part 3

PATIIII

Currentand ErnergingChallenges

Developing l{urnanPoterrtial

1.

2.3.

4.5.6.t.

The purpose of this chapter is to examine the concept of humanpotential and to present methodologies for creating an organiza-

iional climate in which that human potential can develop. On

completion of this chapter, the reader will be able to:

Define human Potential.Discuss the power of education in terms of human potential'Describe three motivational factors influencing human be-

havior.Differentiate between human beings and humans becoming'Describe behavioral change within the context of development'Differentiate between leaders and followers.Match management practices with growth needs as definedby Maslow.

)rlowhere in the world of nursing is it more possible to influence thegrowth and development of other nurses than in nursing administration'ihe nursing administrator creates an environment in which professional

practice can flourish or deteriorate. This chapter focuses on human po-

iential as an important concept in nursing administration. Inner-directedindividuals who are highly self-motivated will produce the answers tothe problems of productivity and dissatisfaction within nursing staff.

HUMAN POTENTIAL AND THE POWER OF EDUCATION

Nurses today want to be recognized as professionals. They want to be

recognized for their contributions to patient care, and they want theright to control their professional practice within the limits of the law.Unquestionably, these rights always involve maximizing human poten-

tial. Human potential means all of one's potentialities: knowledge, tal-ents, capacities, creativity, wisdom, character, and genetic makeup'

l07

108 cunnpxr nNl EMERGTNG cHALLE\GES

The acquisition of technical skill alone does not provide the necessarybase for the independent thinkin-s and action essential in today's nursingpractice. Men and women har,e a great deal of unrealized potential, andhelping staff discover that potentiai can be one of the most exhilaratingexperiences for the nursing administrator.

The identification of needs for -ero.nvth, development, and utilizationof potential is an important part of Maslow's self-actualization. Thisconcept was introduced in Chapter 4, "The Person in the Role of NursingAdministrator." The fully functioning administrator encourages the de-velopment of human potential in self, peers, and subordinates. Optimalbiopsychosocial functioning, so carefully nurtured in patients, needs alsoto be nurtured in oneself and one's fellow workers.

Howard McClusky (1) had a passionate belief in the power of educationto improve the condition of people's lives and to liberate them from themeanness of intolerance and self-interest. Lifelong learning and the ful-fillment of growth needs are indeed powerful tools in enhancing humanpotential. Lifelong learning can hclp individuals become the personsthey are best able to become. In most people, there is a large domainof unexpressed and underexpressed talent that could be developedthrough educative means.

McClusky (l) further theorized that failure to internalize the learnerrole as a central feature of the self is a major restraint in the adult'sachievement of his or her potential. Studying, learning, and intellectualadventure must become part of one's life in both work and social en-vironments.

Striving to learn about employees and matching them with educa-tional and work experiences can be one of the nursing administrator'smost stimulating and rewarding challenges. Because the power of ed-ucation lies both in learning and in teaching abilities, the administratorneeds to be a learner as well as a teacher. Satisfaction with work andassumption of responsibility for professional behavior flourish in an en-vironment that fosters maximizing human potential through continuedlearning.

CHANGING BEHAVIOR

The role of the nursing administrator as a teacher has been largely un-recognized. In fact, in their efforts to stay away from educational roles,many administrators may lose sight of the fact that most education oc-curs in noncredit or nonformal learning environments. Achieving one'smaximum potential involves learning new behaviors. Many adminis-trators spend a great deal of time teaching others how to perform as-signed tasks rather than delegating the responsibility for those tasks.How much better it would be to teach individuals how to approach

tasks socreativit5siened taministrattorr,,ard tland thus

Pritcha:eacher iriundamer:nspires, r

lrocess, als also to:ential ofsame basiand evalu

Nursinnentors.'roles, nurperiencesthc countquently, c

administrdirectionrvill allor,r

MOTIVI

!lotivatiotivates orHerzberg'gories: hyThe hygie

1. Comp

2. Super

3. Relat4. Work5. Salar6. Relat7. Perso

8. Relat9. Statu

10. Secur

.ecessaryi nursingLtial, andilarating

.ilizationion. ThisNursing

rs the de-Optimaleeds also

:ducationfrom thed the ful-g human) persons: domaineveloped

e learnerre adult'stellectual;ocial en-

lh educa-istrator'suer of ed-inistratorwork andin an en-

:ontinued

rgely un-nal rclles,:ation oc-'ing one'sadminis-rform as-rse tasks.epproach

DEVELOPING HUMAN POTENTIAL 109

tasks so that they can grow and develop while unleashing their owncreativity in resolving problems that contribute to the need for the as-

signed tasks. Understanding the logic and rationale behind various ad-ministrative strategies encourages the learner to have positive feelingstoward the ongoing project; as a result, the learner is less likely to resentand thus negatively influence change.

Pritchard (2) suggests that the individual who has been a successfulteacher in nursing can also be successful in administration. The samefundamental principles apply to both areas. Administrative leadershipinspires, encourages innovations, assists the nurse in the self-actualizingprocess, and promotes and facilitates excellent nursing practice. To teachis also to inspire, to encourage creative effort, and to foster the full po-tential of the individual. Both teaching and administration require thesame basic principles for implementation: planning, organizing, leading,and evaluating.

Nursing administrators may perceive themselves as preceptors ormentors. These roles are in essence teaching-learning roles. Within these

roles, nursing administrators can open new doors to the intellectual ex-periences that favor creativity and productivity. Staff nurses throughoutthe country have become increasingly critical of administration. Fre-quently, one criticizes and belittles what one does not understand. Oneadministrative imperative is to plan to change behavior in the desireddirection while recognizing the need to maximize staff potential thatwill allow everyone to move forward together.

MOTIVATION

Motivation is an internal force that incites a person to action; what mo-tivates one person will not necessarily excite another. According toHerzberg's (3) research, rewards can be listed under two broad cate-gories: hygienes, or extrinsic factors, and motivators, or intrinsic factors.The hygienes include:

1. Company policy and administration.2. Supervision.3. Relationships with supervision.4. Work conditions.5. Salary.6. Relationship with peers.

7. Personal life.8. Relationships with subordinates.9. Status.

10. Security.

110 CURRENT AND EMERGING CH-{L LE\rl9

The motivators include:

l. Achievement.2. Recognition.3. Work itself.4. Responsibility.5. Advancement.6. Growth.

If managers want to develop a highly motivated staff, says Herzberg,they should focus on the true initiators of action: the motivators, orintrinsic factors. These intrinsic factors are in keeping with the humanneed theory of Abraham Maslow (4), which postulates that humans havethe need to gror.v and develop beyond basic coping needs. A satisfiedneed does not motivate. If all basic and safety needs are met, one canmove on to meeting belonging needs and so on up the ladder. Self-ac-tualization needs are never fully mct, and by definition, self-actualizationis a self-perpetuating, ongoing, and never finished process.

The work of David McClelland (5) must also be recognized as an im-portant landmark in the field of motivation. He states that, to one degreeor another, there are three basic human needs in all individuals:

' Achievement: the need to excel, to achieve in relation to a set of stan-dards, to strive, to succeed

' Power: the need to make others behave in a way they would not havebehaved othcrwise

' Affiliation: the desire for friendly and close relationship

The nursing administrator needs to rccognize which needs are dom-inant in employees. In order to determine which needs are present, sev-eral approaches may be used. One tool is a questionnaire that incor-porates questions about employee bcnefits, clinical career ladders, andpromotion opportunities. Anothcr approach could be part of the annualobjective-setting process. Employees could be asked to write objectivesrelated to goals they wanl to achicve in the coming year. Some of theseobjectives should be directed toward the employee's professional growth,for example, completing a B.S.N. in order to be eligible for promotion.

While some individuals are motivaled by the need to excrcise power,others arc motivated by the need to achieve. The nursing administrator'schallenge is to find avenues for these needs to be met. There is also astrong need in slaff nurses for affiliation. Some observers suggest thismotivation as the major reason why many more young women thenmen enler nursing.

Expectancy theory suggests that the strength of a tendency to action

-n a cerlact willformanr,, ariableis deterrmerit iniion thalinkagerhe effor

Expecrors. Th,can be

'

:lersonaconsiders]'stemsone cho<

adminisDeci's

tivator.as inforrpeople r

overstincompeteThe skilerstimu

Oversprojectschangcssame tirguilty iI

Underor of ri1fortableof heav'Iation bample,lin order

Havirat a balthe amcaccomp.tools as

Anotfclassic r

classic <

{erzberg,/ators, orre humanrans havesatisfied

, one can'. Self-ac-ralization

as an im-ne degreeals:

:t of stan-

not have

are dom-senl, sev-rat incor-ders, andre annualrbjectivese of theserl growth,'omotion.se power,ristrator'sis also a

;ges1 thisnen then

to action


in a certain way is dependent on the strength of an expectation that an

act will be followed by an attractive outcome (6,7). Attractiveness, per-

formance-reward linkage, and effort-performing linkage are the keyvariables in this approach to developing human potential. Attractivenessis determined by what one would like to have, such as a promotion ormerit increase. Performance-reward Iinkage is the individual's percep-tion that certain actions will lead to a desired reward. Effort-performinglinkage is the perception that a desired reward, such as a raise, is worththe effort to achieve.

Expectancy theory also presupposes the importance of intrinsic fac-

tors. The theory holds that workers attempt to complete jobs they knowcan be accomplished and expend energy on those that will result inpersonal benefit. However, in the world of nursing, employees may notconsider many activities, such as care plans and patient classificationsystems, to be meaningful activities; thus, the question arises as to howone chooses meaningful activities that also meet the goals of the nursingadministrator to provide excellent nursing care.

Deci's theory (S) highlights the concept of competence as a strong mo-tivator. Elaborating on Herzberg's work, Deci describes intrinsic motivesas informing those activities for which there is no apparent reward. Mostpeople will actively look for stimulation in their work. When there is

overstimulation, the individual withdraws and seeks another area ofcompetence. Understimulation results in less than minimal competency.The skillful administrator seeks an environment balanced between ov-

erstimulation and understimulation.Overstimulation can result from the occurrence of numerous clinical

projects and changes at one time. Because staff need time to incorporatechanges into their functioning, three or four changes attempted at thesame time may result in very little lasting change. Also, staff may feel

guilty if they neglect their usual tasks for innovative endeavors.Understimulation can be the result of an environment of no changes

or of rigidity. At times, staff require a period of time to become com-fortable with changes, but this must not continue idenfitely. A situationof heavy work loads and understaffing can also result in understimu-lation because staff are forced to give up the challenging tasks-for ex-ample, patient teaching, patient care conferences, and committee work-in order to meet minimal patient needs.

Having staff involved in setting objectives can contribute to arrivingat a balanced environment. However, staff may tend to overestimatethe amount of work and underestimate the amount of time required toaccomplish objectives. Trial and elTor are sometimes important learningtools as a group of staff struggle to put a new clinical concept into place.

Another useful concept in developing human potential is found in theclassic work in operant conditioning conducted by B.F. Skinner (9). Theclassic operant conditioning process is portrayed as:

tt2 CURRENT AND EMERGING CHALLENGES

Stimulus -------) response --------) consequences -------J future responseto stimulation

Skinner's theory focuses on four variables: positive reinforcement, ex-tinction, punishment, and avoidance learning. This theory providesguidelines for rewarding desirable behavior and for punishment as anegative reinforcer designed to stop negative behavior. The principlesof reinforcement theory can be used to modify behavior in a desireddirection. For example, consider the case of a nursing administratorwho wants to have the staff conduct group patient teaching sessions butnone of the staff has enough confidence to volunteer. In such a situation,staff could be reinforced for learning and practicing skills that wouldlead to conducting group sessions.

Worker motivation appears to be a key factor influencing productivityand quality of employee performance. Gordon (10) takes issue with mo-tivation theorists who stress the responsibility of leaders and managersto motivate followers or subordinates. Gordon maintains that peoplehave their own motives. The responsibility of the nursing administratoris to provide a motivating environment in which people can carry onthe work of the organization. A motivating environment is one that pro-vides opportunities for personnel to (1) express and satisfy their ownmotives and (2) contribute to the achievement of organizational goals.

A nonmotivating environment produces disillusionment, job dissat-isfaction, and role conflict. Role theory is structured on the observablefact that there are prescribed relationships and activities for specifiedroles; for example, a traffic police officer is expected to direct traffic,and a secretary is expected to type the boss's letters. There is littleagreement in our society as to the expectations for the role of a nurse.An ambiguous role, coupled with an abundance of diverse job descrip-tions, compounds the problem and interferes with the maximum de-velopment of potential.

Today's mobile, intelligent, aggressive, and talented nurses needleaders who can help them identify personai and professional goals. Theyneed administrators with enthusiasm, sensitivity, and creativity in pa-tient care and nursing administration; administrators who understandthe difficulties involved in simultaneously pleasing patients, physicians,and administrators. The nurse leader with such qualities seeks to createan environment in which professional nurses are motivated to practiceat their highest level (11).

DEVELOPMENTAL PSYCHOLOGY AND HUMANSBECOMING

Developmental stages occur over the life span. The concept of deveioping,as opposed to that of aging, implies a human becoming rather than a

human brof Carl R,

of these iIt is thatrather thicareer planot simpl

Contintrecogniticis an impmains intrvas almoan enorrnstudies hr

rvith adv:vision, mtimed tespation intinue to Isomethin

Develoya perspe(developnhood, offfor stagn(17) has c

scribingscriptionopmentaMcCluskl

Biologynot repreout in eitime is pt

ciety, carfor both r

mendousfull use o

Many r

ministralpart-tim<staff. A sk

a compolrience. Pcreate arsignmenl

response

ment, ex-provides

nent as aprinciplesa desired,inistratorssions butsituation,rat would

'oductivity: with mo-managersrat peoplerinistratorr carry on: that pro-their own,nal goals.ob dissat-rbservable" specified:ct traffic,:e is littlerf a nurse.b descrip-imum de-

rses need,oals. Theyrzity in pa-nderstandrhysicians,s to createo practice

,eveloping,rer than a

DEVELOPING HUMAN POTENTIAL 1 13

human being. The essence of this distinction is captured in the wordsof Carl Rogers (12): "I should like to point out one final characteristicof these individuals as they strive to discover and become themselves.It is that the individual seems to become more content to be a process

rather than a product." Career development is a lifelong process, andcareer planning programs are based on the concept of humans becoming,not simply being.

Continued learning is the cornerstone of career development, and therecognition of staff members' learning abilities and educational interestsis an important part of administration. The potential for learning re-mains intact over the life span (13). Until the mid-1960s, however, itwas almost universally assumed that adults past their twenties sufferedan enormous loss of intelligence and learning ability (14). More recentstudies have shown that the basic ability to learn changes little, if any,with advancing age. Changes in physical status, reaction time, hearing,vision, motivation, and speed of performance affect performance ontimed tests (15). Retention of the ability to learn favors active partici-pation in a climate of positive motivation in which individuals can con-

tinue to pursue the enchancement of their skills and to seek to become

something better than theY are.Developmental theories are useful in providing the administrator with

a perspective on adult learning capabilities. Erickson's (16) theory ofdevelopment, although predominantly confined to the years of child-hood, offers the potential for generativity and integrity, rather thanfor stagnation and despair, in the last two stages of life. Robert Peck(17) has developed a remarkable picture of the second half of life in de-

scribing middle and old age as productive years. This now famous de-

scription has stood the test of time, as it has been utilized by other devel-opmental psychologists, including Bernice Neugarten and HowardMcClusky.

Biology may influence the determination of societal roles, but it shouldnot repress the development of human potential. Work may be carriedout in either a meaningless or meaningful way. A meaningful use oftime is possible only within the context of a meaningful life. In our so-

ciety, career reentry for women may still occur after the age of 40 and,for both men and women, career change may occur at 50. This has tre-mendous implications for the nursing administrator who seeks to makelull use of a nursing resource in a creative way.

Many options are available in nursing, and the creative nursing ad-

ministrator takes advantage of the various combinations of full-time,part-time, or intermittent employment patterns currentlv available forstaff. A skills inventory completed at the time of employment can providea composite picture of an employee's educational life and r'vork expe-rience. Periodic review of utilization of skills with the employee can

create an environment for reward and creative planning for future as-

signment (18).

114 CURRENT AND EMERGING CHALLENGES

DEVELOPING LEADERS AND FOLLOWERS

An important part of leadership is the ability to identify potential leaders.The willingness to nurture a potential leader at the risk of developingcompetition for one's own role is the mark of outstanding leadership.The nurturance of followers of institutional goals is one of the majorchallenges in organizations, for it is easier to set up personal friendshipsand loyalties. Identifying potential leaders based on personal friendshipsis a pitfall that nursing administrators should avoid. Since friendshiptends to blind one to a friend's faults, it is difficult for the nursing ad-ministrator to objectively evaluate the performance of a friend.

Nurses skilled in clinical practice or education are often moved intoadministrative positions without the benefit of administrative prepa-ration. Programs designed to develop administrators require integrationwith institutional performance improvement. To improve organizationalperformance, it is necessary to develop the institution or the institutionalunit. The development of individual administrators is an important partof the overall schcma.

