Chapter 20

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 20Chapter 20
Application of Theory inApplication of Theory in
Nursing Administration andNursing Administration and
ManagementManagement

Organizational Design
• Work specialization
– Each step of the process performed by a different
individual
– Efficient in use of worker skills
– May lead to boredom and low productivity
• Chain of command
– Line of communication and authority
– Employees should be responsible to only one
supervisor.

Organizational Design—(cont.)
• Span of control
– Refers to the number of employees directed by a
manager
– In nursing, managers should have 6 to 50 direct
reports.
• Authority and responsibility
– Line authority—chain of command, superior–
subordinate relationship; direct line
– Staff authority—support and advise work of line
managers but don’t report to higher management

Organizational Design—(cont.)
• Centralization vs. decentralization
– How decision making is dispersed or diffused
throughout the organization
• Centralized decision making—Decisions are
made by a person or small group at the top of
the organizational structure.
• Decentralized decision making—Decisions are
made a lowest levels feasible.
• Departmentalization
– Subdivides the work of the organization
– Allows for specialization of work

Question
Tell whether the following statement is true or false:
In centralized decision making organizations, decisions are
made by a person or small group at the top of the
organizational structure.

Answer
True
Rationale: In organizations with centralized designs, most
decisions are made by the chief administrators or a small
group or board.

Shared Governance
• “A structural model through which nurses can express
and manage their own practice with a higher level of
professional autonomy” (Porter-O’Grady, 2003).
• In nursing, professional nurses use self-directed work
teams at the unit level to make professional practice
decisions and to accomplish the work of the unit.
• Decentralized organizational structure requires
participation of team members.

Shared Governance—(cont.)
• Models
– Councilor model—uses a coordinating council to
integrate decisions made by staff and managers in
subcommittees that report to coordinating council
– Administrative model—two tracks: managerial track
and clinical track; both tracks include managers and
staff.
– Congressional model—uses democratic process to
empower nurses to vote on issues

Shared Governance—(cont.)
• Implementation of shared governance can take time and
be expensive.
• Long-term savings can be seen.
• Can improve the work environment of nurses leading to
increased satisfaction and improved retention

Transformational Leadership
• Creates vision
• Provides framework for generating commitment to the
vision and establishing identity with the organization
• Develops and sustains organizational trust
• Attends to the self-esteem of those in the organization

Transformational Leadership—(cont.)
• Focus on relationships and develop personal skills
• Coordinate, integrate, and facilitate (rather than leading
and controlling)
• Try to build coalitions and networks to move toward a
shared vision or goal
• Focus on inspiring sense of commitment to the
organization
• Are perceived to have strong ethical and moral character
and are willing to take risks

Transformational Leader Strategies
• Know the people you work with.
• Help people learn and develop.
• Provide frequent feedback about performance.
• Award responsibility and status to coworkers.
• Reward coworkers for job well done.
• Make information available to all involved.

Patient Care Delivery Models
• Total patient care (functional nursing)
– Most patients are assigned to nurses; one nurse
attends to all of the patient’s needs during the shift.
– Patient care may be more efficient, and little
confusion about responsibilities.
– May use a hybrid model with RN and unlicensed
assistive personnel

Patient Care Delivery Models—(cont.)
• Team nursing
– Tries to reduce fragment care—RN is a team
leader. Team may include:
• Other professional or technical nurses and aide
• Team is responsible for care of a group of
patients.
– Team leader coordinates the group and assigns
specific care requirements.
– Duties that cannot be performed by team member
may be performed by team leader.
– Focuses on patients and their needs
– Requires considerable planning and coordination

• Primary nursing
– Assigns each patient a “primary/professional
nurse” who is responsible for planning and
providing care to a group of patients
– When the primary nurse is not on duty, another
RN would be responsible based on that care plan.
– Strong job satisfaction and improved continuity of
care
– Requires a number of RNs and high degree of
coordination

• Patient-centered care
– Principles of PCC derived from quality
improvement models.
– Goal is to decrease the number of health care
workers needed and increase the time nurses
spend with patients.
– Cost of care should decrease; quality of care
should increase.

