Planning and Marketing for a Healthy Organization

The environmental challenges of providing health care in the 21st century require more sophisticated problem-solving solutions. With shrinking fiscal resources and increasing demands in the work place, it is imperative that planning become a major element in any manager’s job description. It is easy to lose sight of the big picture when we are so busy focusing on the small one. In our daily nursing routines, we sometimes fail to understand overriding nursing administration goals and objectives. We become so consumed with our shift’s activities that we cannot see beyond them. As a result, we are not always prepared to deal with situations that arise, and we fail to anticipate situations that may have benefited from advance thought and planning. Nurses are familiar with the process of planning. Planning is an integral step in the nursing process. We understand that without planning, our patients would not fare well. We plan for patient care on a short-term basis, and we anticipate needs on a longterm basis.

Planning differs with the job. A nurse at a unit level may be concerned with daily operations so the period for planning may be a few days, a week, or a month. Middle managers generally plan for 1 to 3 years, whereas top executives plan for 3 to 7 years. Middle managers, because they are involved at the unit level, plan for unit activities such as length of hospital stay, seasonal changes, staff assignments, and so on. On the other hand, top executives plan for activities that involve the entire hospital (both physical and fiscal) operations, that involve larger sums of money, and that require longer time to complete. At the unit level, a 1-day retreat devoted to planning may be sufficient. In larger organizations, it may take weeks to accomplish all of the planning in various departments. This chapter discusses various types of planning in an organization. It explores elements of the strategic planning process and defines the components of marketing.

Types of Planning   

There are various types of planning such as:

■ Business planning, to plan a business organization, plan to test a product, plan a budget

■ Program planning, which involves a major internal or external function such as planning for the hospital’s 25th anniversary

■ Career planning, which involves educational milestones for individuals or groups

■ Performance planning, which involves development, implementation, and evaluation of job descriptions

■ Disaster planning, which involves guidelines, protocols

■ This chapter covers project planning, operational planning, and strategic planning.


Project planning entails planning for a project. Project planning involves a one-time effort, for example, to gather a team of nurses to conduct a community fundraising event. Most unit managers will involve their staff in project planning. This type of planning requires that one:

■ Identify the problem that the project will ultimately address.

■ Name the project. Selecting a name for the project is important. For example, if your department wants to recruit foreign nurses, you may want to name it the Foreign Nurse Exchange Project. Choose a name that will help members quickly identify your project. Once a project has been created, the name can not be changed.

■ Determine the project goals. Setting goals and measurable objectives will guide you through the completion of the project. For example, if a goal is to decrease the vacancy rate of nursing staff, your objective may read: within 6 months, staff will increase by 15%.

■ Specify tasks for each member. Determine the size of the project team, and then distribute the necessary tasks. For example, if you plan to recruit foreign nurses, you may want to designate a person to review the literature to specify which countries export the largest number of nurses. Another project member may meet with the marketing department to start an advertising campaign.

■ Identify resources needed. It is essential to list the resources needed, such as travel monies if the project manager is involved in interviewing staff nurses in another country or release time for all team members to be able to plan and monitor the project.

■ Indicate timelines for completion. To keep all members aware of the progress of the project, it is advantageous to display a chart or timeline that provides the status of each activity and its completion.

■ Implement the project. Once you have gathered all the data and know which group of nurses to target, your team will determine by whom and where the project will be implemented.

■ Evaluate the project. It is important to assess the progress of the project so that evaluation becomes a natural step in the process. Evaluation of the project should always go back to the objectives. Were the objectives accomplished? For example, if you were successful with your recruitment, at the end of the 6-month period, your evaluation should read: 35 (15%) nurses from the Philippines were recruited.

One of the most common problems surrounding plans for projects is the potential for procrastination. Some individuals tend to leave an assignment for the last minute. Thus, it is extremely important to identify a leader when planning a project. The responsibilities of the project leader include clarifying the purpose of the project to all project members, identifying the roles and responsibilities of each of the members, and keeping members on track. The project leader needs to facilitate and help the project members overcome barriers to the project’s success. The leader is responsible for providing necessary financial and human resources to accomplish the project. The leader should recognize members for a job well done.


An operational plan is a detailed work plan for a coming year. It is the blueprint by which the objectives of a unit, for example, are put into measurable actions. It also describes the short-term (a fiscal year) organizational objectives (Table 14-1). Operational planning involves the day-to-day execution of objectives that assist in accomplishing the organization’s mission. This plan is used to identify the responsibilities and resources needed to accomplish the department/unit priorities in the current fiscal year. Operational planning focuses on sustaining the course of action and ensuring the employees’ ability to perform the designated tasks. Middle managers generally get involved in operational planning. Managers examine measures that can reduce the obstacles employees may encounter; this type of planning should not be considered a rigid process. The manager must ensure that all aspects of the operational plan are implemented; the strategies to accomplish the plan may need to change over time. Like project planning or strategic planning (discussed below), operational planning addresses questions such as:

Operational Plan in a Medical-Surgical Unit

Gantt Chart

■ Where is the unit/organization now? (assessment of the environment)

■ Where do we want to be? (goals and objectives)

■ How do we get there? (strategies)

■ How do we measure progress? (outcomes) To answer such questions, the middle manager must gather data (such as budget, patient, and quality improvement data) from both previous and current fiscal years. The operational plan must link goals and objectives to the organization’s strategic plan and link the strategies to the performance indicators or outcomes.