Nelson and Schaefer (19) argue that the development of individualadministrators and institutional development are highly interdependenttasks requiring an approach that integrates the needs of both the in-stitution and the individual. Such an approach involves the setting ofinstitutional goals by top management, followed by the development ofparticipating administrators to move toward those goals. Translated tonursing, programs designed to improve the administrative capabilityof clinical directors and head nurses do not improve the performanceof the nursing department unless they are planned to integrate withnursing dcpartment goals.

The nursing administrator can encourage self-development efforts byestablishing, with the employee, individual performance objectives andperiodic performance evaluation. The administrator's attention to hisor her own self-development further encourages such behavior in others.A positive climate for developing leadership can emerge from rcquiringadministrators to assume the responsibility for the growth and devel-opment of their stalf and assigning individuals to administrative re-sponsibilities appropriate for their experience and interests. Thc activeinvolvement of the supervisor is balanced with the encouragement ofself-evaluation and personal goal setting.

The concept of supervision as a professional growth-producing processis not new, but, except in public health nursing, it is not widely practicedin the nursing field. The supervisory process requires that each staffmember receive one-to-one guidance much more often than once a yearfor performance evaluation. The nursing administrator sets the cxamplefor this process through conferencing on a regular basis with each em-ployee who reports directly to him or her. The conferences, of coursc,

provide tlthe nursistrategiesfor coachdevelop n

It musthighly per

lies in theto life an<

career derpsycholopcareer intcess they

Kleinkropment Ptunites fointerestincludes nuresponsihdirect thtself-knolt

ValuesNeedsSkills andPrevious clnterpersoDecision-r

UNDERSTANI

[;;I EducatiorlFrnanctalI ProiectedI Employm

I

FIGUREand J.O.SeptembAmericarwith perr

UNDERS

I leaders.velopingrdership.re majorendshipsendships'iendshiprsing ad-d.rved into/e prepa-tegrationrizationaltitutional'tant part

rdividualependenth the in-;etting ofpment ofrslated toapability,.ormance-ate with

:fforts b1'

tives andon to hisin others.-equirin-e

rd devel-'ative re-he activeement of

g proccsspracticedach stallce a |eat-erampl.-:ach ei::-i C r)U].:-


provide the opportunity for exchange of information, but they also givethe nursing administrator timc to review objectives, perlormance,strategies, and problcms with cach key person. This time is also usedfor coaching the cmployee so that he or she can gain new skills anddevelop new approaches to old problems.

It must bc recognized that each individual's capacity to dcvelop is ahighly personalized process and that the best tool for self-developmentlies in the ability to accurately assess developmental necds in relationto life and carcer goals. Thorne, Fee, and Carter (20) suggest that idealcareer dcvelopment should match job requircments with the individual'spsychological makeup, educational background, experiential skills, andcareer interests. Figure 9.1 portrays the individual career planning pro-cess they propose.

Kleinknecht and Hefferin (21) also propose a model for career devel-opment programs that can help nursing administrators identify oppor-tunites for restructuring nurses' work experiences to make them moreinteresting and challenging. Figure 9.2 portrays that model, which in-cludes nursing administrator, professional nurse, and career counselorresponsibilities. The program focuses on assisting nurses to develop anddirect their or,vn careers as well as on guiding them toward attainingself-knowledge of:

UNDERSTANDING SELF

ValuesNeedsSkills and abilitiesPrevious career historylnterpersonal styleDecision-making style

- \DERSTANDING ENVIRONMENT TAKING ACTION

i Career job optionsEducational optionstrinancial considerations)rojected skill needsEmployment opportun ties

FIGTRE 9.1 Indrriclu:il r:.rrcl nlanninS procL-ss. (From L-\1. Thorn, F.X. Fee,

' :- J.O. Carter dcr.'lc,p:t.:: , ,'-.';,'lut a:ir e apprr-rach. .\1c':a-gclrettl Rcllett,S::tJnbe-r l9Sl p -19 . 1-:l :'. \\1\ \1rn.i're:srin Publrcaiions Dir ision,r:i--iirinD \lana=:rnren: \.:,- -:. -:: \;.,. \',-,ri. \lr :-:ch:. r->r11 !'d. Reprinred'.\ . . a- Il!-;-I]ll!:]1, :1.

LIFE MANAGEMENT

Mid-life transitionsManagement style in organizationLeisure, retirementFinancial managementSeparation, divorce, deathMarriage, family, parentingAlcohol and drug abuseSelf'understanding, interpersonal

communication, and intimacyHealthStressSexualityHandicaps

lntegratedknowledge of

self andenvironment fordecision making

Self-developmentWork experienceEducationAdditional trainingJob enrichmentJob-keeping skills-Job'seeking skills

116__ CURRENTAND EMERGING CHALLENGES

/\ plan // \'----/z;\

/ manasement \ oRGANlzATloNI structure l

\"c statrsrl

\ / ,"..onn", \I needs | /-\ assessment / /\ ,/ / Manage

| ,i"''ll

\\\

,4;NI career l\ action /\\ ptan /\\___/ \

MEETI]POTEN

Nothingas burnoinson (22

expenditsituationmuch m<

create atrator w.stress an

In thisexampleiby Masl<losophy <

goals of r

also inclmentor Iview, gunition arfor devel

SUMMI

By takinan envir,maximizaccountThe wororeticaland sub<

STUDY

1. Defin2. Discu3. Discu

new t4. List tl

and d

, Mutual \/ aclion \I olannins, I\ career /'counseling '

INDIVIDUAL

FIGURE 9.2 A dynamic career development program. (From M.K' Kleinknecht,and E.A. Hefferin. Assisting nurses toward professional growth: a career de-vefoprnenr mcrdel. Tlrc Joumal of Nursing Adntittistration. July/August 1982, 11,

p. 32. Reprinted with permission.)

. Personal values, interests, and goals related to life and career planning.

. Endeavors and accomplishments related to life and work history.' Life and work decision-making skills'' Personal and professional growth needs and potentials.

' Career concerns and objectives. (p. 34)

Nursing career development programs serve a dual purpose: to helpmeet specific needs of the organization and the individual nurse and toprovide the potential for expanding the reservoir of talent and motivationwithin the nursing division (21).

The followers of today will be the leaders of tomorrow. Setting thepace for the growth and development of the staff involves presentingan image of excitement and enthusiasm for excellence in the nursingdepartment. Technology changes daily, but the need for nurses to developand grow within a physically exhausting environment presents a majorchallenge to the nursing administrator. The nursing administrator hasthe responsibility to provide leadership in creating a climate in whichnurses can practice at their highest level of expertise while continuingto develop as individual professional practitioners. The nursing admin-istrator alone cannot create this climate but has the knowledge and skillsto lead the nursing division to this end'

MEETING NEEDS AND MAXIMIZING HUMANPOTENTIAL

Nothing mars the maximum development of human potential as much

as burnout of either the nursing administrator or staff members. Lev-

inson (22) describes the special kind of exhaustion that can follow the

"*p.rrjit.r.e of intense energy with few visible results. People in such

situations feel angry, helpless, trapped, and depleted' The experience is

much more intense and devastating than ordinary stress. In seeking to

create a professional practice climate, the successful nursing adminis-

trator will seek to prevent burnout in self and staff by alleviating job

stress and dissatisfiction in the early stages whenever possible.

In this regard, Stubbs and Parker (23) have developed work setting

examples u.rd -u1ugement practices to meet human needs as developed

by Maslow. Their methodology translates to nursing as a caring phi-losophy on the part of administration. It includes caring about the career

gouls of staff and about how those goals mesh with the organization. Italso includes caring about professional development opportunities,mentor relationships, and a creative environment that provides for re-

view, guidance, reinforcement, and rewards for work as well as recog-

nition and advancement. This philosophy can well serve as the guide

for developing a motivating nursing environment'

DEVELOPING HUMAN POTENTIAL II7

SUMMARY

By taking a human approach, the nursing administrator can createan environment in which the development of human potential can be

maximized. In order to do this, the administrator must take intoaccount the dilference between human beings and humans becoming.The work of Abraham Maslow and Howard Mclusky provides a the-oretical basis for the development of human potential in self, peers,

and subordinates.

STUDY QUESTIONS

1. Deline human potential and discuss its relationship to education.

2. Discuss the role of the nursing administrator as teacher and learner.

3. Discuss how achieving one's maximum potential involves learning

new behaviors.4. List the hygienes (extrinsic factors) and motivators (intrinsic factors)

and discuss how they are utilized in your operating environment.

einknecht,career de-t 1982, 11,

lanning.Lstory.

e: to help'se and torotivation

:tting theresentinge nursingo develops a majorrator hasin whichrntinuingrg admin-and skills

\

)


21

22.

23.

5. Discuss the importance of performance-reward linkage and effort-performing linkage in expectancy theory. Be sure to include the im-portance of staff opinion in the performance of individual operations.Discuss how to identify and develop a potential leader, with attentionto a career development plan.

KleinlgrowtlJuly/ALevinr1981,

stubbrEcono

REFERENCES

1 McClusky, H.Y. Education for aging: the scope of the field and perspectivesfor the future, in Grabowski, S.W., and Mason, W.D., eds., Edttcation for theAging. Syracuse, N.Y.: ERIC Clearinghouse, 1974.

2. Pritchard, R.E. A philosophy of teaching applied to administration. TheJountal of Nursing Administration, September 1975, 5(7),3840.

3. Herzberg, F., Mausner, 8., and Snyderman, B.The Motivation to Work. NewYork: Wiley, 1959.

4. Maslow, A.H.Toward aPsychology of Being. New York: Van Nostrand,1962.5. McClelland David. The Achieving Society. New York: Van Nostrand, 196l .

6. Vroom, Y.H.Work and Motivatiort. New York: Wiley, 1964.

7. Robbins, S. P. The Administratire Process,2d ed., Englewood Cliffs, N.J.:Prentice-Hall, 1980.

8. Deci, E.L. Intrinsic Motivation New York: Plenum, 1975.

9. Skinner, B.F. Science and Human Behavior. New York: Macmillan, 1953.

10. Gordon, G.K. Motivating staff: a look at assumptions . The Journal of NursingAdminis tration, Novemb er 1982, I 2(l 1), 27 -28.

1 1. Nyberg, J. The role of the nursing administrator in practice. Nursing Admin-istration Quarteily, Summer 1982, 6(4), 67*73.

12. Rogers, C. Freedom to Leant. Columbus, Ohio: Charles E. Merrill, 1969.

13. Arenberg, D.L. and Robertson, E.A. The older individual as a learner, inGrabowski, S.M., and Mason, W.D., eds., Education for the Agizg. Syracuse,N.Y.: ERIC Clearinghouse, 197 4.

Thorndike, E.L., Bergman, E.O., Tilton, J.W., and Woodward, E. AduhLearning. New York: Macmillan, 1928.

Zahn, I.C. Differences between adults and youth affecting learning. AdultEducation, Winter 1967 , 17, 67-77 .

16. Erikson, E. Childhood and Society. New York: Norton, 1963.

17. Peck, R.C. Psychological developments in the second half of life," inNewgarten, 8.L., ed., Middle Age and Aging. Chicago: University of ChicagoPress,1968.

18. Smith, M.M. Career development in nursing: an individual and professionalresponsibility. Nursing Outlook, February 1982, 30(2), 128-131.

19. Nelson, G.M. and Schaefer, M.J. An integrated approach to developing ad-ministrators and organizations. Jounnl of Nursing Administratiorz, Febr"uary1980, 1o(2),3742.

20. Thorn, LM., Fee, F.X., and Carter, J.A. Career development: a collaborativeapproach. Management Review, September 1982, 7 1 (9), 27 -28 , 28-41 .

14.

15.

d effort-: the im-:ations.

rttention

'spectiveson for the

.tion. The

/orft. New

nd,1962.rd,1961.

iffs, N.J.:

n,1953.f Nursing

qAdmin-

,1969.:arner, inSyracuse,

, E. Adult

ing. Adtlt

I life," inrf Chicag<r

ofessional

oping ad-February

.aborative-41.

21

22.

23.

DEVELOPING HUMAN POTENTIAL II9

Kleinknecht, M.K. and Hefferin, E.A. Assisting nurses toward professionalgrowth: a career development model. The Joumal of Nursing Administratiort,July/August 1982, l2(7 and 8), 30 36.

Levinson, H. When executives burn out. HarvardBusiness Review, May/Juner98t, s9(3),73-81.Stubbs, I.R. and Parker, E.R. Motivating for management effectiveness.legalEconomics, September/October 1979, 5(5), 38-40.

10Managtng Firscal

Agnes M. Buback and Nancy V. Moran

The purpose of this chapter is to present fiscal management con-cepts in relationship to nursing administration. Emphasis is onhealth care reimbursement issues, selected principles of managingfiscal resources, tools of fiscal management, and types of budgettechniques. On completion of this chapter, the reader will be ableto:

l. Describe selected reimbursement issues and relate them tonursing administration.

2. Describe the concept of financial management'3. Identify the key concepts of accounting and budgeting.4. Differentiate types of budgets and selected budgeting tech-

niques.5. Discuss the pervasiveness of the budget as a management tool

and its impact on clinical nursing practices.6. Relate the budgeting process to the nursing process.

Why should nursing service administrators become involved in budg-eting and financial mangement? In the recent past, these functions werewillingly and gladly relegated to financial officers or hospital admin-istrators who prepared, monitored, and evaluated the nursing budgetand assumed total responsibility for the broad area of financial man-agement.

Fortunately, nursing service adminstrators saw the error of havingnonnursing personnel assume critical financial functions. Nursingbudgets usually make up the largest proportion of a hospital's operatingbudget. Thus, because money is power, it has become incumbent uponthe nurse adminstrator to acquire a fairly sophisticated level of skill in

120

budgetinunderstamate.

The prfostereddemonstan esseninvolved

Dollannancial c

to budgesional se

nursing r

charges.tivities oto quant

It is clrand poliinto onement skideliveryfinancialisting rertinued dr

REIMB

The currcare enviin manalhealth cr

strategie

Growth

In 1963,tional princrease<economyitures wrcreased l(1). Mosticaid-Me

nt con-sisonnagingbudgetbe able

hem to

F5'

g tech-

:nt tool

in budg-ions werell admin-rg budgetcial man-

of havingNursing

cperating)ent uponof skill in

\,1,ANAC]Nq-ET$Q4LSEEoIJB9ES UL

budgeting and financial management, as well as an awareness andunderstanding of the evcr-changing health care reimbursement cli-mate.

The precarious nature of the health care reimbursement climate hasfostered increasing fiscal conservatism in most hospitals. As a result,demonstrating the value of nursing services in terms of cost has becomean essential activity in which all nursing adminstrators must becomeinvolved.

Dollars do influence clinical nursing practice. During the current fi-nancial crisis facing many hospitals, nursing budgets remain vulnerableto budget cuts. Nursing services commonly are not isolated as profes-sional services, and neither is reimbursement for them. Charges fornursing care remain relatively hidden in room rates or other groupedcharges. In addition, costing out and justifying nursing services are ac-tivities only recently being undertaken by nursing leaders in an effortto quantify and qualify nursing.

It is clear that through a variety of environmental, social, economic,and political changes, the role of the nurse administrator is evolvinginto one that requires a high level of budgeting and financial manage-ment skill. Such skill, if properly applied, may ultimately enhance thedelivery of nursing care through judicious maintenance of human andfinancial resources, vigilant monitoring to most effectively utilize ex-isting resources, and aggressive pursuit of resources to ensure the con-tinued development of clinical nursing practice.

REIMBURSEMENT ISSUES

The current reimbursement climate has a profound effect on the healthcare environment. Therefore, it is important for nursing adminstrators,in managing nursing services, to be knowledgeable about the history ofhealth care expenditures and reimbursement trends and to developstrategies for coping with the financial uncertainties of the future.

Growth of Health Care Expenditures

In 1963, health care expenditures made up 5.6 percent of the gross na-tional product (GNP). Between 1965 and 1973, health care expendituresincreased at an annual rate of l0 percent, while the remainder of theeconomy grew at a rate of 6 to 7 percent. In1979, health care expend-itures were $212.2 billion, or 9 percent of the GNP. This proportion in-creased to 10.5 percent of the GNP in 1982, or a total of $322.4 billion(1). Most of this growth is attributable to the impact of the 1966 Med-icaid-Medicare legislation.


Retrospective Reimbursement

Retrospective, cost-based, reimbursement was the methodology em-ployed by most third-party payers prior to 1983. After services wereprovided, hospitals r.r'ere paid on the basis of expenses incurred. Clearly,this system did little to provide inccntives for controlling unnecessarycosts. Due to the significance of health care cost increases, governmentalregulation became the strategy for cost control in the 1970s.

Public Law 92-603 was enacte d in 197 3 in an attempt by the govern-ment to impose regulations on Medicare providers. This legislation in-cluded institutional budget and financial planning requirements andmechanisms for accountability.

Prospective Reimbursement

The current approach to reimbursement is the prospective approach.That is, hospitals are reimbursed a flat, illness-specific amount deter-mined before services are rendered. Clearly, this method offers incentivesto avoid unnecessary services and extended hospital stays.

