the degree to which thc task provides for the completion the primary nurse and A.D.s and diploma nurses as ass<-rciittcs. of a job 3. Task significance: the degree to which the job has an impact on the lives of othcrs Nursings Contribution 4. Autonomy: thc degree to which the iob gives the nurse freedom to Budgets of health care agencies are based on projected revenucs lrclrrr, ac1 independently and usc personal discrction for example, the numbcr of patient days, the number of procedurcs, itrtcl 5. Feedback: the dcgree to which the job providcs the nurse with in- the number of home visits. Nursing contributes to these projectcd lcv- formation on iob performance. enues because it contributes to the accomplishment of these objcctivcs. If there are not enough nursing staff for a hospital or unit, paticnts To energize oncs staff is to know what those employees do, not to be cannot be admitted. If, on the other hand, the projected number o{pa- expcrt in their jobs, but to know a1d understand their work. The ad- tients is not admitted, not as many nurses are needed. Determining ancl ministrator should walk around the health care setting and stop and implementing ways of balancing thcsc factors are part of the productivity observe what individual nurscs are doing. This praclice conveys to the effort. employee not only that he or she has worth as an individual but also Other factors also contribute to a productive health care environmcnt. that the particular job or position has worth. Recognition of the human For example, nurses nccd lo contributc to such patient care decisions, element is o[ utmost importance in energizing thc division o[ nursing as those to transfer paticnts into and out of intensive care units, to assign staff. special duty nurscs, ancl to aclrnit ernd discharge patents. Although most I decisions arc not control lccl by nurscs, nurses must be involved in thosc Technical and Professional Roles dccisions that affcct thc r-rtilization of nursing resources. Without thisii involvement, objcctivc pnrrlrrtlivity nrcasures may not be valid. Oftcn, Does it matter whethcr technical and professional rolcs arc clarilicd?i health care administrutors nrirkc clccisions based solely on fiscal datzri, Yes it docs matter, not because one role is better than the other, but and arc not awarc of tlrcir irrrpact on nursing productivity.rllll i I(.-