Managers must ensure that employees at the unit/department level are involved in the operational plan. This means that all employees determine together what objectives need to be accomplished in that particular unit and understand the strategies that need to be implemented in order to meet the unit’s goals. A variety of tools, such as flowcharts, diagrams, and matrices, can assist managers as they create detailed operational plans. These tools use arrows, lines, boxes, circles, and other symbols to communicate processes. Some of the common tools that managers use to create operational plans include the Gantt chart (Finkler & Kovner, 2000), critical path method (Baker 2006), and program evaluation and review technique (McGuffin,1999), which is a variation of the critical path method.

Gantt Chart

The Gantt chart is useful for planning and scheduling projects. It allows the manager to assess how long a project should take, determine the resources needed, and lay out the order in which tasks need to be carried out. Gantt charts help the manager monitor the project’s progress and stay on track. Gantt charts help the manager plan out the tasks that need to be completed by scheduling times that the tasks will be carried out and allocating resources. When establishing a surgical center, for example, the manager’s ideal plan may include the timeframe in Table 14-2.

The chart is also useful when working with multiple projects. See Table 14-3. An advantage of the chart is the ability to review projects that are progressing in a timely fashion.

Critical Path Method

The critical path method (CPM) is another tool that helps managers prepare a schedule and plan resources. During the management of a project, the CPM allows a manager to monitor achievement of project goals and take remedial action if the project is not going well. The CPM consists of diagrams that depict the activities and the time line required (Fig. 14-1).

The diagram shows the start event (step 1) and the completion of the task of recruiting staff and

Gantt Control Chart

Critical path method.

marketing the center (step 2). This activity should take 1 week. One activity cannot start until another is completed. Assessing the staff strengths (step 4) cannot be done until completion of step 2 (hiring staff) and step 3 (orientation). In the event that the task is completed in less time, such as hiring staff, the time of completion can be adjusted in the diagram. If you are not graphically oriented, this diagram can be difficult to draw without using commercial software.

Program Evaluation and Review Technique

The program evaluation and review technique (PERT) calculates a realistic timeframe by using the shortest possible time each activity will take, the most likely length of time, and the longest time it might take. Managers can input these figures into PERT to calculate the time to use for each project stage. The formula follows:

Using the formula helps to bias time estimates away from the unrealistically short time scales often assumed. Using a realistic timeframe is helpful when developing the strategic plan for your unit or department.

Practice to Strive


Strategic planning is a systematic process that emphasizes assessment of the environment (economic, political, social, and technological) both internally and externally. It focuses on performance improvement and utilizes strategies to accomplish the organization’s desired outcomes. Business organizations embraced the idea of strategic planning in the 1950s. And in the last 20 years, even institutions of higher education have attempted to implement strategic planning out of a need to respond to challenges with finances, student attrition, and educational demands.

Strategic planning is a management tool that helps organizations set long-term goals. It assures that the individuals working for the organization work together to accomplish set goals and objectives. Executives in the organization are generally responsible for initiating the strategic planning process. The current trend in business is to plan for 2 to 3 years. Because of employee mobility and the changing economy, industry usually is not able toplan for more than 3 years. Strategic plans in certain organizations may be drafted for 10 or more years. The strategic plan, just like the project or operational plan, should be simple and easily understood by the participants. The way a strategic plan is developed depends on the nature of the organization’s leadership, culture of the organization, complexity of the organization’s environment, size, and the expertise of the planners. Strategic planning models can be issue-based, goal-based, and scenariobased. Issue-based strategic planning utilizes a very focused approach as is used in manufacturing businesses (Hiam, 1990) to improve productivity over a specified period. Scenario-based strategic planning is used frequently in human resources or marketing operations (Hiam, 1990) to improve decision making and sales forecasting. The goal-based model is the most widely used in organizations. Its key elements include: the organization’s assessment of the environment, mission statement, vision, development of goals and objectives, strategies to accomplish the goals and objectives, and outcomes (Table 14-4).

Unlike project planning or operational planning, strategic planning requires a multidisciplinary approach. Every single department or unit in an organization must be involved in the plan to ensure that staff members comply with goals and objectives and that strategies are implemented. Managers may initiate the strategic planning process by communicating the initiative in their monthly meetings. They may invite an expert to provide a seminar to inform all the employees about the process. Once the employees are oriented to the strategic plan, they volunteer to work with specific sections. Without this involvement, employees may not buy into the organization’s goals and objectives and may hinder the plan’s success.