The concept of prospective reimbursement was introduced into theMedicare program via the Tax Equity and Fiscal Responsibility Act of1982 (TEFRA). This act may be the most significant piece of legislationaffecting health care to date. It was expected to generate a savings of92.6 billion between 1984 and 1987 through a complex set of formulasbased on diagnosis-related groups, or DRGs (2).

Diagnosis-Related Groups

Researchers at Yale University have developed 467 DRGs, 356 of whichare to be used to determine a hospital's case-mix adjustment. Thesegroups are based on the assumption that patients can be homogeneouslygrouped into various clinical categories that require similar use of re-sources. Considerations in the classification process include principlediagnosis or procedure, presence or absence of surgical procedures, ageof the patient, and presence and complexity of complications or co-morbidities.

The DRG system works as follows. After assignment to DRG categories,a case-weighted cost per Medicare discharge is calculated to determinethe maximum amount of Medicare reimbursement. Hospital target ratesare then calculated and increased by an inflation factor. If the hospital'scost per case exceeds its designated target rate, Medicare pays the targetrate. Some percentage of the excess cost is reimbursed only if the caseis approved as an outlier, but the actual cost is not recovered.

However, an incentive is built into this program if the hospital's actualcost per case is below its target rate. In this event, Medicare payment

is the aclup to wi1

Clearlyexperiencunprofiticontrol s

What z

enue los:ficiency,strategyinsuranctdesirableactivitie:

Implica

Althougtaveragethis reastificatiormany nuultimatequantify

One pracuity, r.r

care cal(nursingThese ntidentify

This lias it is tlthe reimtheir kn<

order toSevere

from themaintairSince hecontinutnurse w(advocatibe accorsional nr

Nursirpro[essi<

ogy em-)es wereClearly,

LQCQSSbIJ

rnmental

3 govern-lation in-ents and

pproach..nt deter-ncentives

into theity Act of:gislationavings offormulas

of whichrt. These

3eneously:se of re-principleures, agens or co-

ategories,etermine:get ratesrospital'she target'the case

l's actualpayment

MANAGING FISCAL RESOURCES 123

is the actual cost per case plus 50 percent of the variance fiom the target,up to within 5 percent ol the target rate.

Clearly, the possibility exists undcr this system that hospitals maycxperience substantial losses of revenue for a variety of reasons, includingunprolitable case mix, inefficiency of operations, and poor financialcontrol systems.

What are the strategies that hospitals may employ to minimize rev-enue losses? One is to offset thc losses through greater operational ef-

ficiency, for examplc, through staffing or supply reductions. Anotherstrategy is to attcmpt to shift rcvenue losses to other payers, includinginsurance carriers and private pay (self-responsible) patients. Other, less

desirable approaches include obtaining revenue from nonpatient careactivities and reducing the quality and accessibility of services (3).

Implications for Nursing Services

Although nursing services are included in the calculation of a hospital'saverage target cost, they do not receive separate reimbursement. Forthis reason, hospital administralors are beginning to pressure for jus-tification of nursing services. This is not enlirely unwelcome news tomany nursing service administrators who believe it is important andultimately politically helpful to be able to clearly and precisely identify,quantify, and justify nursing activities.

One proposed method of justifying nursing services is based on patientacuity, which is related to DRG categories. Twenty-three major nursingcare categories have been developed and subdivided into 356 generalnursing care stralegies, which correlate with the DRG classifications.These nursing care strategies includc detailed nursing care plans thaiidentify both the direct and indirect care needs of the patient (4).

This linkage with the DRG process is an important one for nursing,as it is the first major rational eff<-rrt to correlate nursing services withthe reimbursement system. Nursing service adminstrators must increasetheir knowledge and application of this new reimbursement system inorder to effectively plan and managc nursing services.

Several other important consequences for nursing services will resultfrom the change in reimbursement systems. Hospitals will develop andmaintain a strong focus on efficiency of services and cost containment.Since health care is a highly labor-intensive industry, nurse staffing willcontinue to be pressured through, demands for increased individualnurse work load and efficiency of performance, and perhaps a movementadvocating the use of less expcnsive labor. Such cost containment maybe accomplished at the expense of decreasing the proportion of profes-sional nurses (5).

Nursing service administrators have a critical role in providing strongprofessional leadership and increased professional cohesion in idcnti-

r32 CURRENT AND EMERGING CHALLENGES

Variable costs, on the other hand, fluctuate in some manner with ac-

tivity levels. For example, the number of disposable supplies used-andtherefore the expense related to those supplies-will probably rise orfall as surgical patient days increase or decrease. If they vary to the

same degrei as volume, variable costs may be referred to as proportionalcosts. Some variable costs only partially vary with changes in activitylevels. Payroll expenses, for instance, may decrease when patient days

fall but may not do so in the same proportion or percentage'An obvious advantage of the flexible budgeting technique is that it is

more sensitive to how expenses vary with volume changes. More ap-

parent opportunities may be provided for controlling costs as more is

tno*n utbttt how costs will fluctuate as activity levels change.

The behavior of varying costs may, however, not be easy to identifywithout committing considerable time for study. Managers need to have

a somewhat deeper knowledge of finances in order to effectively par-

ticipate in and benefit from a variable budgeting system. The time re-

quiied for budget development may also be considerably longer than

that required by other budget techniques.

Planned Programmed Budgeting System

During the 1960s, Robert McNamara introduced the Planned Pro-

grammed Budgeting System (PPBS) in the Department of Defense. This

iystem consisis of three components: planning, programming, and

budgeting. First, a plan that includes multiyear objectives and alter-

natiie methods of achieving the objectives is defined. Substantive, orlong-range, objectives as well as fiscal objectives are included, givingrise-to -,rttiy"ur fiscal projections. A program that includes methods

for achievingthe objectives is outlined. Activities necessary to yield the

attainment of tn" specific objectives or outputs and the costs associated

with producing the desired results are then compiled' Finally, financialfo.ecasts and a process to facilitate administrative control of the entireprogram are applied.

Resources are generally allocated on the basis of the defined program

and the associated services, supplies, and so on that are required to

meet the objectives or output. Such requirements may cut across tra-ditional divisional lines but be assigned to a single administrator ordirector. An example of a hospital setting in which a PPBS might be

utilized is the emeigency room service. Specific objectives might be de-

veloped, activities necessary to meet the objectives delineated, and re-

,o,r..", assigned from multiple departments to accomplish the objec-

tives. Administrative responsibility would then be under the control ofthe emergency room service director.

In geneial, FfeS -uy facilitate price establishment for services, out-

put, Ir products. Moreover, it facilitates the organizational linking of

resources to outcomes, products, or services. However, PPBS involves

comple;trators.the futuit difficrservices

Zero-Br

The zerrPresiderto budgamountcharactrrebuildi

Everyeach buthis goaat leastdevelop,tional dtbenefit r

Sinceest operto "buyprocessthe flonrto forcedevelop

The trextensivdevelopplementing to p

RELATPROCI

Budgetiit is inteframew<erally, a

ducing tthat areexaminzthe focu


tivity belo insure

the cashnization.lhe leastthe mostr balance

) predict;ash bal-mine thefore, thisensuring

y budgetbudgets,the other

:chniquese become;, such asny event,

'rinciplesand cons

cribed in:ide with,, a singlelescribed

and stillbudgets.-time es-:d) dollar

ocooU

FIGURE 10.3 Fixed budget.

amount are established and are not altered throughout the budget period

regardless of whether changes in volume (number of services rendered)occur (see Figure 10.3).

From the brief description above, it is readily apparent that this ap-

proach is fairly straightforward to prepare and manage. It is easilyunderstood by most managers regardless of their level of financial so-

phistication, and it is highly adaptable to accounting systems. Variances

can be compared to a constant. Perhaps the greatest potential advantage

of the fixed budget in our current reimbursement climate is that thetechnique is in harmony with the intent of allocating a fixed amount ofresources (dollars).

The less desirable consequences of the fixed budget include the factthat it is not or cannot easily be adjusted for actual changes in activitylevels. It is further difficult to analyze variances caused by changes involume or price if actual activity levels vary.

Flexible Budgeting

The flexible, or variable budget, was characteristic of the 1970s. It has

been described as a series of fixed budgets based on varying forecastsor activity levels. Various cost expenses are identified according to howthey behave in relation to volume. Mechanisms exist within the flexiblebudget approach to adjust forecasts and actual budget during the fiscalperiod on the basis of changes or varying activity levels and the asso-

ciated costs. Although most health care institutions do not fully imple-ment this technique, most are concerned with identifying how costs varywith volume changes.

The first cost category usually identified during the flexible budgetingprocess is fixed costs, which are costs of time. These costs accumulateover the fiscal period irrespective of volume or output. Examples of suchcosts include depreciation, insurance premiums, and the like. They occurregardless of whether patient days, acuity, or other work load indicesincrease or decrease.

Volume (number of services)

t3a CURRENT AND EMERGING CHALLENGES

It is important that the statistical forecasting of patient activity becarefully considered in development of the commodity budget to insureaccuracy of the planning function.

Cash Budget

The final budget component, as illustrated in Figure 10.2, is the cashbudget, which delineates the cash flow in and out of the organization.It is important to the financial health of any business that the leastcostly method of financing cash needs be determined and that the mostadvantageous investment opportunities for any temporary cash balancesurplus be identified (6).

A properly prepared cash budget enables management to (1) predictthe timing and amount of future cash flows, net cash flows, cash bal-ances, and cash needs and surplus and (2) systematically examine thecost implications of various cash management decisions. Therefore, thistool assists in both protecting a hospital's cash position and ensuringthat it invests its assets appropriately.

It is important to note that the cash budget is not a primary budgetin and of itself. It is derived from the operating and capital budgets,not from fundamental operating forecasts and decisions, as are the othermaster budget components.

TYPES OF BUDGETING APPROACHES

In developing a budget, an enterprise may utilize a variety of techniquesor approaches. Some of these, such as zero-based budgeting, have becomefamiliar through frequent use in the news media, while others, such asvolume-adjusted budgeting, are not quite so widely known. In any event,it is helpful for the nursing administrator to know the basic principlesunderlying the major techniques as well as some of the pros and consassociated with each.

In this section, several budgeting approaches are briefly described inrather pure form. Thus, the descriptions may or may not coincide withthe realities of budgeting in any given institution. That is to say, a singlecorporate entity may use variations or combinations of the describedtechniques in order to meet its purposes.

Fixed Budgeting

Fixed budgeting is often viewed as the traditional approach and stillseems to be the most common technique utilized for nursing budgets.In general, a fixed budget is developed based on a single, one-time es-timate of work load or activity. Expenditures for a specific (fixed) dollar

oqooU

amounlregardloccur (r

Fromproachunderslphisticzcan be ,

of the I

techniqresourc

The Irhat ir i

levels. l

volume

Flexibl

The flerbeen dror acti\,they bebudgetperiodciated <

ment ttwith vc

The fprocessover thtcosts inregardlincreasr

MANAGING FISCAL RESOURCES t29

udget, aal struc-for a re-Lzation'soughoutpolicies,rt be ac-nizationssful. Fi-:dgeablenitoring,

umerousnot havethe cash

y for themponentre capitale admin-nent andthe levelhe devel-istrators,a typical

Capital Budget

The capital budget identifies expenditures on assets whose returns areexpected to extend beyond one year (6). Definitions of capital equipmentvary among institutions but may typically be defined as major movableequipment items that have a unit cost greater than or equal to $500 anda life expectancy of two or more years. Nursing administrators typicallyparticipate in the development of this budget by assessing and sub-mitting patient care unit equipment needs. Capital construction budgetitems are costs related to the acquisition and maintenance of the physicalplant. Although nursing administration involvement is seldom soughtin development of the capital budget, the benefits of participation maybe well worth the administrator's efforts of seeking participation.

Operating Budget

The operating budget is a plan of revenue and expenditures geared toa certain level of services to be rendered for a particular period of time.In most institutions, the operating budget consists of two distinct com-ponents: the revenue budget and the expense budget. The revenue budgetincludes revenue and statistical projections, while the expense budgetencompasses payroll and commodity elements.

The revenue budget defines the plan that quantifies future incomebased on statistical forecasts of activity. This linkage of dollars to patientactivity indicators is an important area for nursing involvement. Pre-dicted levels of patient activity directly influence the plans for nursestaffing reflected in the payroll budget.

Expense budgets incorporate all institutional expenditures, most no-tably payroll and commodity components. The payroll budget identifiesall anticipated payroll expenditures for the fiscal year by departmentor other specific grouping. It includes the following elements: (1) regularsalaries, indicated by appointment hours as well as dollars; (2) specialsalary items (e.g., overtime pay, temporary and agency salaries, holidaypay, shift differential, on-call pay); (3) fringe benefits, (e.g., health in-surance premiums, retirement plans); and(4) miscellaneous payroll ex-penses such as prerequisites and tuition refund payments. The payrollbudget tends to occupy more of the nursing administrator's time inplanning, developing, monitoring, and evaluating than do the otherbudgets.

The commodity budget identifies all nonpayroll expenditures that donot meet the institution's definition of capital equipment. It may includethe following items: postage, telephone and telegraph services, travele\penses, equipment depreciation charges, repairs and maintenance,general and office supplies. medical and surgical supplies, and phar-maceutical supplies.

L23 CURRENT AND EMERGING CHALLENGES

In order to develop and execute a meaningful and relevant budget, aset of organizational prerequisites must exist. The organizational struc-ture of the institution must be effective and stable. Provisions for a re-sponsible accounting system must be operational. The organization'sgoals and objectives should be well-defined and disseminated throughoutthe organization to maintain a constant focus on the mission, policies,plans, programs, anci priorities. Adequate statistical data must be ac-cumulated and distributed to appropriate persons in the organizationfor the financial control and evaluation functions to be successful. Fi-nally, the organization must develop a cadre of fiscally knowledgeablemanagers who are able to contribute to the development, monitoring,and evaluation of the financial plans.

Types of Budgets

The master budget of an organization may be composed of numerousbudget subsets. Nursing service administrators typically do not havesignificant involvement in all budget components-for example, the cashbudget-but do have substantial responsibility and authority for thedevelopment and monitoring of others, such as the payroll componentof the operating budget. Still other budget subsets, such as the capitalbudget, may require the nursing administrator's input, but the admin-istrator may have no authority or responsibility for development andcontrol. Institutional policies and practices normally dictate the levelof nursing administration participation; however, in view of the devel-opment of substantive financial skills by many nursing administrators,these practices are being challenged. Figure 10.2 illustrates a typicalschema of master budget components.

OPERATING BUDGET

PayrollCommodity (supply)RevenueStatistical

Capital

The ca1

expectevary anequiprra life erpartici,mittingitems at

plant. Iin devebe well

Operatit

The opea certaiIn mostponentsincluderencomp

The rbased oractivitydicted Istaffing

Expertably paall anti<or othersalariessalary ilpay, shisu.rancepenses s

budgetplanninbudgets

The cr

not meethe follrexpensegeneralmaceuti

CAPITAL BUDGET

Capital equrpmentCapital construction

CASH BUDGET

ReceiptsDisbursementsNet cash

FIGURE 10.2 Master budget model.

for the

rctivity-

e entity

an item

vo sides

'ding of: period

income,Ie same

ountingwell as

e, of theI frame-ill begintasks oflso pro-rospital:e in to-

I have aof fiscalrent ac-ound orms mayr sectioninitions

ent andamiliar:

Ls actual

UANA_GM.G_II$E4! 3E!A!3cE_s- _- ) ?7

Cost center'. organizational unit for which costs can be determinedVariable cosl: expense that changes in relation to volume (output)

changes (e.g., surgical supplies)Fixed cost'. expense that is a function of time and is not related to

changes in volume (e.g., equipment depreciation)Direct cosl: expense that can be traced specifically to a given cost ob-

jective (e.g., salaries)Indirect cost: an expense that cannot be related to a

(e.g., equipment depreciation)Full-time equfualent (FTE): unit of staffing measurement

worked by a full-time (40-hour-per-week) employee in a

cost objective

related to timeperiod of one

yearFiscal year: the 12-month budget year designated by an institution;

may or may not coincide with the calendar year.Variance: difference, expressed in dollars or percentage, between

budgeted amount and actual expenseProfit center: organizational unit for which costs can be determined

and revenue producedAccounts receivable: funds owed to a provider, usually for patient care

services renderedAccounts payable: frnds owed to other institutions, usually for supplies

THE CONCEPT OF BUDGETING

A budget may be viewed as a descriptive plan as well as a process. Asa plan, a budget may be (1) a numerical depiction of the activities ofthe institution derived from written objectives and the behaviors neededto achieve the objectives, (2) a financial description of department ob-jectives and activities, and (3) a financial plan serving an as estimateof and control over operations to occur in the future. As a process, abudget may be (1) the process of allocating limited resources to unlimiteddemands and (2) the process of relating expenditures to revenues to ser-vices rendered and then evaluated.

Viewing a budget as both a plan and a process suggests the followingset of objectives for a budget in an institution:

' To provide a quantitative expression of policies, plans, programs, andpriorities

' To provide a mechanism of evaluating financial performance withpolicies, plans, and programs

' To provide a useful tool for the control of costs' To create and reinforce cost awareness throughout the organization


Six basic accounting principles comprise useful information for thenursing service adminstrator:

1. Entity concept: the hospital (or any business) is viewed as an activity-driven entity capable of taking economic actions.

