management style: impact on care quality and use of …

MANAGEMENT STYLE:IMPACT ON CARE QUALITYAND USE OF RESTRAINTS

VARIABLES AFFECTING USE OF RESTRAINTS

WHAT ISMANAGEMENT STYLE

� Characteristic way of

� Making decisions

� Relating to subordinates

� Styles depend on prevailing circumstances

� Styles depend on subyacent theories on human behaviour (X & Y Theory)

� Styles depend on subyacent theories on organizations (CAS vs. Proffesional Bureaucracy)

Tannenbaum 1958, Schmitdt 1973, McGregor 1957, Anderson & McDaniel 2000

Relations

hip

oriented

lead.

MGMT. STYLE MODELS

MODELO LIDERAZGO BONOMA-SLEVIN

� Consensus Manager (0, 100): estilo directivo basado enteramente en el consenso. Exponen el problema al grupo y animan a que este tome la decisión importante

� Shareholder Manager (0,0): Estilo directivo pobre. Poca o ninguna información es intercambiada con el grupo. El grupo tiene la autoridad final para tomar la decisión.

� Consultive Autocrat

(100,100): Estilo que solicita mucha información al grupo, pero deja todas las decisiones importantes para sí.

� Autocrat (100,0): Piden poca o ninguna opinión del grupo y toma decisiones solo

Teoría X Teoría Y

Persona típica disgusta trabajar y lo evitará

en lo posible

El trabajo es tan natural como el juego o el

descanso

Persona típica evita responsabilidad, poca

ambición, busca seguridad

Las personas por sí mismas no son perezosas.

Llegan a tener ese hábito a través de la

experiencia

La mayoría de personas deben ser

presionadas, controladas y amenazadas con

castigos para hacerlas trabajar

Ejercitará autodirección y autocontrol para

objetivos compromisos

Hay potencial. En condiciones favorables

acepta y busca responsabilidades. Tienen

imaginación, ingenio y creatividad que

pueden aplicarse al trabajo

Papel gerencial: reprimir y controlar Papel gerencial: desarrollar el potencial y

dirigirlo hacia objetivos comunes

McGregor 1957

Underlying theories for human management style

SELF ORGANIZATIONOF COMPLEX ADAPTIVE SYSTEMS

(CAS)

In Physics

� Prigogine, Nobel Prize

1977

� Complex Quantum

Systems 1997

� Irreversible

thermodynamics

In Biology, Human Society, Cybernetics� Capra 1996

� Pareto 1906

� McCulloch 1952-1968

NURSING HOMES ARE COMPLEX ADAPTIVE

SYSTEMS

� Spontaneously self-organizing (whether

recognized or not)

� System parameters alter conditions of self-

organization from which effective behaviors

emerge

� Managers can influence system parameters to

facilitate better outcomes

� Certain mgnt practices work better than others

CAS APPLIED TO MANAGEMENT THEORY

Complex

Adaptive System

� Adaptive capacity to

perturbation

� Homeostasis

� Self-similar

� Non-linear (small causes can have large results)

Multi-agent

System

� System composed of

multiple interacting agents

SYSTEM PARAMETERS OF COMPLEXITY SCIENCE FOR ORGS. & MANAGEMENT

1. Information Flow

2. Connectivity

3. Cognitive Diversity

4. Participation in decision making

5. Formalization

SYSTEM PARAMETER: CONNECTIVITY

High performing NH

� We help each other out

� We are part of decision

making

Low performingn NH

� I don’t bring up issues

unless it harms a resident

� You pay a price if you say

sthg. to Nursing

Mission is

value based

Mgmt is seen

as helping

out on the

floor

Involve

frontline

staff in

planning &

problem

solving

Forbes-Thompson 2007

SYSTEM PARAMETER: INFORMATION FLOW

High performing NH

� Multiple methods of

formal and informal

communication

� Everyone has a say

Low performingn NH

� Formal communication

methods unused

� Little to no informal

� Why don’t they ask us, we

are the ones with the

resident

Multiple

methods of

formal comm

Recognize

and work

with patterns

of informal

decision

making

Transparent

decision

making

Open to

ideas

SYSTEM PARAMETER: COGNITIVE DIVERSITY

High performing NH

� All disciplines involved in

planning

� Family and community

involved in home’s life

Low performingn NH

� Top down decisions

� Problem solving in isolation

� If you offer your opinion, it

doesn’t help

Elicit diverse

opinions and

ideas

Involve all

disciplines

Acceptance

of diversity

Try diverse

ideas

Forbes-Thompson 2007

MGMT STYLES: UNDERLYING THEORIESPEOPLE AND ORGANIZATIONS

POWER STYLES & RESTRAINTS

Manager

Employee Employee Employee

Manager Manager

Autocratic Laissez-faireParticipation

Leader Whole group EmployeesDavis & Newstrom 1991

POWER STYLES & RESTRAINTS

Employee

Manager

Laissez-faire

Employees

Lai, IAG 2005: Low intensity interventions ≠ significant

restraints reduction.

Bourbonniere 2003: Weekend = + Restraints

Huizing 2007: Autonomy in Nurses’ decision making =

+Restraints

Huizing 2006a and 2006b: Low intensity interventions ≠

significant restraints reduction

Olazarán 2010: Metaanalysis: significant reduction with low

intensity interventions, but far from optimum

POWER STYLES & +RESTRAINTS

Employee

Manager

Laissez-faire

Employees

Empowerment of Nurse Aides = + Restraints?

POWER STYLES & +RESTRAINTS

Employee

Manager

Laissez-faire

Employees

Empowerment of Nurse Aides = + Restraints?