One benefit of strategic planning is that it helps managers make current decisions in light of future consequences. For example, if your unit plans for expansion from 16 to 32 beds within 6 months, you need to start planning for staffing now. Planning helps managers develop a comprehensive basis for decision making and exercise maximum direction in organizational control. In addition, strategic planning assists managers to:

■ Resolve organizational problems goals; they are shared with the entire organization

Strategic Planning Process

■ Improve performance strategies; they are accepted by all staff

■ Build teamwork expertise; staff must work together to identify goals and objectives and determine strategies.

Strategic Planning Process

Strategic planning is a step-by-step process that delineates ongoing group activity. Table 14-4 demonstrates the steps of the process.


The first step of any planning process is assessing the environment. At any level, the assessment conducted is both external and internal (Table 14-5). At the unit level, an environmental assessment includes assessment of employees, for example. The manager needs to examine how the staff is likely to feel and react to the contents of the project, operational, or strategic plan. Even at an organizationalevel, a nursing executive needs to know the staff in the departments he/she oversees. Because staff plays a crucial role in strategic planning, some key questions that a manager should ask before any type of planning occurs include:

■ Who are the best, most interested staff members in your unit/department?

■ What is the emotional or financial interest they have invested in the organization?

■ What motivates them?

■ Are there staff members who are not ambitious, who do minimal work?

■ What do staff members think about administration?

■ Who are the informal leaders who influence the unit/department?

■ How can everyone be engaged in the planning process?

Once they have answered these questions, managers need to inform all staff members about the necessity of planning, answer the “what’s in it for me” questions, and guide the staff toward the realization of the plan. Managers must talk to staff directly if they perceive a lack of interest or a lack of understanding of the process. Most people are willing to share their views, and asking their opinions will make them feel like they are contributing to the organization’s plans.

When creating a project or operational plan, it is important to assess the department’s/unit’s immediate physical environment as well. When developing

Environmental Assessment

a staffing plan at the unit level, for example, you must determine future patient census on the unit based on past data. When does the patient census peak? When does it drop? In which months of the year does a particular disease become prevalent? What kind of financial resources will be required? Based on these data, you can make projections and continue in the planning process

When preparing a strategic plan, the assessment becomes a bit more expansive. The manager must assess the internal and external environment of the organization thoroughly.

The external assessment should include the competition for services in the community. For example, determine which hospitals are around the area and what kind of specialized care they offer and compare it with yours. Take a look at the markets, and identify your customers. Health-care trends also influence planning. If the elderly population in your community indicates an upward trend, your organization may choose to accommodate the elder’s needs by planning a skill care unit or expanding the cardiac care unit.

In order to assess the internal environment, strategic planners must identify a variety of systems within the organization. Important to assess are patient care standards, not only to comply with accrediting organizations but also to improve the care offered. Other assessments include financial resources, information systems, research capabilities, staff development, and educational systems. In any health-care organization, nursing is the largest human resource group. Thus, it is imperative that this segment of employees be taken into consideration as the organization conducts strategic planning. The quantity and quality of staff development and educational systems need to be assessed, especially when considering expansion of services.

Environmental Assessment Techniques

One technique used to assess the environment is the PEST, which stands for political, educational, social, and technology factors that affect an environment. In the political realm, managers analyze factors such as legislative activities, antitrust regulations, and environmental protection laws that may affect the organization. In the economic environment, analysis includes trends, events, and economic indicators specific to the marketplace in which the organization operates. The PEST also assesses areas and services of potential growth and monitors trends in industry, global economy, interest rates, and energy availability. In the societal environment, it analyzes population growth, age distribution, regional changes, health status of the population (death rates, communicable diseases, Medicare/Medicaid resources), and safety issues. In the technological environment, it helps managers focus on what the organization has or lacks in terms of current technology as well as on what is available. The SWOT technique is another tool to help managers conduct a thorough environmental assessment. The acronym stands for the strengths, weaknesses, opportunities, and threats in an organization. SWOT requires analysis of multiple factors related to the health-care industry: human resources, the physical facility, the population, and the economic stability of the organization, for example. Table 14-6 presents a brief example of a SWOT analysis.

The risk analysis, another environmental assessment technique, helps the manager spot project risks, weaknesses in the organization, and external risks. For example, suppose an organization discovers that a group of physicians plans to build a neurology center and recruit nursing staff from your

SWOT Technique

units. This has the potential for affecting not onlythe finances of the hospital but also the patient care offered. Conducting a risk analysis helps the manager to make additional plans to neutralize some risks.


Mission statements identify why the organization exists (see Chapter 4). They encapsulate the overriding purpose of the organization. Vision statements identify the future of the organization. They provide the ultimate level the organization aims for. Mission and vision statements can be one sentence, a number of phrases, or multiple sentences. When creating a mission statement, it is imperative that all individuals in the organization understand the purpose of the content. For example, the mission statement at a hospital in Ashland, Kentucky, reads: “To Care. To Serve. To Heal.” These phrases summarize why the hospital exists. Such statements are generally simple so that employees can identify with and remember them. A children’s hospital’s mission statement in Virginia reads: “To provide the highest level and quality of pediatric care available in our community.” This statement is concise and easy to interpret. St. George’s Hospital Medical School University of London has a mission statement that reads: “To promote by excellence in teaching, clinical practice, and research the prevention and understanding of disease.” This statement lets you know that this is a teaching hospital with a medical school where research is a priority. The vision statement accompanies the mission statement but is more future-oriented. It states where the organization is going, the ultimate position that the organization plans to achieve: “To achieve a local, regional and national reputation as leader in health care.” This

could be a vision statement of an organization that has been operating only at the local level. A hospital could have a vision statement that reads: “To provide world-class care in our communities.” This is a very clear, self-explanatory statement.