2. Transactions concept: all transactions that have an effect on the entitymust be reflected in accounting reports and records.

3. Cost valuation concept: the most useful basis of valuation of an itemis the price paid for the item.

4. Double entry concept: accounting records should reflect the two sidesof every transaction (i.e., changes in assets and liabilities).

5. Accrual concept: the accounting system requires the recording ofrevenue when realized and the recording of expenses in the periodin which they contribute to operations.

6. Matching concept: to accurately present and determine net income,revenue and expense items must be brought together in the sameaccounting period. (6)

This text provides only an introduction to the practice of accountingto differentiate it from the concept of financial managment as well asto illustrate what is probably the most notable tool, or technique, of thefinancial management process. Mastery of the basic conceptual frame-work and definitions of financial management and accounting will beginto prepare the nursing service adminstrator for the herculean tasks offorecasting and preparing the nursing service budgets. It will also pro-vide him or her with the necessary broad view of the world of hospitalfinances within which the effective nurse manager must practice in to-day's health care environment.

Fundamental Fiscal Concepts and Definitions

As previously indicated, contemporary nursing managers must have asolid foundation in the fundamental concepts and definitions of fiscalterms in order to effectively participate in financial management ac-tivities. For individuals who have no finance or business background orskills, it is important to note that the definitions of many terms mayvary according to the institutional setting. It is the intent of this sectionto provide an overview of the most common concepts and definitionsbefore proceeding to develop the concept of budgeting.

There are numerous terms related to financial management andbudgeting with which the nursing administrator must become familiar;

Annualize: to project yearly data based on less than 12 months actualinformation

Cost t

Variachanges

Fi-x.ed

changes

Directjective (

Indire(e.g., eq

Full-tiworkedyear

Fiscalmay or

Variatbudgete

Profitand revr

Accouservices

Accou;

THE C(

A budgea plan, :

the instito achie'jectivesof and cbudget ndemandrvices rer

Viewirset of ob

' To propriorit

. To propolicie

' To pro' To crei

)tive ap-iccess ord future

rent, the,ial man-both the;, imple-

;sociatedLs chang-adminis-possible.rncial of-rtive andhose em-order to

ristrators:ial man-

; varioustems. Al-rethodol-unting tofinancial

lhe art of'eting, inystem, orrment theragementand prac-

___-->. Kaluzny,t Services.:mission.)

l. Planning

A. Assessing theenvironment

B. Programming

ll. lmplementing

C. Budgetine

"*a,",* [-

iJSH::L

lll. Controlling

External environment

f--C.rd-_ll-R"ilgi*-l|lect*"rrgi*i

r *::;"-:;---1Fhfid]I Protessronar I

l\4arketing

t cr,""t;-l

tfip"ifti-l

-

I l-undrng I

r-*,'*_lt R"il-l

Organizational environment

t P*p*=_l f-t.rr-lf-Fil'f.t-l [-uffilI of labor I

I Pnlici.s ll I

fP..;d,,"n I structure I

tlr.@ I--P"rrti';l

Goals and objectives

IP"tt'C---_lt fi"".---_lt Fr.r;"d;rbilty I

t R;;;JI I lr.--;r I

lTasksandl l-lI activrtres I ll vateriats ll

L__.1 lffilf;,-,-;,1 [ffi:rl.-lI r-'tl I l.".no,oe"tl lc,pitu,ouogetl lr t'*-llI fE'p"t1] I I I I I llaatancesneetllI ll ll llr'"a;rl

Working capital

f-c"-t-d, --..l

I nec"i".bb.l

Fil;b'lI Liabilities

I

[-L.i-, I

Noncurrentassets,liabilities Residualequities

tr*;t'."t'lf- Bril"!"s.l

t-Gr-lTEqrD."rt I

fs.--rt"ro",,lI caeitat

I

fApp'"p'htilll-c'""6--lt c""t.*G--l

I-otn*--_l

General controls

reffitn."ntl T r'.*r.t* IF;*,'__lt h.f",".";;l

I svstem I

I Policiesancl ll-lI procedures lll Accountinc llt_ll-o*"""rtb"-l ll oPe'ationat ll

r-lll Other llt-l

Report characteristics

f R"p*til e.*trok_l

Type of reports

External

f;il.un."m"dtb;_l

T- op"'"d;lfotn",---l


fying, defining, and evaluating standards of nursing care. Effective ap-plication of the leadership function will certainly affect the success orfailure of nursing services to thrive during both the current and futuretrends in reimbursement.

FINANCIAL MANAGEMENT

Armed with fundamental knowledge of health care reimbursement, thenursing administrator is ready to consider the concept of financial man-agement. In a broad sense, financial management encompasses both theacquisition and the utilization of funds and includes planning, imple-menting, and controlling functions (see Figure 10.1).

Historically, the arena of financial management has been associatedwith the complex world of accountants. This traditional view is chang-ing, however, as it has become necessary for nursing service adminis-trators to provide quality services in the most efficient ways possible.This is not to minimize or negate the roles of a hospital's financial of-ficers, but, rather, to highlight and advocate a strong consultative andcollegial relationship between nursing administrators and those em-ployed in financial administration within the organization. In order tomaximize the effectiveness of these relationships, nursing administratorsmust be conversant with the basic concepts and tools of financial man-agement.

A variety of financial management tools abound, including variousquantitative methodologies and accounting and reporting systems. Al-though it is beyond the scope of this chapter to define these methodol-ogies, it is important to delineate a working definition of accounting tostimulate further study and to avoid confusing accounting with financialmanagement.

Basic Accounting Principles

Berman and Weeks (6) define the practice of accounting as "the art ofcollecting, summarizing, analyzing, reporting, and interpreting, inmonetary terms, information about the enterprise." It is the system, ortool, that provides managers with the data necessary to implement thedecision process called financial management. Financial managementhas a broad operational scope, of which accounting principles and prac-tices are but one informational piece.

FIGURE 10.1 Over-view of financial management functions. (From A.D. Kaluzny,D.M. Werner, D.G. Warren, and W.N. Zuman, Management of Health Services.Englewood Cliffs, N.J.:, Prentice-Hall,@ 1982,p.291. Reprinted with permission.)

l. Planning

A. Assessinlenvironm

B. Programr

C. Budge

ll. lmplemer

lll. Controllin

Obtairand uresout

vith ac-d-andrise or' to therrtionalactivitynt days

hat it islore ap-more is

identifyto haveely par-time re-;er than

red Pro-rse. Thisng, andrd alter-etive, orl, givingmethodsgield thesociatedinancialre entire

programluired toross tra-lrator ornight beht be de-, and re-re objec-ontrol of

ices, out-inking ofinvolves


complex calculations and requires sophisticated input from adminis-trators. It may involve multiyear projections and extend further intothe future than is reasonable to predict. Such a system may also makeit difficult to measure performance against outcomes of patient care orse rv i ces.

Zero-Based Budgeting

The zero-based budgeting (ZBB) technique was popularized by formerPresident Carter when he was governor of Georgia. The phrase appliesto budgets in which amounts of services are identified for incrementalamounts of money, in increments above zero. The technique is furthercharacterized by a periodic reevaluation of all programs and a requiredrebuilding from base.

Every department is required to justify and defend its entire budgeteach budget period, as if its activities were entirely new. To accomplishthis goal, decision packages containing a description, evaluation, andat least two levels of activity effort to attain the proposed objectives aredeveloped. The decision packages are then rank-ordered at organiza-tional decision points advancing up the hierarchy based either on a cost-benefit analysis or some alternative decision process.

Since decision packages should theoretically be developed at the low-est operational level capable of producing them, the ZBB process servesto "buy" the decentralized manager into the planning and budgetingprocess of the organization. It further tends to increase commitment ofthe front line manager to outcomes of the approved packages. ZBB helpsto force a focus on planning and ensure close integration with budgetdevelopment.

The technique requires that managers have appropriate and fairlyextensive information about the organization and its goals in order todevelop good decision packages. It frequently requires a long-term im-plementation period, well-defined fiscal procedures, and in-depth train-ing to prepare effective first-level managers to participate.

RELATIONSHIP OF BUDGETING TO THE NURSINGPROCESS

Budgeting may be viewed as both a plan and a process. As a process,it is interesting to integrate its components with a commonly recognizedframework: the nursing process. Both processes may be defined gen-erally, according to Webster, as "a series of actions or operations con-ducing to an end." Both are composed of discrete and identifiable stepsthat are repeated in a continuing cycle through a feedback loop. Uponexamination, many similarities exist between the processes, althoughthe focus of the nursing process is the individual patient, and the focus

I34 CURRENT AND EMERGING CHALLENGES

FIGURE 10.4 The nursing process.

of the budgeting process is the aggregate plan of resources and programsdesigned ultimately to benefit all patients.

Marriner (7) defines the nursing process simply as "the applicationof scientific problem solving to nursing care." It is a continuing cycleof the components of assessment, planning, implementation, and eval-uation, as shown in Figure 10.4. Each of these components may also

serve to illustrate the budgeting process. The components are examinedhere individually for comparative purposes.

Assessment

In the nursing process, assessment is performed by various means ofdata collection in an effort to isolate and define an individual patient'sproblems. Based on data collection, a statement of the patient's problemis made; this statement is called a nursing diagnosis.

Data collection techniques may include observation (e.g., physical as-

sessment), interviewing (e.g., health history), and review of current andpast medical and nursing documents (e.g., medical records, nursingnotes, Kardex). The end step of the assessment phase yields a concise

and precise problem statement to bring to the planning phase'

TABLE IO.IExternal Considerations in Budget Forecasting

Extental Conditions Examples

TABLE I

Internal

Internal I

Revenuer

Expenset

CapitalPersonne

In therequiresan indivgardingbe futurapparen

Foreciclearly,precise.prehensaccurat(

Assess

is also c

sets of e:

budgetbeyondamplesprovideenvironportant

Altho,sessingcasts ercurate I

regardirpreparamarketpatientistratoradminir

Planni

In the rends w

Political

Social

EconomicTechnological

Market conditions

Medicare legislationPolitical party philosophies regarding health care

Population (birth rate, growth of elderlypopulation)Unemployment ratesEquipment innovations (CT scanner)Pharmaceutical product advancement (poliovaccine, antibioticsDemand for hospital beds, outpatient servicesActions of health care competitors

MANAGING FISCAL RESOURCES I35

lTABLE IO.2Internal Considerations in Budget Forecasting

Internal Conditions Examples

Revenues

Expenses

CapitalPersonnel

Volume of services x incomeCharitable contributionsFixed (building overhead)Variable (disposable supplies)Prices and interest ratesQuantity and quality of human resources

rograms

rlicationng cyclend eval-ray also(amined

neans ofratient'sproblem

'sical as-rent andnursingconcise

Ith care

In the budgeting process, assessment is known as forecasting. It toorequires collection of data from many sources in an effort, not to isolatean individual patient's problem, but to isolate a set of assumptions re-garding the future. How far into the future? Budget forecasting shouldbe futuristic enough to visualize the attainment of the commitmentsapparent in current budget decisions.

Forecasting may seem to be an exercise in reading a crystal ball, and,clearly, many intermediate and long-term forecasts cannot be absolutelyprecise. However, if properly performed with consideration for a com-prehensive set of elements, short-term forecasting should be relativelyaccurate.

Assessment, or forecasting, is a crucial part of the budget process butis also one of the most complex steps. Consideration must be given tosets of external as well as internal conditions. External conditions requirebudget planners to examine and adapt to the changing environmentbeyond the hospital's walls. Table 10.1 illustrates some common ex-amples to consider (8). Internal considerations in budget forecastingprovide the organization with a means of reacting in concert with theenvironment. Table 10.2 displays a set of internal considerations im-portant to the budget forecasting phase of the process (9).

Although the nursing administrator is not intimately involved in as-sessing all external and internal conditions, knowledge about such fore-casts enhances the relevance of the nursing budget. For example, ac-curate knowledge about technological conditions aids in predictionsregarding patient acuity, which is a prerequisite piece of data for thepreparation of the nursing payroll budget. Likewise, forecasts regardingmarket conditions, economics, and revenue aid in the determination ofpatient census data, another key assessment area for nursing admin-istrators. At the end of the assessment, or forecasting, phase, the nursingadministrator is prepared for the substantial task of planning.

Planning

In the nursing process, planning begins with the nursing diagnosis andends with identification and development of a nursing care plan. The

lio

'ices


plan is highly individualized for each patient and reflects the prioriti-zation of patient problems, along with mutually identified immediate,intermediate, and long-term goals for problem resolution.

In the budgeting process, planning begins with external and internalfactor forecasting and ends with the development of the financial planor line-item budget. The budget plan, like the individualized nursingcare plan, is a highly specific one, reflecting the prioritization of nursingprograms and goals exhibited quantitatively in numbers and dollars.

In both processes, the planning function may be viewed as determiningin advance what is to be done, how it is to be done, when it is to be done,and who is to do it (1). The importance of planning cannot be over-emphasized. The process itself constitutes a mechanism for siftingthrough the data collected in the assessment, or forecasting, phase andprovides the nursing administrator with a sense of direction and focuson the nursing department's objectives. It also enables the administratorto anticipate and compensate for changes that may occur throughoutthe fiscal year. If properly prepared, the budget plan serves to ensurecontinuity of plans from one fiscal year to the next. The assurance ofcontinuity is an important function, as planning and implementationof major nursing program may be years in duration. Finally, the budgetplan facilitates the nursing administrator's ability to quantitativelymonitor, control, and evaluate nursing programs, services, and activitiesthroughout the fiscal year.

These same benefits of the planning process-direction and focus, an-

ticipation of change, continuity, control, and evaluation-clearly applyto the nursing process as well. Planning, whether for individual patientsor budgets, creates a blueprint for action, incorporates the dynamic na-

ture of the environment, and utilizes a base (forecasting or assessment)

for development. Both processes are also participative, the nursing care

plan with the patient and family, and the budget plan with all levels ofnurse managers.

What constitutes a good nursing care or budget plan? The plan shouldreflect clearly stated objectives and be communicated effectively. Itshould be economically feasible and professionally sound. Plans shouldexhibit an integration of pieces into a whole and provide flexibility forchanges and consideration of alternatives. Implementation shouldproperly proceed only after meeting this test of criteria.

Implementation

In the nursing process, the implementation of the nursing care plan isthe actual provision of nursing care. Guided by the nursing care plan,the nurse continues to assess, plan, and evaluate the nursing care whileimplementing the plan.

Implementation of the budget entails the realization of revenues and

expensesities. It tthe begirthe nursation fut

Evalual

Appraisinursingnurse incomes aplan. Fefor reassprocess.

In thecontrol.and notin the nperformFeedbacreports,

Whileshift-to-nursingshould h

financialat the ltsponsibSchmie<

It is er

budgetirprocess(and evamodificiadminirknowlecthe bud

SUMM

An overmanagenents pr

prioriti-nediate,

internalial plannursingnursinglollars.rminingle done,le over-: siftingrase andrd focusnistratoroughout) ensurerance ofentation: budgettativelyrctivities

)cus, an-ly applypatientslmic na-:ssment)ring carelevels of

n shouldively. Its shouldrility forshould

: plan isrre plan,re while

Lues and

MANAGTNG FTSCAL RESOURCEQ _ 137

expenses that reflect the various nursing programs, services, and activ-ities. It begins, pending appropriate institutional budget approval, withthe beginning of the institution's fiscal year. As in the nursing process,the nursing administrator continues assessment, planning, and evalu-ation functions upon implementation of the budget.

Evaluation

Appraisal of the nursing care provided is the means of evaluation in thenursing process. The use of the nursing audit, for example, assists thenurse in comparing the outcome of nursing care provided with the out-comes and objectives indicated in the individual patient's nursing careplan. Feedback mechanisms such as the audit assist in spotting pointsfor reassessment and replanning and complete the cycle of the nursingprocess.

In the budgeting process, evaluation is usually known as financialcontrol. It is a function that should continue throughout the fiscal yearand not be viewed as an end of the fiscal year exercise. Like evaluationin the nursing process, budget control involves comparison of actualperformance with a predetermined standard (i.e., the approved budget).Feedback usually is processed from the institution's periodic financialreports, such as revenue and expense statements and trend reports.

While the nursing care plan is nearly continuously monitored on ashift-to-shift basis, the budget is most manageably evaluated by thenursing administrator on a monthly basis. Just as the nursing care planshould be evaluated by nursing staff who are providing the nursing care,financial control activities should involve those persons who are involvedat the level at which costs are incurred. This concept is known as re-sponsibility accounting and is well developed in the literature bySchmied and others (1).

It is evident that there are many similarities between the nursing andbudgeting processes, although the focus of each is quite different. Bothprocesses share the elements o[ assessment, planning, implementation,and evaluation, which are linked in a continuous cycle of feedback andmodification. Such a comparative analysis maybe useful for the nursingadministrator in educating members of the nursing staff who areknowledgeable about the nursing process but lack substantial skills inthe budgeting process.