Asking direct care staff

to reduce use of restraints

is Management passing on a

hot potato

Lack of Mgnt restraint prohibition

or restraint policy

= lack of commitment

In case of injurious accidental fall:

Who will be to blame?

POWER STYLES & -RESTRAINTS

Manager

Employee

Autocratic

LeaderDavis & Newstrom 1991

Outlawed: Denmark, Japan, some US States

Lai 2005: Management support is crucial, probably more

crucial than staff education

Gulpers, … Capezuti, 2010: EXBELT study (management prohibition)

POWER STYLES &- RESTRAINTS

Employee

Manager

Participation

Whole groupAnderson, Issel and McDaniel 2003

N= 152 nursing homes (Texas)

+ RN participation in decision making = - BPSD

+ level of communication openness = - use of restraints

+ relationship oriented leadership & - formalization = - complications of immobility

STYLES & USE OF RESTRAINTS

DIFFICULTIES AT IMPLEMENTING OPEN-PARTICIPTIVE MGNT STYLES

STRUCTURAL DIFFICULTIES

� Highly regulated industry -> Rules = thinking

unnecessary

� Nurse Aides = low or undertrained

� Management chain untrained in human

management

� Supervisors’ unrecognized importance

� No legal Change-of-Shift overlap

MGMT STYLES: UNDERLYING THEORIES

RESTRAINTS MANAGEMENT CHAIN

SUPERVISORS = KEY ROLE

ALLEGIANCESHINDER CLASSIC MANAGEABILITY

Ashmos 1998

OTHER EFFECTS OF CAS MANAGEMENT

Anderson & McDaniel 1999

PARTICIPATION =

+ QUALITY- COSTS

100500

100

50

0

ROTACIÓN AUXILIARES EN FUNCIÓN AL TIPO DE

LIDERAZGO DE DIRECTORES

Baja Rotación Auxiliares Alta Rotación Auxiliares

ConsultativeAutocrat

AutocratShareholder

ConsensusManager

Donoghue 2009

FACTORES EN AUXILIARES

Rotación

� Falta de respeto

� Dirección inadecuada

� Conflicto laboral o familiar

� Dificultad del trabajo

� Bajas sin cubrir

Retención

� Vocación

� Defensa de paciente

� Relación con residente

� Religión o espiritualidad

� Santuario ante problemas en casa

� Flexibilidad

7 FG, N: 47 Mikas 2009

ESTUDIO CUIDADORES RESIDENCIAS ALBACETE, N=258, 4 MODELOS GESTIÓN

López-Escribano 2009Obsérvese dispersión y valor mínimo = 0

LEADERSHIPEVOLUTION TO QUALITY

CARE

MGNT FUNCTION:

CONCLUSIONS MGT STYLES & RESTRAINTS

� Legal & Managerial restraint prohibition

� Companies defend employees if injurious falls

� Daily 30 min Change-of-Shift overlap = legal requirement to boost participation

� Train Management ladder in CAS

� - restraints

� - costs

� + quality

� Thank you

Value Mgt

Medio-bajo

RN PARTICIPATION IN ORGANIZATIONAL DECISION MAKING AND IMPROVEMENTS IN

RESIDENT OUTCOMES

Anderson, Isel 2003

Testable theoretical model depicting the relationships between nursing management practices and resident outcomes

while controlling for organizational and director of nursing characteristics.

From:Nurs Res. Author manuscript; available in PMC 2007 September 25.

Published in final edited form as:

Nurs Res. 2003; 52(1): 12–21.

MODELO LIDERAZGO BONOMA-SLEVIN

� Consensus Manager (0, 100): estilo directivo basado enteramente en el consenso. Exponen el problema al grupo y animan a que este tome la decisión importante

� Shareholder Manager (0,0): Estilo directivo pobre. Poca o ninguna información es intercambiada con el grupo. El grupo tiene la autoridad final para tomar la decisión.

� Consultive Autocrat

(100,100): Estilo que solicita mucha información al grupo, pero deja todas las decisiones importantes para sí.

� Autocrat (100,0): Piden poca o ninguna opinión del grupo y toma decisiones solo

BURNS 1978, BASS 1998, 2000

Liderazgo transformacional

� Carisma: provee visión y sentido de misión, instila orgullo, granjea respeto y confianza

� Inspiración: Comunica expectativas altas, usa símbolos para centrar esfuerzos, expresa propósitos importantes de forma sencilla

� Estímulo intelectual: Promueve IQ, racionalidad y solución cuidadosa de problemas

� Consideraciones individualizadas: Presta atención personal, trata a cada empleado de forma individual, entrena, asesora

Liderazgo transaccional

� Recompensa condicionada: pacta intercambio de recompensas a cambio de esfuerzo, promete recompensas por buen rendimiento, reconoce logros

� Gestión por excepción (activa):pendiente de desviaciones de normas y estándares, toma acción correctiva

� Gestión por excepción (pasiva): Interviene solo si no se cumplen estándares

MODELO LIDERAZGO BONOMA-SLEVINConsensus

Manager

Consultive

Autocrat

Shareholder Autocrat

50

10050

100

Inp

ut

de

in

form

aci

ón

de

l g

rup

o d

e s

ub

ord

ina

do

s

Gra

do

de

ap

ert

ura

a l

as

op

inio

ne

s d

e l

os

de

má

s

Grado en el que puede delegar la autoridad y decisiones

ESTUDIO ROTACIÓN NNHTS

1.333 Residencias, estratificadas representativamente USA, Castle 2007

Profesión Rotación

año

Directores: 53%

DUE 36%

LPN 37%

Auxs. 60%