Goals, in general, are global statements that help an individual or an organization plan for the future in a constructive way. Goals should delineate clearly he desired end product. Goals may be short-term, to be accomplished within a week, a month, or a year. Or they may be long-term, indicating what the organization aspires to become 5 to 10 years from now. For planning purposes in organizations, goals are written for the operational plan and the strategic plan. Operational goals at the unit or department level are statements that indicate future directions. Goals are more specific statements of the organization’svision, enumerating the accomplishments to be achieved if the vision is to become real. Strategic plan goals are institutional goals often written by executives or upper-level administration members who oversee the organization’s activities and are able to conduct environmental assessments. A current trend encourages all individuals in the organization to participate in the goal-setting process, but involvement depends on the size of the organization. For large companies, involving all employees may be next to impossible. Operational plan goals are congruent with strategic plan goals (Table 14-7).


Objectives are descriptions of performances or activities. They are statements that make goals more specific and measurable and give managers the ability to evaluate goal achievement. For this reason, over the last two decades organizations have included objectives in their operational and strategic

Strategic and Operational Goals


plans. When incorporating objectives into plans, keep asking yourself, “Are you sure we can do this?” Objectives are the specific, measurable results produced while implementing strategies (Table 14-8). As you work with objectives, state them separately, and show related information that is linked to strategies. This means that if you listed a number 1 under objectives, make sure you have a number 1 in the strategies. Objectives are written in a logical sequence, preferably in numeric order. For example, all objectives related to human resources (individuals), staff development, or clinical practice should be grouped under those sections. Be sure that the period for the objective is clear and realistic. The time line ensures achievement of the outcome by the target date. If there is no time line stated in an objective, that objective is assumed to be bound by the fiscal year covered by the plan.


Strategies are a series of actions or behaviors that assist planners in achieving the objectives. Strategies link to a particular objective and intended outcomes. Well-planned strategies provide specific directions to achieve objectives (see Table 14-8; 14-9). Strategies are not static. They can change and be modified during the implementation of the plan. Strategies may be clustered under a common objective. For example, if the Human Resources department has an objective to increase the diversity of the staff, the strategy may be to (a) travel to the South to recruit minority physicians, and (b) advertise nursing positions in minority nursing journals. Strategies


must be resource driven and sequential. Being resource driven means that the constraints of people, equipment, operating systems, money, and other resources are considered when developing a strategy. Strategies must be designed after the desired outcomes are written. Managers must assess whether the strategies produced the desired outcomes.


In the implementation phase of the strategic plan, all the strategies planned are carried out. The success in the implementation of the strategies depends on the involvement of managers who must monitor all the activities to ensure accomplishment of the objectives.


Outcomes are the results that you plan to accomplish. Outcomes must be realistic and achievable. If the vision is an expansive one, such as “to offer the best service in the world,” managers need to determine how to write goals and objectives to assure outcomes are achieved. Otherwise, outcomes may fall short of expectations. Outcomes are indicators against which you measure the success in meeting your objectives (see Table 14-9). Outcomes reflect the effectiveness in meeting the expectations of the planners. It is important to select benchmarks, measures that compare the organization with others. For example, if your objective reads that the nursing turnover rate in your facility will decrease below the national standard, then your outcome would be measured by comparing your rate with the national average as a benchmark.


The evaluation determines the organization’s progress toward attaining the identified outcomes. How did the organization respond to the implementation of the plan? How was productivity achieved? To what level? Was the budget sufficient? The evaluation compares outcomes or results with objectives. Dashboards and scorecards (Table 14-10) are tools that help organizations to achieve strategic outcomes. These software application tools have been used extensively in the last few years because of their ability to amass large volumes of information, making it easy to monitor trends and to respond to time-sensitive events. Dashboards and scorecards can promote performance visibility and effectiveness.

The purpose of the dashboards is to foster better communication between managers and staff. The

Dashboards and Scorecards

dashboard enables the user to communicate via threaded discussions, and employees can monitor metrics that are relevant to their roles. Supervisors generally used scoreboards to measure individual or group performances. These performances measure productivity related to specific events. The dashboard evaluates performance against metrics (measurements) using predefined goals. For example, in a hospital setting, a supervisor will use the dashboard to determine patient care hours during the months of December through February, when most cardiac patients increase the census on a medical floor. These dashboards will give the nursing staff an idea of how the unit should be staffed to maintain quality of care.