SUMMARY

An overview of current health care reimbursement issues, financialmanagement concepts, accounting principles, and budgeting compo-nents provides the nursing administrator with a framework for dealing


with the complexities of a nursing service budget within a health careinstitution. Many, instructive correlations exist between the componentsof the budgeting process and the components of the nursing process.

The substantive and skilled involvement of nursing administrators inthe fiscal process and subsequent allocation of institutional resourcesis essential. ultimately, the quality and quantity of nursing care availableis directly related to the effectiveness with which the nursing admin-istrator is able to influence the resource allocation process.

STUDY QUESTIONS

1. what does prospective reimbursement mean for a hospital? specif-ically, for nursing services?

2. Formulate a statement on the role of one nursing service adminis-trator in the changing reimbursement climate.

3. Describe the concept of financial management and its relationshipto clinical nursing practice?

4. Differentiate financial management, accounting, and budgeting.5. List one or more characteristic features of a fixed budget, a variable

budget, a planned programmed budget system, and a zero-basedbudget technique.

6. outline two or more factors the nursing administrator might considerin preparing to participate in each of the budgetary approaches.

7. Describe the similarities between the budget process and the nursingprocess.

8. Contrast the focus of the nursing process and the budget process.

REFERENCES

l. Schmied, E., ed. Maintaining Cost Effectiveness. Wakefield, Mass. NursingResources,1979.

2. Grimaldi, P.L. Public law 97-248: the implication of prospective paymentschedules. Nursing Management, February 1983, 14{2) 25*27.

3. Coburn, R.W. and Harper, D.V. An alternative to cost-based hospital reim-bursement. Health Care Financial Management,May 1983, 37(5) 3644.

4. Curtin, L. Determining costs of nursing services per DRG. Nursing Manage-ment, April 1983, 14 (4): 16-20.

5. Levinstein, A. Art and science of management: tough times ahead? NursingManagement, December 1983, 14 (12): 65-66.

6. Berman, H.J. and Weeks, L.E. The Financial Management of Hospitals, 5thed. Ann Arbor, Mi.: Health Administration Press, 1982.

7. Marri8. Robbi

tice-H9. Rowlz

town,

BIBLI(

Connors,zations

LaMonicAddiso

Pyhrr, P.

Riggs, HWildowsl

Ith careponentsocess.ators insourcesvailableadmin-

MANAGING FISCAL RESOURCES I39

7. Marriner, A.The Nursing Process, St. Louis: Mosby, 1975.

8. Robbins, S.P.TheAdministrativeProcess,2d ed. Englewood Cliffs, N.J.: Pren-tice-Hall, 1980.

9. Rowland, H. and Rowland, B. Nursing Administration Handboo,ft. German-town, Mo.: Aspen Systems Corporation, 1980.

Specif-

dminis-

-ionship

ting.,uariableo-based

:onsider:hes.

nursing

)cess.

Nursing

)ayment

al reim-44.Manage-

Nursing

tals, 5th

BIBLIOGRAPHY

Connors, T.D. and Callaghan, C. Financial Management for Nonprofit Organi-zations. New York: American Management Association , 1982.

LaMonica, E.L.TheNursingProcess: AHumanistic Approach. Menlo Park, Calif.:Addison-Wesley, 1979.

Pyhrr, P. Zero-Base Budgeting. New York: Wiley, 1973.

Riggs, H.E. Accounting: A Suruey. New York: McGraw-Hill, 1981.

Wildowskey, A. The Politics of the Budgetary Process. Boston: Little, Brown , 1964.

11

The purpose of this chapter is to present conflict and conflict res-olution within the framework of professional nursing practice.Nursing administrators must cope with the competing pressuresand demands of hospital administrators for cost effectiveness, ofmedical staff for competent nursing assistance, and of nursing per-sonnel for improved wages, benefits, and working conditions. Al-though such continued conflict can and does produce feelings ofstress in nurse administrators, it can also provide an opportunityfor the individual and organization to change and grow. On com-pletion of this chapter, the reader will be able to:

1. Define conflict and describe three pertinent theories of conflict.2. Discuss functional and dysfunctional aspects of conflict.3. Identify examples of types and sources of conflict.4. Discuss strategies of conflict resolution.5. Describe five power bases.6. Relate collective bargaining to conflict resolution.

Conflict is an inherent part of all organizations. Within a health careorganization, it may result from divergence of opinion, incompatibility,transmission of erroneous information, or competition for scarce re-sources. Although often viewed as a negative manifestation of humaninteraction, conflict can have positive as well as negative aspects. Theconcepts, theories, and processes related to conflict and conflict reso-lution have been the subject of extensive and intensive study.

Conflict has a variety of definitions. Robbins (1) depicts conflict as"all kinds of opposition or antagonistic interaction. It is based on scarcityof power, resources or social position, and different value structures"(p. 231). This definition is based on the premise of awareness. Admin-istrators must first perceive a conflict situation before they can studyit. Such awareness is especially pertinent for the practitioner, for whomconflict implies interpersonal, intergroup, and intragroup interactions.

140

Managing ConflictGladys Ancrum

Leinirand proing beergroup fremphasor moretheir "fzsomethi

PHILOoF co

Early clconflictto elimithe litercreatedor cowoSince tlcourage

In coralthougophy, c<

was maures to .

entirelysoning r

eficial tneededpropos€

Interrsition aIndeed,in needthat dotivationout thadecisiorquate d,

group. l

ministrand doactionit

Socia

:t res-ctice.isures)ss, ofg per-rs. Al-lgs of:unitycom-

flict.t.

'lth careItibility,)arce re-:human:cts. Theict reso-

nflict asscarcitl.

lctures '

.\dmin-rn studrlr rvhom'actions.

MANAGING CONFLICT 141

Leininger (2) views conflict as "opposing viewpoints, forces, issues,

and problems which confront individuals, groups, and institutions, hav-ing been generated from a variety of internal and external personal andgroup forces" (p. 18). On the other hand, Archer (3), in her definition,emphasizes resource allocation because when a situation involves "twoor more competing individuals or groups wanting more resources thantheir "fair share" or than is available, or have different ideas about howsomething ought to be done, the stage is set for conflict" (p.85).

PHILOSOPHICAL AND HISTORICAL BACKGROUNDOF CONFLICT MANAGEMENT

Early classical writers on management, the traditionalists, consideredconflict a destructive force and believed it was the role of the managerto eliminate conflict from the organization. This philosophy dominatedthe literature until the 1940s. Traditionalists felt that if a staff membercreated a conflict situation by disagreeing with the views of managementor coworkers, then that person must be discharged from the organization.Since the reason for dismissal was rarely discussed, others were en-

couraged to abide by rules and regulations'In contrast to the traditionalists, the behavioralists held the view that,

although harmful, conflict was inevitable. In the behavioralist philos-ophy, conflict in complex organizations was accepted, and an attemptwas made to rationalize its existence. This was done by devising meas-ures to reduce, rather than to eliminate, conflict. Such measures focusedentirely on the development of conflict resolution techniques. This rea-soning eventually led to the view that conflict could be turned to ben-eficial use. Thus, Robbins (1) espoused that a positive approach wasneeded if conflict was to be of value to an organization, To this end, heproposed the current interactionist philosophy.

Interactionists recognize the need for conflict and encourage oppo-sition as a creative force that must be stimulated as well as resolved.Indeed, they are concerned when conflict is inadequate or absent andin need of greater intensity. The interactionists believe that organizationsthat do not encourage conflict increase the probability of or lack of mo-tir,ation, creative thinking, and effective decision making. They pointout that companies have failed because few staff members questioneddecisions made by management; in such cases, apathy allowed inade-quate decisions to remain in effect because of a conflict-free managementgroup. In the field of health care, Stevens (4) notes that most nurse ad-ministrators do not consider the stimulation of conflict to be beneficialand do not bf intent engage in this practice as it is promoted bf inter-actionists.

Social scientists and hun-ranisis har e studied conflict and conflict be-

)ur major

:hiatrists,re of con-:e as wellr evident.i.

behaviorgroup.

ulture ac-:elated to

ted to po-economic

o conflictransdisci-this area

ing, man-onflict ef-if none isrum, withlme pointI and val-recessarily

nents, arend highlyrpropriaterps withintrators to.he energy

:. It is theive value.listinctionor precise.ional con-,f conflict)

MANAGING CONFLICT I43

is a challenge to administrators (p. 20)." A conflict that may be dys-

functional at one time, in a given setting, or as perceived by individualsat a certain level in the organizational hierarchy may be consideredfunctional at another time, in a different setting, or by individuals at ahigher status level in the organization' For example, a conflict may ariseover an administrative decision to use computers for recording patientdata, especially if the staff nurses were not involved in the decision andthey perceive this change as an increased burden. However, managementrationale for the change was that data on the population served by theorganization would be more readily available and accessible and facil-itate planning for needed services.

CHARACTERISTICS OF CONFLICT

Baldridge (6) noted that the situations that provoke conflict can be de-

scribed by four general characteristics. The first is known as the icebergphenomenon, in which an apparent problem serves to draw attentionto other critical issues under the surface. The superficial problem israised as a pretense for bringing more fundamental issues to light. Forexample, an initial problem related to staffing, such as nurse assignmentpatterns, may actually be merely the externalization of a much morebasic issue: the wish to gain participation in decision making at thestaff nurse level.

The second characteristic situation is related to issues that cause large-scale conflict that tends to have a unifying effect on diverse interestgroups. This had occurred in almost all campus resistance movements,in which individuals usually have no common interest other than beingbound by the current conflict situation.

Third, conflict is often the result of rising expectations, rather thanthe presence of intolerable conditions. Nurse administrators need to becognizant that major concessions and improved conditions can inducea high level of expectation and thus actually provoke new conflict withthe repetition of a similar pattern.

Fourth, the issue in conflict often has moral overtones that justify andlegitimize radical action. Individuals use issues such as sex discrimi-nation and nurse power as ultimate goals to justify almost any short-range excesses. However, at the other end of the organizational spectrum,the same tactic is used by nurse administrators when they demand au-tonomy in their negotiations with the governing boards of health careagencies.

TYPES OF CONFLICT

Although, as we havc seen, conflict situations have similar characler-istics, the lorms of conflict arc highly diverse. Thev mav be categorized


as intrapersonal, interpersonal, intergroup, or interorganizational innature. Intrapersonal conflict, which was mentioned earlier as a psy-chiatric phenomenon, is incongruous to an individual's role; there islack of conformity between a person's goals and what is expected withinthe framework of his or her role. "Intrapersonal conflict exists in thecognitive and affective realms of an individual's mind. Thus, an indi-vidual may perceive that he or she is conflicting with the organizationor other employees, but the conflict, in fact, exists only in that person'smind, not at a behavioral level" (7, p.299).

However, intrapersonal conflict can be the underlying cause of inter-personal conflict. For example, emotionally distressed persons bring totheir jobs feelings that relate to their private lives. Preoccupation withpersonal problems can produce less concentration on work-related re-sponsibilities and decision making. The behavior due to mental pro-cesses, especially for the nurse administrator, can be the source of in-terpersonal conflict among peers, subordinates, and coworkers of otherdisciplines.

Interpersonal conflict arises between two or more individuals or withina group. For example, withholding information may create a conflictbetween a nurse administrator and her assistant. Conflicts among di-vision heads, staff nurse and physician, and committee members mayoccur for the same reason.

Interpersonal conflict may be inherent in a person's role when thereis disagreement between the values and beliefs of the occupant of therole and the expectations set forth by others. In many health care in-stitutions in the 1980s, the nursing administrator is charged with theoverall responsibility for the practice of nursing. However, disagreementcan occur if one professional challenges the practice decisions of a mem-ber of another profession. Kalisch and Kalisch (8) refer to a commonsource of conflict in the traditional behavior pattern between physiciansand nurses as "physician's dominance and nurse's deference." Thishierarchical attitude and expectation is found not only at the practicelevel but extends through executive-administrative levels.

In the capacity of executive-level administrator, the nurse adminis-trator is expected to perform an array of activities with an unusuallydiverse professional group. Kelly (9) maintains that the role of nurseadministrator is extremely difficult to enact because "that role is oftenstereotyped and contradictory, with multiple split opinions on its powerand authority. A top-level nurse administrator . . . lisl surrounded bydifferent sets of behavioral expectations to satisfy from groups higherup, lower down, and on the same level in the structure" (p. 157). Studiesconducted by Arndt and Laeger (10) and Halsey (ll) both concludedthat conflict and role strain existed for the nurse administrator resultingfrom pressure to respond to role prescription from a variety of sources.

It is vital that the nurse executive examine his or her role conception.

The ermakintulfillito the

Intersuch a,

transnbetweeflict. S:

(12) pcas badthe corempha

SOUR

Power,of confinterpe"givenpowerof onevaluesgroupstrol of

Frenrhas po'power,power.an indianotherewardthat anis basevidualbased <

emulat,to havr

Becathe nurdescrituse of 1

are awuses ot

ional ins a psy-there is

d withints in thean indi-nizationperson's

of inter-bring toion withlated re-rtal pro-'ce of in-r of other

cr withinL conflictmong di-)ers may

ren therent of ther care in-with thegreementrf a mem-common,hysiciansce." This: practice

adminis-rnusuallyof nurse

.e is oftenits powerunded byps higher). Studies:oncluded'resultingf sources.Inception.


The executive should take an activist's position in regard to that role,making it the sort of role he or she perceives it to be, rather than merelyfulfilling the role others expect or anticipate. An attempt to subscribeto the latter philosophy can be a source of intrapersonal conflict.

Intergroup, or interorganizational, conflict arises between two groups,such as in the form of interdepartmental issues. Disagreements and thetransmission of erroneous information between departments, such asbetween medicine and nursing, are common sources of this type of con-flict. Such conflicts are depicted as harmful by management, but Argyris(12) points out that "instead of trying to stamp out intergroup conflictas bad and disloyal, the executives must learn how to manage it so thatthe constructive aspects are emphasized and the destructive aspects de-emphasized" (p.23).

SOURCES OF CONFLICT

Power, defined as the ability to influence others, may be a major sourceof conflict. Frost and Wilmot (13) emphasize that, because it is alwaysinterpersonal, power exists only in a human context and is, in a sense,"given from one party to another in conflict" (p. 52).Within this context,power is not an actual show of force, but it is the perceived potentialof one party to exert influence on another party, depending upon thevalues and nature of the relationship of those involved. Individuals andgroups have power when they have access to information and have con-trol of resources and support services to carry out tasks.

French and Raven (14) describe five situations in which one personhas power over another. These five bases of social power are rewardpower, coercive power, legitimate power, referent power, and expertpower. The basis of reward power is the ability to offer rewards. Thus,an individual is made to perceive that compliance with the wishes ofanother will lead to positive rewards. Coercive power, the opposite ofreward power, is exercised in such a way that one individual perceivesthat another can mediate punishment for him or her. Legitimate poweris based on agreement and values held in common, enabling one indi-vidual to exercise power over the other by consent. Referent power isbased on identification with the ideals of an individual and the wish toemulate that person. Expert power is present when a person is perceivedto have superior knowledge or skill in a particular field.

Because of position, knowledge, profession, and organizational context,the nurse administrator may acquire and use all of the kinds of powerdescribed. The nurse executive should neither avoid nor overplay theuse of power, nor fail to use it for ethical and legitimate purposes. Othersare aware of potential resources of power, and the administrator whouses overkill in a power conflict risks loss of effectiveness. Thus, the

-146 cURRENT AND EMERGINGIHALLE_NqES

administrative nurse must frequently come to terms with conflicts be-tween personality, professional ideals, and the needs of the institution.

By position and title, the nurse administrator's legitimate power andauthority is generally recognized throughout the organization. However,the precise scope of this power and authority may be an area of conflict.An issue in many health care facilities is who controls the practice ofnursing. The director of nursing has the authority, but the extent of hisor her power may be limited to resolving problems that occur withinthe department. Unless the director has other powers to augument hisor her legitimate power, legitimate power may not be sufficient for theadministrator to decide a nursing practice issue related to the overallorganization or to other disciplines.

The nursing administrator also has substantial reward and coercivepower based on the right to hire, evaluate, promote, and discharge in-dividuals. The nursing director needs to be sensitive to the fact thatpower is only a part of the continuing relationship between the super-visor and the supervised and that power is not an acceptable substitutefor skillful leadership and motivation.

The nurse administrator has expert power derived from two sources:professional knowledge and administrative skills. The fact that these

two types of expertise are not always compatible can become a sourceof intrapersonal conflict. It is generally accepted that one's clinical ex-

pertise diminishes with the immediacy of administrative burdens. Thisionflict is pointed out by Aydelotte (15), who notes: "The director ofnursing is in a unique place in the organizational structure of a hospital.She is not an executive in the full sense, nor is she solely a practicingprofessional. She provides professional expression for the particulargroup she represents by initiating and encouraging innovations in itspractice. . . . Concomitantly she exercises influence in determining goals

ind policy, and in directing the movement of her professional grouptoward departmental and institutional goals" (p'62).

Referent power, based on personal characteristics, may or may notbe strong enough to induce others to emulate the nursing administrator.However, referent power can be diminished when the nursing admin-istrator develops hostile, defensive personality patterns.