• Patient-centered care—principles
– Patient redeployment
– Support services decentralization
– Worker cross-training
– Creation of interdisciplinary teams
– Patient involvement
– Task simplification

ANCC Magnet Recognition Program
• Originated as a result of a policy study by the AAN in
1983 to identify characteristics common among hospitals
that could successfully recruit and retain good RNs
• Characteristics were termed “Forces of Magnetism.”

ANCC Magnet Recognition Program—
(cont.)
• The Magnet Recognition Program was developed by the
ANCC to recognize health care organizations that provide
exemplary nursing care.
• Serves as a method to disseminate successful best
practices and strategies in nursing among institutions
• Magnet hospitals provide solutions to address nurse
recruitment and retention and improve nursing
leadership.

ANCC Magnet Recognition Program—
(cont.)
• Magnet recognition program is based on quality
indicators and standards of nursing practice.
• Magnet model components
– Transformational leadership
– Structural empowerment
– Exemplary professional nursing practice
– New knowledge, innovations, and improvements
– Empirical quality results

Case Management
• Case management is “a collaborative process that
assesses, plans, implements, coordinates, monitors, and
evaluates options and services to meet an individual’s
health needs through communication and available
resources to promote quality cost-effective outcomes”
(CMSA, 202).

Case Management—(cont.)
• Case management is a role developed in the 1980s in
response to the PPS and DRGs.
• It is an expansion of the total patient care system and
was originally community based.
• Case managers serve as the liaison between patients
and families, health plans, care providers, and
purchasers to determine the extent of coverage and
coordinate treatments.

• Impenitent case management—models
– New England Medical Center Model—focuses on
managing patient care to control resources
– St. Mary’s (or Carondelet) Model—Case manager is
used to control costs associate with patient stays and
reducing length of stay with optimal patient
outcomes.

• Typically, cases managers are assigned to groups of
high-risk patients within a specific population (e.g.,
pediatric oncology, adult transplant).
• Case manager coordinates care from preadmission and
often beyond discharge.
• Case managers may be employed by hospitals, HMOs,
insurance companies, and disease management
companies.

Disease Management
• Disease management is “a patient care approach that
emphasizes comprehensive, coordinated care along a
disease continuum and across health care delivery
systems.”
• It is proactive approach to providing health care services.

Disease Management—(cont.)
• Evidence-based method to identify individuals with
chronic illnesses who are at high risk of experiencing
serious health problems and to provide early
intervention to avoid or minimize these problems
• Typical diagnoses/candidates for DM
– AIDS
– CHF
– Some cancers
– Diabetes

Question
Which of these cases would be most appropriate for
disease management?
A.A 7-year-old male with asthma
B.A 35-year-old male with AIDS
C.A 62-year-old female with an acute MI
D.An 86-year-old female with a hip fracture

Answer
B. A 35-year-old male with AIDS
Rationale: Although all of the individuals might benefit from
DM services, disease management is most for those
individuals who are at very high risk for experiencing
serious health exacerbations but promoting
comprehensive, coordinated care across health care
systems.

Quality Management
• Key principles focus on:
– Customer: Quality is defined in terms of what is
acceptable to the customer.
– Process improvement: efforts/steps taken to
examine and improve work processes
– Variance analysis: monitoring and analysis of
variations to routine systems and processes
– Scientific methods are used to statistically review
variance and determine type of variation.

Quality Management—(cont.)
• Key principles focus on—(cont.)
– Leadership: understanding of concepts and
techniques of quality improvement and promoting
involvement of all personnel
– Employee involvement: All members of the
organization should be educated related to QM.
– Benchmarking: organized, planned methods and
processes to identify, adapt, and disseminate best
practices

Evidence-Based Practice (EBP)
• EBP—problem-solving approach that enables clinicians to
provide highest quality care through:
– Critical appraisal and critique of the most recent and
relevant research
– Consideration of clinician’s clinical expertise
– Consideration of patient preferences and values
• To implement EBP in an institution, there must be
support and commitment for administrators

Question
Which of the following is NOT a key principle of Quality
Management?
A.Analysis of variations to routine processes
B.Attention to process improvement
C.Provider-defined quality
D.Use of organized methods and processes to disseminate
best practices

Answer
C. Provider-defined quality
Rationale: In quality management models, quality is
defined by the customer.

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