Scorecards are used by executives and middle managers to monitor the progress of planned goals and objectives. The executive or the manager presents summaries monthly or quarterly of unit goals accomplished. The length of stay, for example, can be measured by using the scorecards. If a unit’s goal is to keep inpatients diagnosed with cellulitis for only 2 days, the manager can compare the current length of stay with that of the previous month or quarter. In addition, the scorecards can be used to compare the unit’s data with national benchmarks. Other benefits of the scorecards include increase in employee participation, elimination of initiatives that do not contribute to the unit or the organization’s goals, and development of consistent key performance indicators.


A marketing plan is important for an organization to succeed. It should form part of the overall strategic plan because marketing can make a large contribution to the profitability and success of an organization. Whereas strategic planning is an overall organizational plan, marketing can be organizational or departmental. It is the process of exchanging resources for goods and services to meet the needs and wants of the individual as well as of society. In this sense, marketing fits in with the strategic plan because an organization such as a hospital has to be able to function by meeting the needs of individuals. At a departmental level, marketing is a tool used to advertise services or to recruit staff. The health-care industry embraced marketing concepts in the 1970s. Marketing concepts are methods that create awareness about a particular organization. Their purpose is to attract customers, to sell their products, or to offer services. These methods include public relations, such as news releases, feature stories, press conferences, or open houses; advertising and mass media, such as newspapers, magazines, and journals; broadcasting, such as radio and television; or electronic, like banners, links, and directories.

In a hospital setting, marketing means that the hospital must produce services that the consumer needs. To this end, many hospitals maintain a marketing department. The marketing manager must understand financial analysis because it is important to know the financial impact of proposed marketing strategies. In addition, the marketing manager must possess skill in market research, product development and management, pricing, negotiating, communicating, salesmanship, and recognizing new opportunities. The basic components of a formal marketing plan include a situational analysis, goals and objectives, marketing strategies, and evaluation


The SWOT analysis (see Table 14-6) is a very simple but effective means of carrying out an analysis of the hospital or a product for marketing purposes. Very specific questions that managers need to answer include:

■ Who are the hospital’s main competitors?

■ How do they position themselves?

■ What is their pricing structure?

■ What are the standard terms of business for the health-care industry?

■ How does the hospital compare with its competitors?

The strengths of the hospital should be communicated in marketing promotional materials and all advertising. The weaknesses that managers may discover need to be corrected. Hospitals operate in dynamic environments. External influences (opportunities and threats) over which managers have little or no control can make or break the hospital. Marketing managers must identify opportunities in order to exploit them and anticipate threats in order to plan to handle them. Some examples of opportunities or threats include

■ Economic: unemployment rates, poverty, pricerise of equipment

■ Patients: know the current patient base: age, gender, income, ethnic background, neighborhood, increase in the chronic nature of diseases, preventive care patterns or habits

■ Politics: changes in the legislature, decrease in funding for Medicare/Medicaid

■ Technology: rapidly changing technology that is costly; know how it affects your services; know when it will become obsolete; know if the hospital is equipped to adapt quickly to changes

■ Competitors: establishment of new hospitals or specialty centers, know exactly which services they offer, number of beds, number of employees, know their location and the potential population from which they will draw The challenge of the marketing plan is to monitor the external environment continuously to anticipate threats and opportunities and set interventions in place that will protect the hospital from the worst and enable the organization to profit from the best.


Major overall goals of health-care marketing include: (1) maximizing the marketplace’s consumption of an organization’s products; (2) maximizing consumer satisfaction; and (3) contributing to the quality of life. Thus, marketing plays an important role in the entire health-care industry. Hospitals offer a myriad of services in order to satisfy patients’ needs and increase their quality of life. An example of a hospital marketing goal could be to enhance its cardiovascular program. A marketing objective could be: “within a year, increase by 20% the number of open heart surgeries.” Nursing departments can assist the organization to accomplish marketing goals. Increasing the awareness of patients for the services that the units provide (Table 14-11), tracking costs at the unit level, and assuring that length of stay is congruent with diagnosis are examples of important nursing activities that will affect patient outcomes. Providing nursing care with respect, courtesy, and safety will improve customer satisfaction. Increasing the

Unit-Specific Goals and Objectives

educational level of the nursing staff will directly and indirectly affect patient quality of life as well.


Marketing strategies are actions intended to accomplish the marketing plan objectives. Marketing has been identified mostly with promotions and advertisement. But according to Philip Kotler (2002), one winning marketing strategy is to “define the target market.” In hospitals, the target market is patients. At the department level or in a specialty hospital or community-based program, the market may be more specific, such as adolescents with eating disorders, people with heart problems, and children. A hospital should strive to offer quality and unique services to patients if the goal is to remain ahead of the competition. In order to remain viable, an organization must remain knowledgeable of the changes in the population. For example, if the elderly become the majority of the population, the organization must develop services to target that population. Marketing strategies that a hospital can employ to remain visible and competitive include:

■ The design of a Web page that expresses the hospital’s mission, vision, services, and other attributes. The Web page should be attractive and easily accessible, with links to questions and answers related to hospital services or with links to common disease information.