Nurse administrators who are knowledgeable about the various typesof power and power bases and how they are used are better able tofunction in a enlightened position and provide a climate for more ef-

fective leadership. Nurse administrators need to make informed andhigh-risk decisions that may be potential sources of conflict. As membersof the executive team in health care delivery settings, nurse adminis-trators must take risks and move into positions of power. Much of thepower that administrators gain is derived from their access to infor-mation. The nurse executive who is aware of the information networkof the organization realizes there are formal channels that transport

informto com

Martsituatihave tldiffereand au

the phconflicthe nutspecialand anstatus.sourcel

As ntconflicmanag

STRA'

Negoti

NegotieHowev,limitecNevert.serviceadminiplishinlwith aa majoand re

Neg<(18) virlyzed tsuch s1

towartstructlnegotiand ttnegoticomplnegotinegoti

CURRENT AND EMERGING qFTALL!Ngqs_148

cohen (19) presents another perspective on negotiation. He views itas a process of information, timing, power, and pressure to secure acommitment to change behavior. power, the ability to use resources toachieve worthwhile goals, may include risk taking, competition andpersistence. cohen stresses that successful negotiatlon is tased on ac-curate and sufficient information gathered by critical listening, ques-tioning, and reading cues. It is important to note that, in order to achieveagreement in negotiations, group tension must be reduced. Stress reliefmay be achieved by the following steps: (1) the maintenance of timelimitations by both parties and (2) the application of pressure on thenegotiator to take or avoid risks.

General guidelines to effective negotiations include belief in oneselfas an able negotiator; willingness to seek assistance in problem solving,in the recognition that the objective is collaborative seitlement as com-mitments made to individuals, not necessarily organizations; encour-agement of an exchange of information; and the ability to assess andvalidate changing circumstances in the negotiating protess.

Collaboration

I-win-you-win collaboration as a strategy or technique is closely relatedto negotiation, and the terms are sometimes used interchangeably whenconflict resolution is discussed by different authors. However, collab-orative theory supports the belief that people should bring their differ-ences to the surface and delve into the issues to identify underlyingcauses and to find an alternative mutually satisfactory to both parties.The approach is based on the assumption that people will be motivatedto invest time and energy in such problem-solving-activity. The conflictis viewed as a creative, positive force that will lead to an improved stateof affairs to which both sides are fully committed. when progress canno longer be made, a mediator (third-party consultant) may be employedto assist the parties to arrive at a win-win position.

collaborationists further argue that theirs is the preferable strategyfor the good of an organization because (l) open and honest interactionpromotes authentic interpersonal relations; (2) conflict is used as a cre-ative force for innovation and improvement; (3) the process enhancesfeedback and information flow; and (4) the solution of disputes in itselfseryes to improve the climate of the organization by enhancing openness,trust, risk taking, and feelings of integrity (20).

collaboration has been found to be most effective in situations in whichthere is (1) a high degree of required interdependence; (2) power parity,allowing the parties to interact openly, utilizing all of their resourcesto further their beliefs and concerns regardless of their superior-sub-ordinate status; (3) potential for mutual benefits; and (4) the expectationof organizational support.

Nursing administrators are frequently encouraged to develop lead-

ershipthe sarcoordirgoals. Imust uThey nand wlacquire

In thstructulare oftegoal ofization,patientrauthoripower.power (

One rdependexamplfor newnursingnumbertient capatientment tcopportrof the c

Furthersources.attainrrerarchysubgror"cians, nbe mort

Collecti

Collecti,their errstaff. Tlwhetherworkingissues ar

be a barIn 194

NAGTNG C_ONFLTCT__149

ership skills that emphasize the resolution or suppression of conflict. Atthe same time, they often find that power is necessary to direct andcoordinate day-to-day activities, compete for scarce resources, and attaingoals. However, to perform these tasks effectively, nurse administratorsmust understand and be able to plan strategies for dealing with conflict.They need to know how power is distributed within the organizationand where they stand within the power structure to determine how toacquire the leverage needed to fulfill their role.

In the organizational hierarchy of a hospital, the two major powerstructures are the administration and the medical staff. These two groupsare often inherently in conflict because of differences in their goals: thegoal of the administrators is to realize an efficient, cost-effective organ-ization, and that of the physicians to obtain optimum resources for theirpatients. In most hospitals, physicians do not have formal organizationalauthority over hospital employees, including nurses; yet, they do havepower. Thus, an important task of the nurse executive is to increase thepower of nursing without aggravating organizational conflict.

One route by which this objective can be attained is to emphasize thedependence of other organizational units of the hospital on nursing. Forexample, if the chief of pediatrics wants to open an intensive care unitfor newborns, he or she must rely on the nursing director to staff it. Thenursing director in turn must provide personnel not only in sufficientnumbers but also with the necessary critical-care skills for quality pa-tient care, ready and fully trained on the day the unit accepts its firstpatient. Rather than treating this accomplishment as a routine assign-ment to be expected of a nursing director, the director should use theopportunity to make the hospital community aware of the importanceof the director and of nursing in general to the realization of a goal.Further, the director should convey the idea that he or she has re-sources-that is, power-and is ready to use them to help or hinder theattainment of an objective of a member from another area in the hi-erarchy. Moreover, power may be augmented by gaining support fromsubgroups within a high-power group. Thus, by supporting the physi-cians, nurses can gain leverage in dealing with administrators who maybe more interested in satisfying physicians than nurses.

Collective Bargaining

Collective bargaining produces conflict not only between nurses andtheir employers, but also between nursing administration and nursingstaff. The principle questions related to collective bargaining are (1)whether it should serve primarily for economic gains and improvedworking conditions or whether negotiations should include patient careissues and (2) whether the American Nurses'Association (ANA) shouldbe a bargaining agent.

In 1946, the American Nurses' Association adopted a program of eco-

MA

: views itsecure a

iources toition and,ed on ac-ing, ques-to achieveress relief:e of timerre on the

in oneselfn solving,rt as com-s; encour-rssess and

:ly relatedrbly when:r, collab-reir differ-nderlying;h parties.motivatedre conflictoved state)gress canemployed

e strategyrteractionI as a cre-enhances:s in itselfopenness,

s in which'er parity,resourceserior-sub-rpectation

:lop lead-

150* cunRpNr nNn EMERGING CHALLENGES

nomic security. However, because the ANA program included a no-strikepolicy, collective bargaining activities remained relatively conservative.Indeed, the idea of group action to improve salary and working con-ditions precipitated a conflict concerning the question of professionalethics . In 1966 , this position changed (2 I ). Finally , the 197 4 Health CareAmendments of the National Labor Relations Act gave employees ofnonprofit health care organizations the right of collective bargaining.Today, the majority of the members of the nursing profession at thestaff level seem to accept the validity and necessity of collective actionto attain economic goals and improve working conditions.

The issues that remain in conflict are in the area of professional goals:who shall control nursing, nursing practice, and nursing quality. Legally,the authority, responsibility, and accountability for hospital operationsand patient care are in the hands of hospital administrators (22). Nursesare individually and legally accountable for their nursing practice, butbecause they are employees of a hospital, management in the person ofthe director of nursing is in fact responsible for institutional quality.

Many leaders of the nursing profession have published their views onthe impact of collective bargaining on nursing. The thrust of argumentsof those opposed to the principle is that the concept of collective bar-gaining is counterproductive to professionalism, while those in favorsuggest that ir is "an opportunity to develop a new model of labor re-lations which will benefit not only employees and management, buthealth care delivery as a whole." Cleland (23) describes a professionalcollective bargaining model that emphasizes benefits for professionalnursing practice. Her model provides for the joint devclopmento[ professional policy decisions by nursing staff and administrators.The policies would give nurses control of their practice and wouldallow thcm to determine standards of practice and to definc qualityof care.

A study cited by Erickson (24) indicates that "staff nurses are not al-ways supportive of professional or patient care issues, and indeed thatrank-and-file nurses seem to be primarily motivated by economics."Further, she raises the question of whether staff nurses are really in-terested in using collective bargaining to improve patient care or onlytheir own economic status. Herzog (25) deals in further detail with theschism existing in nursing and concluded that "until nurses agree uponan accepted set of standards of practice, the issues of quality and practicewill remain controversial."

Sargis (26), in a study in which 216 directors of nursing responded toa questionnaire, concluded that directors of nursing service show notendency to support the professional organization as a collective bar-gaining agent and that a great deal of ambivalence exists about collectivebargaining activities, which may finally alienate the directors of nursingfrom ANA.

SUMN

Confliccan ha'rconflictThere arvhich r

from oritable cactionisas well

Fourpsycholthe antlEach ap

Situaproblerrthat ten(4) mori

The t'includirorganiziis especand "haFrenchpower.

Manyresolutithree ofdisadva

STUDl

1. Forn2. Com

actic3. Citc4. Wha

Expl5. Of tl

asn6. Wha

MANAGING CONFLICT 1s1

no-strikeservative.<ing con-rfessionalalth Careloyees ofrgaining.:n at theve action

ral goals:'. Legally,perationsl). Nursesctice, butperson ofquality.views on

nguments:tive bar-: in favorlabor re-nent, butrfessionalrfessionalelopmcntistrators.rd wouldc quality

re not al-leed thatnomics."really in-e or onlywith the

,ree uponI practice

onded toshow notive bar-:ollectivef nursing

SUMMARY

Conflict, often viewed as a negative manifestation of human interaction,can have positive as well as negative aspects. How a person perceivesconflict may be influenced by the definition and theory he or she accepts.There are three major philosophical views of conflict: (1) traditionalist,which views conflict as a destructive force that should be eliminatedfrom organizations; (2) behavioralist, which views conflict as an inev-itable occurrence that should be reduced or controlled; and (3) inter-actionist, which views conflict as a creative force that must be stimulatedas well as resolved.

Four approaches to understanding conflict are (/) the interpersonal-psychological approach , (2) the interactional-sociological approach, (3)the anthropological approach and (4) the economic-political approach.Each approach assumes a different source of conflict.

Situations that can provoke conflict include (1) the use of an apparentproblem to bring a more critical issue to the surface, (2) large-scale issuesthat tend to unify a diverse interest group, (3) rising expectations, and(4) moral overtones that justify radical action.

The types of conflict that mav be encountered are (1) intrapcrsonal,including role conflict; (2) intcrpcrsonal; and (3) intergroup, or inter-organizational. Power is onc of thc primary sources of conflict. Thisis especially true whcn the disposition of power is seen as a "have"and "have-not" situation. There are five kinds of power, as delined byFrcnch and Raven: reward, coercive, legirimate, referent and cxpertpowcr.

Many techniques or approaches may bc used effectively for conflictresolution. Ncgotiation, collaboration, and collective bargaining arethree of the most common strategies. Each has its own advantages anddisadvantages.

STUDY QUESTIONS

1. Formulate a definition of conflict.2. Compare and contrast thc rraditionalists, behavioralists, and intcr-

actionists approach to conlict.3. Cite at least two cxamples and sourccs of conflict.4. What strategics of conflict rcsolution would you bc likely to utilizc?

Explain?5. Of the five bases of powcr, which ones are the most applicable to you

as nursing administrator? Why?6. What is the relationship of collective bargaining to conflict resolution?

t52 CURRENT AND EMERGING CHALLENGES

REFERENCES

1. Robbins,S.P.ManagingOrganizationalConflict:ANontraditionalApproach.Englewood Cliffs, N.J.: Prentice-HalI, 1974.

2. Leininger, M.M. Conflict and conflict resolution: theories and processes rel-evant to the health professions. The American Nurse, December 1974,6(12),t7-22.

3. Archer, S.E. and Goehner, P.A. Nurse: A Political Force.Monterey, Calif.:Wadsworth, 1982.

4. Stevens, B. J. The Nurse as Executive,2d ed. Wakefield, Mass.: ContemporarvPublishing, 1980.

5. Lewis, J.H. Conflict management. Journal of Nursing Administration, De'cember 197 6, 6(10),, 18-22.

6. Baldridge , J.Y. New Approaches to Managemenf. San Francisco: Jossey BassPublishers, 1979.

7. Zey-Ferrell, M. Dimensions of Organizations. Santa Monica, Calif.: GoodyearPublishing Co.,1979.

8. Kalisch, B. J. and Kalisch, P.A. An analysis of the sources of physician-nurseconflict. Journal of Nursing Administration, January 1977 ,7(l),50-57.

9. Kelly, J. The role of the top level nurse administrator, in University of Min-nesota, Proceedings, Nursing Administration: Issues for the 80s-Solutions forthe 70s. Battle Creek, W.K. Kellogg Foundation, 1977.

10. Arndt, C. and Laeger, E. Role strain in a diversifed role set: the director ofnursing service. Nursing Research, March l97O , 1 9(3), 253-259 .

11. Halsey, S. The queen bee syndrome: one solution to role conflict for nursemanagers, in Hardy, M.E. and Conway, M'E., Role Theory: Perspectives forH ealth Professionals. New York: Appleton-Century-Crofts, 197 8.

12. Argyris, C. How tomorrow's executives will make decisions. Think, June1967, 33(6),22-2s.

13. Frost, J.H. and Wilmot, W .W. Interpersonal Conflicf. Dubuque' Iowa: WilliamC. Brown Co., 1978.

14. French, J.R.P. and Raven, B. The bases of social power, in Cartwright, D.and Zander, A., eds., Group Dynamics: Research andTheory. New York: Har-per & Row, 1968.

15. Aydelotte, M.K. Administration and directors of nursing. Hospitals, Novem-ber 197 4, 48(23), 6 1-63.

16. Marriner, A. Conflict theory. Superisor Nurse, April 1979, 10(4)' 12-16.

17. Kelly, J.A. Negotiating skills lor the nursing service administrator. NtLrsingClinics of-North America, September 1983, 18(3), 427-438.

18. Strauss, A. Negotiations: Varities, Contexts, Processes and Social Orders. SanFrancisco: Jossey Bass Publishers, 1979.

19. Cohen, H.YouCan Negotiate Anything. Secaucus, N.J.: Lyle Stuart Publishers,1980.

20. Likert, R. and Likert, J.G.Ways of Manttgittg Conflict.. New York: McGraw-Hill, 1976.

21. McClelland, J"Q. Professional and collective bargaining: a new reality fornurses and manage menl. The J oumal of N ursing Administration, November1983, 8(l r), 36-38.

22. JacorNich<ton: I

Clelar1974,EricksionaHerz<profe34-3tSargigaini26.

23.

24.

25.

26.

l{2- cunnerur nNo EMERGTNG cHALLENGES

havior particularly since World War II. They have identified four majorapproaches to understanding confl ict :

1. The study of interpersonal conflict is spearheaded by psychiatrists,psychiatric social workers, and psychiatric nurses. This type of con-flict can and does occur within the individual. Ambivalence as wellas disordered perception, feeling, and behavior are usually evident.These symptoms are associated with psychiatric problems.

2. The interactional sociological approach focuses on group behaviorand interactional phenomena in decision making within a group.

3. The anthropological approach emphasizes the stresses of culture ac-climatization, value and cultural conflicts, and conflicts related topersonality and the social environment.

4. The economic-political approach emphasizes conflicts related to po-litical concerns, power games, coalitions, and political and economicprocesses.

Leininger (2) predicts the evolution of another approach to conflicttheory in the health care professions, one concerned with transdisci-plinary and intradisciplinary conflicts and problems. It is in this areathat nurse administrators must be knowledgeable in identifying, man-aging, and resolving conflict. They must not only deal with conflict ef-fectively and use it constructively, but must also stimulate it if none isapparent. Lewis (5) notes that "we should visualize a continuum, withtoo much conflict at one end and too little at the other. At some pointbetween these extremes, the quantity of conflict is functional and val-uable. This point is determined by management and will not necessarilybe the same for any two organizations" (p. 18).

FUNCTIONAL AND DYSFUNCTIONAL CONFLICT

Health care institutions, such as hospitals and health departments, arefrequently classified as complex organizations. In complex and highlydiversified organizational settings, conflict is inevitable. Inappropriateresponses to conflict can be unhealthy for individuals and groups withinthe organization. It is a frequent concern of nursing administrators toreduce conflict and tension to a tolerable level and to channel the energygenerated by conflict situations toward constructive goals.

Conflict in and of itself can be a positive or negative force. It is theuse or misuse of this force that determines its effect and relative value.Thus, conflict may be seen as functional or dysfunctional. The distinctionbetween functional and dysfunctional conflict is neither clear nor precise.Lewis (5) emphasizes that "determining the point when functional con-flict is reached (as opposed to dysfunctional conflict or lack of conflict)

is a chafunctionat a cerlfunctionhigher stover an i

data, es;they per<

rationalrorganizaitate pla

CHARA

Baldridgscribed tphenomtto otherraised as

example,patternsbasic issstaff nur

The se,

scale corgroups.'in whichbound b

Third,the prestcognizara high lethe repe

FourtlIegitimi:nation arange exthe samrtonomyagencies

TYPES

Althougistics, tl

i Approach.

:ocesses rel-t974,6(t2),

erey, Calif.:

Intemporary

;tration, De-

Jossey Bass

[.: Goodyear

sician-nurse50-57.

:sity of Min-Solutions for

: director of

Lct for nursespectives for

Think, June

wa: William

rtwright, D.r York: Har-

a/s, Novem-

), t2-16.tor. Ntusing

Orders. San

. Publishers,

k: McGraw-

' reality for, November


22. Jacox, A. Collective action: the basis for professionalism, in Hein, E.C. andNicholson, M.J ., C ontemporary Leadership B ehavior : S elected Readings. Bos-ton: Little, Brown, 1982.

23. Cleland, V.S. The professional model. Ameican Journal of Nursing, Februaryt974, 7s(2), 288-292.Erickson, E. Collective bargaining: an inappropriate technique for profes-sionals. N ursing F orum, March 197 l, I 0(3), 300-3 I 0.Herzog, T. The National Labor Relations Act and the ANA: a dilemma ofprofessionali sm. The Joumal of Nursing Administration, October 197 6,6(10),34-36.

26. Sargis, N.M. Will nursing directors' attitudes affect future collective bar-gaining? The Journal of Nursing Administration, December 1978, 8(12), 21-26.

24.

25.

Leadership in Careof the Elderly

The purpose of this chapter is to introduce care of the elderly as achallenge for nursing administrators to provide leadership in healthcare delivery settings. On completion of this chapter, the readerwill be able to:

l. Describe trends in demography that contribute to the growthof the age group over 65.

2. Contrast the standards of health care for the aged and youngerpatients in health care settings.

3. Identify the characteristics of the frail and not so frail elderly.4. Clarify the difference between age-related changes and dis-

eases that affect psychological and physical functioning in oldage.

5. Present a systematic plan for assuming leadership in stimu-lating better care for the elderly.

6. Describe obstacles to implementing a geriatric focus in ahealth care delivery setting.

7. Discuss the factors that influence the nursing care of elderlywomen.

The greatest challenge for nursing administrators in the 1980s is pro-viding leadership in the care of older people. Not only is the populationin the United States aged 55 and older growing at a rapid rate in num-bers, but is is also steadily growing in proportion to the rest of the pop-ulation. Speaking to the American Public Health Association in Montreal,November 1982, Robert Butler past Director, Institute on Aging de-scribed the threat of nuclear war and the growing number of agingAmericans as the two most critical challenges facing American society(1). One out of every five Americans is currently 55 or older, and one innine is 65 or older (2). In other word s, ll .2 percent of the population is65 or older. The proportion of people in the 65-plus age group will in-

154

FIGUREto 2050 (

Health S

crease t(over halFigure 1

The fenursingolder adhealth-r,educatic

Life e:significaancy of6e.s). winonwhit

Sincecelerate<expectarages: gr(mortalit

lyasahealthreader

;rowth

ounger

lderly.rd dis-in old

stimu-

rsina

elderly

0s is pro-:pulation: in num-I the pop-Montreal,\ging de-of aging

rn societynd one inulation isp will in-

LEADERSIIIP IN CARE OF THE ELDE_BII J55

I I Age 53-b4

lltilliili:i.i:iiilli1l Age o5+@-

01900 1950 1960 1910 1980 1990 2000 2010 2020 2030

FIGURE 12.1 Numberofpersons aged 55 andoverby age group, 1900 and 1950to 2050 (data for 1980-2050 are projections). (From the National Center forHealth Statistics.)

crease to approximately one out of eight by the year 2000. By that year,over half the population of the United States will be older than 35 (see

Figure 12.1).The fastest-growing group is the old old, those over 75 years. If the

nursing profession is to respond adequately to the growing numbers ofolder adults, it must intensify its commitment to the special health andhealth-related problems of older people at every level of administration,education, practice, and research (3).

Life expectancy at birth reached at record 73.3 years in 1978, withsignificant gains made by both sexes during the 1970s. The life expect-ancy of women continues to be longer than that of men (77.2 versus69.5). White women have the highest life expectancy (77.8), followed bynonwhite women (73.6), white men (70.2) and other men (65.0) (2).

Since 1950, life expectancy in the older ages has increased at an ac-celerated pace (see Figures 12.2 and 12.3). Most of the increase in lifeexpectancy before 1950 was due to decreasing mortality at the youngerages: growing numbers of people reached old age because of decreasedmortality rates in the younger age groups. Since World War II, life ex-

156 _cURRENTAND EMERGING CHALLENGES

Under 18 18-54 55-64 65+

1910

1920

1930

1940

1950

1960

1970

1980

r990

2000

2010

2020

2030

2040

2050

Go

o 20 40 50% bu 6u ruu

FIGURE 12.2 Distribution of the total population by age group, 1910 to 2050(data for 1980-2050 are projections). (From National Center for Health Statistics.)

pectancy at the older ages has increased at a faster rate than at birth.Life expectancy at age 65 increased 2.4 years between 1950 and 1978

(2). Significant declines in the number of deaths from heart disease andstroke have been a major factor.

It is anticipated that the number of older people will increase even

more in the decades ahead. This is not an unreasonable or unwantedspeculation when one considers the fact that, for humans to travel toand live on other planets, a much longer life span will be required. As

FIGURage 65,

White male Other male Whitefemale Otherfemale

30

U1900-1902

1909- 1919- 1929- 1939-1911 r92r 1931 1941

1949- 1959- 1969- 1977 1978195i 1961 r97r

01900-7902

1909- 19i9- 1929- 1939- 19491911 7927 1931 1947 1951

1959- i969- 1977 19781961 I91l

to 1978. (b) Life expectancy atHealth Statistics.)

100

l0 to 2050;tatistics.)

L at birth.and 1978sease and

3ase evenrnwantedtravel to

luired. As

(b)

FIGURE 12,3 (a) Life expectancy at birth, 1900age 65, 1900 to 1978. (From National Center for

157

I _5-8 cunner,rr ANrD EMERGTNG cHALLENGES

19601980 (projection)

2000 (projection)

75-84

100 120 r40 160 180 200 220 240 260

FIGURE 12.4 Sex ratios (women per 100 men) aged 55 and over by age group,1960, 1980, and 2000. (From Bureau of the Census.)

women disproportionately outnumber men in the older age group, onewonders what new social patterns will develop by the year 2000 (see

Fie. n.q.For health care professionals, including nurses, the impact of the in-

creased aging population is one of major importance. The utilization ofall health care services increases dramatically with age. Most older peo-ple have one chronic condition, and old people with multiple chronicdiseases are common. The most common chronic conditions in old agerequiring health care services are arthritis (44 percent), hypertension(39 percent), hearing impairment (28 percent), heart conditions (27 per-cent), visual impairments (12 percent), and diabetes (8 percent) (2).Therefore, chronic conditions have serious impact on care needs for thosewho require services ranging from daily personal care to hospitalizationin acute or long-term care facilities. Figure 12.5 describes the impactof chronic conditions on daily living.

The utilization of hospitals and nursing homes increases significantlyin old age. The hospitalization rate for people 65 and older is tr.vo-and-a-half times greater than for younger people (2). While most people 65

and older are not hospitalized in any given year, older people will con-tinue to account for an increasing share of total hospital usage.

Diat

Hyp€(hishpress

Visuelmpa

Hearrimpa

100

90

80

70

60

@950oL

40

30

20

10

0

FIGUREof chroni(From N

Rate per 1,000 persons by age

Arth ritis

Heart disease

Dia betes

Hypertension(high bloodpressure)

Visua I

lmpairment

Hearingimpairment

i00 150 250

(a)

100

90

80

70

60

400- 350300 450 500

260

e group,

up, one)00 (see

i the in-ation ofler peo-chronicold agertension(27 per-rnt) (2).br thoserlizationimpact

ificantlyrvo-and-:ople 65vill con-

65 74 75-84

60co950o

d

100

90

80

70

30

20

i0

40

30

20

[0

co

oc40

85+

Confined to bed

Needs help in house

Needs help in neighborhoodNeeds help outside neighborhoodNo disability

(b)

65-7 4 75 84

Needs help bathingNeeds help dressingNeeds help eatingNeeds help with toiletNo disability

FIGURE 12.5 (a) Prevalence of chronic conditions by age group, 1979. (b) Impactof chronic conditions on daily living for the older population by age group,1977 .

(From National Center for Health Statistics.)

lVobility Self-care

159

!60 CURRENT AND EMERGING CHALLENGES

The nursing home population has also increased remarkably in thelast 20 years. In 1963, there u,ere 505,000 people living in nursing homesin the United States. The latest data show that the number has grownto 1.3 million, a 150-percent increase (2). Less than 5 percent of all peopleover 65 are in nursing homes, but this figure increases significantly inthe middle old and old old groups. Seven out of 100 people in the 75-84 age group and one out of five in the 85-plus group are in nursinghomes. Women are likely to be present in larger numbers than menbecause there are more women in this age bracket.

The causes of death, and therefore the nature of health care, for oldpeople are markedly different than for young people. Heart disease,stroke, and cancer account for three-fourths of all deaths in the groupaged 65 and older.

Thus, the demographic changes in our population project an increasingnumber of older people as well as increased need for health care servicesThe significance of long-term care-long considered less important thanshort-term care-will become fully recognized in the next decade. Long-term care encompasses a continuum of interrelated health and socialservices. It includes both institutional and noninstitutional services andrequires coordination of public policies, funding, and case managementto provide appropriate services for individuals with changing needs (4).

The concern for the elderly in today's health care world is not solelythe result of the greatly increased number of older people. Changes infederal legislation since the 1930s have contributed much to the eco-

nomic status of the 65 and over group. As a result of the Great Depression,

the Social Security Act was passed, establishing a retirement incomesystem and a system of federal grants to states to provide financial as-

sistance to the aged (4).Nurses can expect to deliver care to increasing numbers of old people

who can pay for health care either through private insurance or Med-icare-Medicaid reimbursement. All facets of care are available, rangingfrom highly complex technological procedures to wellness-based, self-care, teaching-learning approaches. For most of the old age group whoare not incapacitated by disease, intellectual functioning and the ca-pacity for learning neither cease nor diminish because of chronologicalage (5). This fact allows nurses to creatively develop those options fornursing care that uniquely meet the nursing care needs of older people.

STANDARDS OF HEALTH CARE

There is a rapidly growing opinion on the part of all health professionals

that older people should not be treated as separate systems, organs, anddiseases. Rather, they should be treated by a single practitioner as com-

plete I(6). rh

'Accer'Com1' Carir' Affor

Trancenterrservicecare thfederalbetweecrease(the totneed ar

MuclserviceLibowLong Is

for treain the rsciencemedicivolve e

In prpeople,iatricsnot allfruitiorplace imaintaoutagnursinS

Highcontinttologicirelocatin the g

no morpostrel,change

Then

,ed for

lderly,/omen.ed, so-r takesedicalrilizerssword.rlly as-des to-: olderg task,:ses do

rey be-ions. Itry menn olderstmen-ical di-

LE4rpEBqHIp rN!43E q rHE!!DEB_LY _169

2. Why are population trends considered important aspects of society?

3. People are living longer in the United States today than at any othertime in history. Explain how this affects the health care deliverysystem. Include the effects of Social Security and Medicare-Medi-caid.

4. Describe holistic care. Give reasons why such care could be beneficialto the care of the elderly.

5. Explain Libow's position on nursing homes, and contrast it withyour own concept of nursing homes.

6. Discuss the concepts of primary and secondary aging.7. Explain the importance of distinguishing the aging process from a

disease process and give the major reasons why aging is sometimesconsidered a disease.Define frail elderly.List the steps essential for nursing administrators to provide lead-ership in stimulating better care for older people.

Give reasons why it is vitally important that nursing personnel un-derstand the concepts of geriatrics.What is the most frequently cited reason for disinterest in workingwith the elderly? What are some of the others?

12. What is geriatric burnout?13. List some of the special needs of elderly women.

8.

9.

10.

11.

rursrngs. Mosttial forociety'satientslminis-g fromrt meet

REFERENCES

l. Friedman, E. Medicare called unfit for the elderly. Hospitals, January 1,

1e83,57(l), t7,20.2. Allan, C. and Brotman, H. Chartbook on Aging in America. Washington, D.C.:

Government Printing Office, 1981.

3. Abdellah, F.G. Nursing care of the aged in the United States of America.Journal of Gerontological Nursing, November 1981 , 7(ll), 657-663 .

4. Koff, T.H. Long-Term Care: An Approach to Sewing the Elderly. Boston: Little,Brown, 1982.

5. Pierce, P.M. Intelligence and learning in the aged. Journal of GerontologicalNursing, May 1980, 6(5),268-270.

6. Warfel, B.L. Information on Aging. Newsletter from the Institute of Ger-ontolo6;y, Wayne State University and the University of Michigan, no. 27 .

October 1982.

7. Libow, L.S. Geriatric medicine and the nursing home: a mechanism formutual excellence. The Gerontologlst, April 1982, 22(2), 134-l4l .

8. Coffman, T.L. Relocation and survival of institutionalized aged: a reex-amination of the eviden ce. The Gerontologisf, October l98 l, 2 1 (5), 483-500.

ursrng

168 cu_BIrBNr eNo EMERGTNG cHALLENGES

may simply be the failure of the organization to recognize the need fora geriatric emphasis.

ELDERLY WOMEN: A SPECIAL NEED

Nursing care programs often ignore the special health needs of elderly,and, in particular, they may not even recognize the needs of older women.Lillard (24) describes older women as economically disadvantaged, so-cially isolated, and negatively stereotyped. The medical profession takesa different view of men and women experiencing the same medicalproblems, and it is not uncommon for women to receive tranquilizersthat are not appropriate. Ageism and sexism form a double-edged sword.Postmenopausal women have frequently outlived their culturally as-cribed usefulness and frequently face additional negative attitudes to-ward feminine aging. The vast majority of elderly people are olderwomen, and since the care of the elderly is primarily a nursing task,the opportunities for negative behavior are compounded if nurses donot have a geriatric interest.

Women are less apt to have supportive family groups (25). They be-come widowed before men, and they have fewer remarriage options. Itis not socially acceptable for older women in our culture to marry mensubstantially younger than themselves. Health problems abound in olderwomen, and few doctors seem interested in these problems. "Postmen-opausal syndrome" and "senility" frequently cover up a medical di-agnosis or lack of it.

SUMMARY

Responsibility for care of the elderly as a significant part of the nursingadminstrator's role has not been addressed in most organizations. Moststaffing studies focus on high turnover rather than on the potential fornursing leadership in providing quality care for old people. Our society'sconcept of aging and the attitudes of health professionals and patientsinfluence the development of optimal care programs. Nurse adminis-trators should encourage creative approaches to care, ranging fromchanging attitudes toward old people to designing programs that meettheir special needs.

STUDY QUESTIONS

l. How does the increasing elderly population relate to nursingadministration and practice?

4.

2.

3.

tvl

Ptislc:

DtC

Eyr

D

Edc(

D

Lel

Gd,

\

tv\

L

5.

6.

7.

8.

9.

10.

11.

12.13.

REFl

1. Frl9

2. AlGr

3. AtJo

4. K(Br

5. PiNi

6.WorOr

7. Lim

8. C(AI

ective ofrl health,(18) sug-nd, indi-- encour-ing withutilized

rdepend-

nication:d by en-nursingrest, andd out byeriencesnctional

ral com-rple and[ound torportantresidentleasuresual, andnctionalnce self-re apply

Le major: setting.regativenifestedlaborate:, in the:serving.erlife isLl in thecost. In

e all thens seeming.

LEADERSHIP IN CARE OF THE ELDERLY 167

Most deaths occur in old age. In environments where most attentionis given to lifesaving measures, older people are not given high priority.The United States is a youth-oriented society, and negative attitudestoward aging are well ingrained in health professionals long before theirprofessional education. Because of their knowledge, health care providershave potentially the most negative attitudes toward old people.

According to Benson (21), negative attitudes toward old people pervade

all levels of nursing personnel. Various reasons for this include:

l. Preference for working with younger people.

2. Nurse's age and experience with the aged.

3. Type of agency where the nurse is employed.

4. Stereotypic view of old people.

5. Lack of gerontological content in the nurse's educational program.

Miller (22) describes a "geriatric burnout" that occurs with nurses

who work with chronically ill elderly patients who eventually deteriorateand die. Society does not reward working with the elderly, and nursinghomes have a poor image. The most difficult staffing problem in acutecare settings occur on adult medical-surgical units. Increasingly, these

units contain a large number of older adult patients'Overcoming negative attitudes is difficult, for they are usually strongly

held. In defining programs and goals with a geriatric emphasis, thenursing administrator will have to support behaviors that will produccpositive attitudes. Adclson and colleagues (23) havc identified behavioralcalegories dcemcd positive intcraction. Bccause it is usually easier toidentiiy negative behaviors, it is a creative challenge to identifl,positivebchaviors. The categories includc:

1. Banter.2. Asking for feedback.3. Giving procedural information.4. Compensating for disabilities.5. Social touching.6. Attending to patient comforts.7. Smiling.8. Speech pace.

These behaviors seem to reflect common sense, but they are not uni-formly demonstrated across age groups.