■ Offering free, on-site, classes for various age groups. Through this effort, more potential customers will be attracted.

■ Conducting other activities in the community at large to publicize the hospital, including health fairs, fundraising events, speaker’s bureaus, and recruitment activities.

■ Promoting hospital services is another marketing strategy. Promotional methods include newspaper articles, public service announcements, printed materials, newsletters, billboards, paid advertisement, and introductory offers of special services, such as massage therapy in conjunction with physical therapy, and free demonstrations, consultations, and seminars.


The nurse manager communicates with the marketing manager to receive periodic feedback evaluation throughout the planning and implementation period. As with other plans, evaluation includes a comparison of objectives with outcomes to assess success. In marketing evaluation, actual figures are compared with the figures determined in the environmental assessment to highlight any significant changes, trends, or results. The nurse manager notes the trends and communicates these to staff to incorporate in future plans.

Marketing Plan Sample

Marketing Plan Sample (continued)

All Good Things...

In this chapter we addressed the importance of planning at any level in an organization. Planning is a systematic process in which all employees must be involved to be able to accomplish the mission and the vision of the organization. Identification of strengths, weaknesses, threats, and opportunities will help employees understand the organization and help them to establish realistic goals and objectives. A variety of tools for planning and scheduling projects are available for managers to use in developing and implementing their operational or strategic plans. In addition, knowledge of marketing concepts will prove essential for managers who wish to capture a share of the target population and stay ahead of their competitors in the demand for health-care services.


Health care is undergoing a transformation that embraces business values while trying to hold onto the professional concept of caring. Health care is a business with limited financial resources. Nurses are finding themselves providing care in an environment where the economics of health care are highly competitive and the costs of health care are closely monitored and frequently contemplated. “Nurses are entering into a new reality of practice that is controlled by costs” (Turkel, 2001, p. 69). Nurses need to keep in mind that money spent in any area must be budgeted. If unbudgeted money is spent, if the category is over budget or over the projected budget, then that money must be subtracted from another area. There is not an infinite supply of money that can be spent, no matter what the reason. Take for example a personal budget. If you overspend, you try to accommodate this by spending less in another area. Or you go into debt. In contrast, if you spend less than the budgeted amount and are under your budget, you may have money saved for another area or to compensate for overspending. We do, however, have more control over our personal spending than the spending of our organizations. Our organizations are subject to many variables that influence both revenue and expenses. Just think for a minute about the many events that increase labor costs. Sick calls, leave of absence, and an increase in census or acuity are just a few of the incidents that increase the dollars budgeted for staff.

Fiscal Planning and Budgeting

“All planning involves choice a necessity to choose from among alternatives. This implies that planning is a proactive and deliberate process” (Marquis & Houston, 2006, p. 146). Planning skills are an essential function of nursing management so that personal as well as organizational needs and goals can be met. Planning has specific purposes and is one approach to strategy making. Planning also represents specific activities that lead to achievement of objectives. Fiscal planning is an important, but often neglected, element of the planning process. Fiscal planning must reflect the philosophy, goals, and objectives of the health-care organization. As with all elements of planning, fiscal planning must be proactive, flexible, and clearly stated in measurable terms. The intended goal of fiscal planning is to create a budget that will meet the needs of the nurse manager and unit. When creating the budget, a function within fiscal planning, the nurse manager should take into consideration what may occur in the future that could potentially affect the unit’s budget. The nurse manager must be proactive: look to the future and estimate or try to predict the “what ifs” or what could happen during the projected budget period. When predicting the budget for the fiscal year, start with what is currently known and what has happened. Review the previous year’s budget to determine where the spending has been within the amount projected as well as areas where the spending has resulted in a surplus or deficit situation. It is important for the nurse manager to realize that there are uncontrollable factors that can affect the bottom line of the budget. The nurse manager must clearly state, in a way that can be quantified or measured, what is to be included within the budget and be flexible to adjust for any unanticipated factors that can influence the budget. Fiscal planning should incorporate short-term and longterm planning. When preparing to create the fiscal budget, nurse managers should involve as many staff in the input process as possible. Keep in mind that practice makes perfect. Fiscal planning and working with a budget are learned skills. The more times managers plan and work with fiscal budgets, the more they are able to improve their skills and ability to complete the budget process.

“An essential feature of fiscal planning is responsibility accounting, which means that each of an organization’s revenues, expenses, assets, and liabilities is someone’s responsibility” (Marquis & Houston, 2006, p. 215). This typically means that the individual with the most direct control on any of these financial elements should be held accountable for them. In the department of nursing, this accountability generally is integrated into the responsibilities of the nurse manager. This results in the manager needing to be an active participant in unit budgeting, having a great deal of input into what is to be included in the unit budget, receiving

regular budget data reports that compare actual expenses with budgeted expenses, and being held accountable for the financial outcomes that result from the operational budget.

The purpose of budgeting is to define a road map for revenue and expense while identifying cashneeds. “A budget is a plan that uses numerical data to predict the activities of an organization over a period of time, and it provides a mechanism for planning and control, as well as for promoting each unit’s needs and contributions” (Carruth, Carruth, & Noto, 2000, p. 16).

A budget’s value is directly correlated to its accuracy. The level of accuracy is directly connected with the fiscal planning process. The more comprehensive the fiscal planning, the more people who provide input, the greater the amount of information gathered prior to finalizing the budget, the more accurately will the budget reflect the manager, department, and organization. Marquis and Houston tell us “because a budget is at best a prediction, a plan, and not a rule, fiscal planning requires flexibility, ongoing evaluation, and revision” (2006, p. 217). All budgeting is initiated through planning and forecasting. Budgets serve a dual purpose: they are numerical expressions of plans, and they become control standards against which results are compared or benchmarked. Types of budgets and the time frames of the budgets may vary. Budgets are management tools. Preparing and working with a budget enable managers to reflect upon previous expenses and to be aware of current and future costs as well as the amount of resources that have been and will be utilized. As part of working with and comparing budgets, a manager will review periodic budget reports generally on a monthly basis. As part of this monthly budget review, the manager will compare actual expenditures for the month with the approved budgeted amount and the year-to-date budget status (see Box 16-1).


Nurses have been expertly educated to use the nursing process. The same type of process is the most widely used approach to preparing a budget: Assessment →  Planning →  Implementation →

Evaluation Assessment

The first step within the context of the organization’s strategic plan and financial plans is to assess the department and determine what needs to be covered in the budget to meet the organization’s goals. The nurse manager assesses the needs of the area for which the budget is being created. It is important to involve as many staff members as possible in the budgeting process so that they have an appreciation for the resources needed to deliver their particular services or product. When nurse managers and their staff are involved in fiscal planning, staff members become more cognizant of what things cost and gain fiscal awareness that will lead to cost-consciousness and potential savings. In the assessment phase, a significant amount of effort is spent validating the standard of care hours for patients in different cost centers. (i.e., intensive care unit, nursery, etc.). The standard of care hours is most frequently expressed as nursing hours per patient day (NHPPD). In other words, how many hours of care in 24 hours will be available to each patient? This number is used in the budget preparation process as a target. Another term used more recently to discuss the standard of care hours is nurse/patient ratio. This is expressed as one nurse to six patients (1:6), for example, and means that there will be one nurse provided for every six patients. California has legislation that mandates this ratio for medical-surgical patients. Other states are researching the outcomes of this legislative move on patient care and resource use (Garretson, 2004).

NHPPD or nurse/patient ratios are calculated into full-time equivalents (FTEs) to plan budgets. An FTE is an accumulation of 2080 paid hours. It is not a person or position. It may be four people being paid for 502 hours each, or two people being paid for 1040 hours each (Fig. 16-1). Rohloff states that the majority of organizations define FTE by using 8 hours/day, 40 hours/week (8/40), and 2080 hours/year. Also common practice is to hire many full-time nurses at 12 hours/day, 36 hours/week (12/36), and

Nursing Hours per Patient Day (NHPPD).

1872 hours/year. Finance generally reflects these nurses as 0.9 FTE (Rohloff, 2006). The FTE calculates the paid hours until the FTE hours of 2080 (or less if a 36-hour week) are reached. These hours are paid but not necessarily worked. Each accumulation of 2080 includes productive (actually worked) and nonproductive (holiday, vacation, sick) hours. The nonproductive hours are also called paid time off. Nonproductive hours become a significant budget calculation because it is time that must have staff coverage, an additional cost. Nonproductive calculations are dependent on benefit time off and vary from employer to employer and personnel category. For example, nonproductive time for a registered nurse may include three weeks of vacation, four holidays, and three education days. This is 28 nonproductive days or 224 hours. Nonproductive time for budget purposes is projected yearly during the planning phase of budget preparation. It is based on the total number of FTEs in each personnel category and their respective nonproductive time based on benefit polices. The salary costs are then calculated and added to the budget. The assessment phase also entails forecasting and calculating the projected patient days for the new budget period. Projected patient days are based on historical trends, new programs approved for implementation, changes in care delivery, and reimbursement levels. For example, last year’s actual days in post partum were 5250. The new budget is using these days and new patient days that reflect the addition of two nurse midwives who have been given privileges to care for and deliver patients. For the new budget year, it is projected that 600 new patient days will result from these new practitioners.

The projected patient days for the new budget year will be 5850 (5250 Х 600).


The second step in the budgeting process is to develop a plan. The length of time that the budget is to cover must be determined, and this time frame is the budget cycle. Budgets are usually developed to cover a 12-month period, known as a fiscal year. The fiscal year may or may not coincide with the calendar year. A fiscal budget year is broken down into quarters and typically further subdivided into months.

Most budgets are created for a 1-year period; when the budget period is over, the budget planning process starts anew. Although a yearly budget is the most common budget, a perpetual budget may be utilized. A perpetual budget is a continual process by which a budget is created each month so that a continuous 12 months of future budget are always available.