Other obstacles besides negative attitudes stem from institutionalgoals that do not permit creative care planning. Such obstacles may befinancial or related to inadequate nursing resources. Or the problem

fl

A variety of educational programs can be designed, irrespective ofhealth care setting, that can improve the physical health, mental health,self-esteem, and independence of the aged person. Gershowitz (18) sug-gests that the best mode for restoring psychological health and, indi-rectly, physical health is through remotivation techniques that encour-age patients to use their own past experiences and skills in coping withthe present. Prior life experiences, values, and interests can be utilizedby a knowledgeable staff in assisting older adults to greater independ-ence and improved quality of life.

Feier and Leight (19) suggest that the intellectual and communicationdeclines common in nursing home residents can be counteracted by en-gaging residents in meaningful activities. For old-timers in nursinghomes, regularly provided experiences may no longer be of interest, andcognitive performance may decline as a result. Studies carried out byFeier and Leight (19) demonstrated that when learning experiencesmeaningful to residents were provided on a regular basis, functionalcapacity improved.

Sperbeck and Whitebourne (20) support attention to functional com-petence and the need to teach staff how to work with older people andchange behavior. Because institutional dependency has been found tobe related to poor self-concept and low life satisfaction, it is importantto investigate altering both behavior and setting to enhance residentautonomy. Nurses have a major role to play in identifying measuresthat will offset the effects of cognitive, elimination, audiovisual, andmobility problems. Regardless of disease processes, these functionaldisabilties commonly interfere with activities that could enhance self-esteem and encourage independence. The same principles of care applyin acute, long-term and home care settings.

OBSTACLES TO A GERIATRIC EMPHASIS

A negative attitude toward the elderly is frequently cited as the majorcause of disinterest in working with old people in any health care setting.Aging may be equated with disease or even death, both having negativeconnotations in our society. All societies deny death. This is manifestedin various ways of ignoring the dying person or carrying on elaboraterituals to keep the dead with the living, as seen, for example, in thepractices of keeping cremated ashes in the living room or preservingdeparted family members in cryogenic vaults. Belief in an afterlife isone of many societal supports, and the clear if unwritten goal in theinstitutions where most of us will die is to preserve life at any cost. Infact, modern medicine has added more to immortality than have all thetheologians and church people in history combined. Physicians seemdetermined to do almost anything to keep a human system going.

N/.

is g;

Thetow,profhav,

Atall I

1. P2.N3.74.s5.L

Mwhoandhomcareunit:

Orheldnurspositcatcidcnbehr

1.I)l

3.(4. 1

5.

6.

7.

8.

TTfo

g(fi:

.ce, andged pa-lmandsfluence: singleNursing. nursesr which

w some; death.rn of re-ral mis-he phy-ysicians

rly. Therwerless. elderlyro have,onic ill-lgy, Putrments.withoutrance of'eal andce a tre-ires rec-

TLY

.on, and:ility toho lived

80s, andge per seted, whoI or oth-:r peopleo late to

LEADERSHIP IN CARE OF THE ELDERLY 165

Stryker-Gordon (11) has described essential steps for nursing admin-istrators in providing leadership in stimulating better care for olderpeople. These include:

1 Read in the field and divest oneself of false beliefs.2. Examine one's personal experience with the elderly.3. Pursue continuing education.4. Take on the challenge of making quality care for the elderly com-

parable to quality care for other individuals.5. Develop a cadre of interested nursing staff who are able to make ob-

servations and obtain information from the elderly.

The authors would add:

6. Create geriatric clinician or clinical specialist roles that give insti-tutional necognition to the importance of older adult care.

The lag between nursing knowledge and practice is greater for theelderly than for any other age group. Few nurses are prepared for ger-iatric care, and few nurses know that the aging process alone is not acause of a patient's psychological condition; other causes might be drugs,nutrition, disease, or depression due to grief. The nursing administratorhas wide influence in an institution and is in a better position than anyother person to affect the care of large numbers of patients. For everyorganization that becomes a center of geriatric expertise, higher expec-tations of care will be sought in other organizations.

The nursing administration role in nursing homes is at a significantcrossroad. National efforts are under way to improve the expertise ofnurse leaders through increased opportunities for education for lead-ership in long-term care (15). Nonnursing leaders are losing power astheir competencies and motives are challenged. Nurses are learning thatthey hold the expertise to meet regulatory agencies' demands and thatit is the nursing profession that keeps the doors of the nursing homeopen (16).

The 1981 White House Conference on Aging (17) provided an additionalstimulus for the nursing profession to offer leadership in the care of theelderly. Major emphasis was given to the importance of such nursingleadership in health care services. Nurses have already demonstratedleadership in establishing preventive health care services in nontradi-tional settings with a focus on wellness. Nurses have served as healthcare givers, counselors, and client advocates, and it is important nowto direct such efforts to promoting health for older adults. Health wasrecognized at the conference as the chief determinant in improvingquality of life for our senior citizens.


for health care workers to prevent confusion, minimize dependence, andprovide physical care for older patients' Skill in caring for the aged pa-

tient can be improved only if someone in a leadership position demandsnew standards of care. The nursing administrator has wide influencethroughout the institution and, aside from the physician, is the singleperson most likely to affect the care of large numbers of patients. Nursingadministrators can establish the goal of having better-prepared nurses

by sharing gerontological knowledge and providing resources with whichstaff nurses may enhance their skills.

Aging is not the same as disease. The aging process may slow some

mental and physical functions, but it is the disease that causes death.Stryker-Gordon (11) notes two major obstacles to the assumption of re-sponsibility for improving the care of older patients: (1) a general mis-understanding by nurses of aging and (2) the fact that, due to the phy-

sicians' attitudes toward geriatric care, nurses cannot rely on physicians

as the traditional source of expertise.Nurses are in a unique position to influence care of the elderly. The

frail, disabled, and dysfunctional elderly are a particularly powerless

and voiceless constituency (12). Burnside (13) describes the frail elderlyas those people who have reached a great age, over 75, and who have,

during their long lives, accumulated multiple disabilities, chronic ill-nesses, or both. These changes, combined with an aging physiology' putsuch people at increased risk of physical and psychosocial impairments.The fraililderly person is under constant stress from within and withoutand has difficulty maintaining daily living activities. Maintenance ofwellness is difficult and illness is frequent. Recognizing the real andpotential physical changes in old age, nursing administrators face a tre-mendous challenge in planning patient-centered care that requires rec-

ognition of environmental and learning needs.

ASSUMING LEADERSHIP FOR CARE OF THE ELDERLY

The basic assumption underlying all rehabilitation, remotivation, and

reality-orientation care models is that older adults have the ability tolearn new behaviors. In the words of Howard Mcclusky (14), who livedand functioned as a professor until the age of 82:

In general, then, we are justified in sayin^g that even into the 70s and 80s, andfor"all u'e L.ro* ut long as we live on the functioning side of senility, age per-se

is no barrier to learniig. There is no one at any age, even the most gifted, whois without limitation ii learning. Thus limitation per se-age related or oth-erwise-should not be our criterion for appraising the capacity of older people

for education. We can teach an old dog new tricks, for it is never too late tolearn. (pp.l2*13)

Strlistratrpeoplt

1. Rei

2. Exi3. Pur

4. Talpar

5. De.ser

The ar

6. Cretut.

Theelderl'iatricCaUSe r

nutrit.has wiotherorganitation

Thecrossrnurseershiptheir c

they hit is tlopen (

Thestimdelderl.leaderleadertionalcare gto dir<recogrqualit

ieriatricftologist,

rt's ownr. Olderpeople.: healthI oppor-.ge with: health

rminant,ologicalical anding. Thediseasesitation.may nothe phys-r explain

LEADERSHIP IN CARE OF THE ELDERLY T63

the aging process. A number of investigators are conducting experimentson cultured cells. Leonard Hayflick (9), in California, has shown thatcultured human fibroblasts double only a limited number of times before

they deteriorate, lose their capacity to divide, and die. However, he does

not think that people age because some of their cells lose the capacityto divide. Rather, he attributes aging to the loss of cell function thatoccurs before cells reach their limit for division. As cells malfunction,body organs and whole systems are affected and eventually die (10).

Other investigators attribute senescence to errors in cell operationsregulated by DNA. The aging body's increasing susceptibility to diseasemay be directly related to declining levels of thymosin. The increase indisease in the elderly occurs during the same period that the thymosin-producing thymus gland shrinks with age. Other biological theoristsespouse the wear-and-tear theory, the lipofuscin theory, the cross-linkagetheory, and the immunological theory (9).

One cannot help but think that theories of aging that focus on changesin individual cells are not comprehensive enough. Yet the nature of thiskind of research and the interest in prolonging life at any cost necessarilyaffects physicians, nurses and the decisions they make in caring for peo-ple. Many doctors and nurses still speak of finding a cure for old age,

as if it is a disease rather than part of the life cycle. There always seems

to be hope that some medication will be found to block the aging process.

In a sense, then, aging presents a negative picure to health profes-sionals. In care settings, the loss of physical functions tends to blur theimage of older people as lively, unique individuals. Students in nursingand medical schools must understand the function of all body systems;failure of these systems is viewed as an indication of the decline of thewhole person.

Loss of function in primary aging occurs at varying levels in all organsand systems. Diseases, however, contribute a secondary aging effect andare the chief barrier to extended longevity. In primary aging, agingwithout disease, changes occur in audiovisual, neurological, cardiovas-cular, metabolic, renal, and respiratory function (10). When disease ispresent, more function is lost and at a faster pace.

Nursing service administrators are responsible for nursing practice,research, and education as they relate to professional nursing withinthe institution. Yet little if any attention is directed toward the care ofold people, who now account for 25 percent of all health care costs.According to Stryker-Gordon (11), the health care system in the UnitedStates has two standards of care: one for the aged and one for youngerpatients. These problems of double standard are primarily due to failureof the nursing and medical professions to incorporate gerontologicaland geriatric knowledge into their educational curricula, research, andclinical practice.

In hospitals, nursing homes, and home care settings, there is a need

162_ CURRENT AND IUEBG'ING CJIALLENGES

nil

Yl.:lio'"[:iil"':ffi n"ntPharmaceutical supplies

FIGURE 12.6 The geriatric health care system. (From L.S. Libow, Geriatricmedicine and the nursing home. Reprinted by permission of The Gerontologist,April 1982, 22(2), 139.)

that involves provision of services across settings from the patient's ownhome to a skilled nursing home to an acute hospital, and so on. Olderpeople are no more limited to place of care than are younger people.Frequently, the acute care hospital is the point of entrance to the healthcare system, and it is at this point that nursing has the greatest oppor-tunity to influence decisions about continuity of care and linkage withaftercare. Figure 12.6 presents a model of the type of geriatric healthcare system outlined by Libow.

THE FRAIL ELDERLY AND SECONDARY AGING

In the medical world, where a disease-illness orientation is predominant,social-psychological theories of aging are less important than biologicaltheories. The identification of the causes of the numerous physical andmental afflications is the goal of research in the biology of aging. Theaverage human life has increased mainly because infectious diseaseshave succumbed to antibiotics, immunization, and improved sanitation.

Various biological studies indicate that the cause of aging may notbe outside us but within us. Simple descriptions of changes in the phys-ical and mental characteristics of the aged are not sufficient to explain

the a1

on cuculturthey <

not tlto diroccurbody

Othregul:may tdiseasproduespourtheorl

Onein indkind oaffectsple. Mas if ittobeh

Inasionalrimageand mfailurewhole

Lossand syare th,withotcular,presen

Nunresear(the insold peAccorcStatespatienrof theand geclinica

In h,

Skilled nursing facility"Nursing home"

Long-term care facility

Health-related facility"lntermediary care"

Geriatric diagnosticand

comprehensive careclinic

, in the;homesi grownipeoplerntly inthe 75-nursingan men

for oldlisease,e group

:reasingservicesnt thane. Long-d socialices andrgementeeds (4).:t solelyanges inthe eco-pression,income

ncial as-

d peopleor Med-ranging

sed, self-oup whoI the ca-rologicaltions forr people.

Fessionals

3ans, andr as com-

LEADERSHIP IN CARE OF THE ELDERLY 161'

plete people with individual medical, emotional, and social histories(6). This single practitioner could provide:

. Accessibility to care.

' Competence of the practitioner.' Caring focus.

' Affordable care.

Translated into reality, this mode of treatment would provide patient-centered care, with an emphasis on maintaining cost-effective, humaneservices. The elderly today pay more out-of-pocket expenses for healthcare than when Medicare programs were first established. Even thoughfederal expenditures for health programs increased by 35 to 40 percentbetween 1970 and 1980, out-of-pocket expenses paid by the elderly in-creased 295 percent during the same period (6). Although 45 percent ofthe total health care bill is currently paid by Medicare, many items ofneed are excluded.

Much of the inefficiency in care delivery is related to the lack of optimalservices geared toward the special needs of older people. Dr. Leslie S.

Libow (7), the medical director at the Jewish Institute for Geriatric Care,Long Island, New York, envisions the nursing home as a respected placefor treating people. He sees the nursing home as a major center of activityin the nation's health care scene and an extension of the university healthsciences.campus. Training of undergraduate and graduate students inmedicine, nursing, social services and allied health sciences would in-volve exposure to geriatrics and nursing home patients.

In proposing a framework for improving the standards of care for agedpeople, Libow suggests that aging is the celebration of survival and ger-iatrics the fruition of the clinician. Increasingly, the nursing home-ifnot all long-term care facilities-is the place for that celebration andfruition to occur. Libow sees the nursing home image changing from aplace in which to die to a respected place for treating people. Libowmaintains that there is no respectable science and art of medicine with-out a geriatric medicine and no true geriatric medicine without thenursing home.

High standards of care for the elderly are based on the belief that acontinuum of care is affordable, available, and desired. Recent geron-tological research has come to grips with the inconsistent findings ofrelocation research. Increased mortality is not a typical or usual findingin the geriatric relocation literature (8). Increased mortality has occurredno more often than increased survival. Neither mortality effects norpostrelocation decline have been observed as often as has no significantchange in postmove mortality rates.

Therefore, it is conceivable to imagine a full-service geriatric program


9. Forbes, J.F. and Fitzsimons, Y .M. The Older Aduh. St. Louis: Mosby, 1981.10. Steinberg, F.V., ed. The aging of organs and the organ systems, in Care of

the Geriatric Patient,6th ed. St.Louis: Mosby, 1983.

I 1 . Stryker-Gordon, R. Leadership in care of the elderly: assessing needs andchallenges. Joutaal of Nursing Administration, October 1982, I2(10), 4144.

12. Moses, D. Nursing advocacy for the frail elderly. Jourutal of GerontologicalN ursing, March 1982, 8(3), 144-145.

13. Burnside,I.M. Nursing and the Aged. New York: McGraw-Hill, 1981.

14. McClusky, H.Y. Education. Background paper for 1971 White House Con-ference on Aging. Washington, D.C.: Government Printing Office, 1971.

15. Lodge,M.P.ProfessionalPracticeforNurseAdministratorsinLong-TennCareFacilities. Unpublished report of the American Nurses' Foundation and theFoundation of the American College of Nursing Home Administrators. BattleCreek, Mich. W.K. Kellogg Foundation, 1983.

16. Eliopoulos, C. The director of nursing in the nursing home setting: anemerging dynamic role in gerontological nursing. Journal of GerontologicalN ursing, August 1982, 8(8), 448-450.

17. Benson, E.R. and McDevitt, J.Q. Health promotion by nursing in care of theelderly. Nursing and Heahh Care, January 1982,3(1), 39-43.

18. Gershowitz, S.Z. Adding life to years: remotivating elderly people in insti-tutions. Nursing and Heakh Care, March 1982, 3(3), l4l-145.

19. Feier, C.D. and Leight, G.L. A communication-cognition program for elderlynursing home residents. The Gerontologisl, August 198 l, 2 1 (4), 408416.

20. Sperbeck, D.J. and Whitbourne, S.K. Dependency in the institutional setting:a behavioral training program for geriatric staff. The Gerontologisl, June1981 , 21 (3) , 268-27 5.

21. Benson, E.R. Attitudes toward the elderly. Journal of Gerontological Nursing,May 1982, 8(5), 279-281.

22. Mlller, D.B. Society changes and the human resources component in long-term care. Nursing Homes, July/August 1982,31(4),4-9.

23. Adelson, R., Nasti, A., Sprafkin, J.N., Marinelli, R., Primavera, L.H., andGorman, B.S. Behavioral ratings of health professionals' interactions withthe geriatric patient. The Gerontologlsl, June 1982, 22(3),277-281 .

24. LilIard, J. A double-edged sword: ageism and sexism. Journal of Geronto-logical Nursing, November 1982, 8(l l),630-634.

25. Simms, L. M. and Lindberg, J. Women and the lengthening life span, inTheNurse Person New York: Harper & Row, 1978.

BIBLIOGRAPHY

U.S. Department of Commerce, Bureau of the Census. Statistical Abstract of theUnited States:1981. Washington, D.C.: Government Printing Office, 1981.

U.S. Department of Health and Human Services. The Need for Long-Term Care:A Chartbook of the Federal Council on Aging. Washington, D.C.: GovernmentPrinting Oliice, 198 l.

Part

FhPrNu

part 3

Education

rvelopment of human

human beings

human potential109tasks

nursing staff

thusof potential

persomaximum potential

world of nursing

human poiential