In the planning phase, the required personnel and supply costs are calculated for the projected patient days. This work is completed using a computerized spreadsheet application. The nurse manager begins the planning process by reviewing past budget history to determine average supply costs and the number of patient days or the average daily census for the unit. The nurse manager needs to determine if there will be any significant changes within the unit’s supplies, either quantity utilized or if there will be any new supplies or an increase in current supplies related to patient volume, acuity, or diagnosis/procedure specific care. For example, a surgeon has joined the staff and will be performing a highly specialized robotic procedure. The surgeon is projected to perform 1500 procedures per year. The addition of this patient population will thereby: (1) significantly increase the patient days and the average daily census that should be budgeted for the unit, (2) increase the acuity of the patients cared for by the nursing staff, and (3) result in the nurse manager ordering high-cost specialty supplies to care for this patient population. Table 16-1 presents the remaining activities in the planning phase. These activities take the budget plan through its review and approval process. The budget process begins with the organization setting a direction and ends with implementation. This time frame is usually about 3 months. The activities from budget spreadsheet to final budget listed in Table 16-1 are the mechanics and review process of a budget. Usually the budget parameters are given to the manager as a spreadsheet application, which is the working document for the manager’s cost center. The budget is presented to the reviewers; when it meets the operating standards set in the planning phase by revenue and expenses, it goes forward to the board of trustees for the last review. After action is taken by the board, the budget is returned to the manager for implementation.


The third step is to implement the budget. Prior to implementing the budget, the nurse manager should thoroughly review the final budget and be certain that the budget is fully understood. The nurse manager will typically meet with her direct supervisor and a member of the finance department to generate the budget for the fiscal year. Being actively involved in the process allows the nurse manager to communicate information about their unit while learning the facility budget creation, approval, and implementation process. A nurse manager who is inexperienced in the area of budgeting should carefully review the budget for her area and ensure that a thorough review of the facility budget process is provided in order to establish a solid understanding of budgeting. The nurse manager should take the initiative to inquire about areas of the budget about which she or her staff members have questions.

During the implementation step of the budget process, the nurse manager must be actively involved in monitoring and analyzing budget activity to remain within the budgeted parameters and to avoid inadequate or excess funds at the end of the budget period. The nurse manager should review the approved budget for the fiscal year with the unit staff. It is especially important for the nurse manager to explain any changes from the previous year’s budget. The staff needs to understand projected changes in staffing, patient population, and supply usage. The more the staff understands the budgetary goals and the plans to carry out those goals, the more likely the goal will be attained. The manager generally is accountable for deviations in the department’s budget. Some deviation

Budget Preparation Process

from the proposed budget can be anticipated, but large deviations must be examined for possible causes, and corrective action must be taken. Box 16-2 lists the rules of budgeting that managers live by. These rules or guidelines are the basic underpinnings that most organizations believe to be essential for sound fiscal responsibility. Budgets should be prepared, explained, and monitored by the same person who will be accountable for compliance with the budget. This person understands the workings of this budget best. This also means that expenses are charged to the cost center (e.g.,patient unit) that incurred them (spent the money) and are under the control of the manager. Within operating budgets for a cost center there are salary, supply, and equipment dollars. These dollars can be used only in these designated areas and cannot be carried over to the next budget year if not spent. Changes from the budget as planned are called variance and must be explained to the department head and have steps taken to correct them.


The fourth step is evaluation. The budget should be reviewed regularly to determine the level of adher ence to the budgeted figures. The fiscal budget should be reviewed as often as daily when the newly

approved budget is implemented. If variances from the approved projected budget are present, the nurse manager must react quickly by examining the budget closely. The nurse manager should determine what areas within the budget are either above or below the projected budgeted amount. This is accomplished by comparing the projected budgeted amount with the actual amount spent. Modifications in spending should be made throughout the budget period to accommodate for any deviation, and corrective measures should be put in place to bring the year-to-date total into the projected targeted amount. The budget process is continual and cyclical in nature. As the evaluation step is being completed, the nurse manager has begun to assess any deviations from the budget, thereby beginning the cycle once again (Fig. 16-2).

Steps in the budget process.


The operating budget is a combination of the revenue and expense budget. It is a forecast of the revenue that is expected to be earned during the defined budget period and the expenses incurred to earn the revenue during the same period. The personnel costs are a significant part of this budget. This budget is a plan for the unit’s or organization’s daily operating revenue and expenses. It includes the workload budget (FTEs); units of service, such as patients days or visits; and expense budgets with personnel costs, supplies, equipment, and overhead. A program budget contains all the items that are a cost in a particular care delivery program. This type of budgeting is frequently completed for new programs and expansions of existing programs of care or services. This is usually completed in the early phases of fiscal planning and budget preparation. If the new program is approved for implementation during the budget review process, then its budget becomes part of the operating budget. Capital budgets summarize the anticipated purchases for the fiscal year and usually have a dollar minimum cost to be included (e.g.

 $300). The life span of equipment projected during this phase of budget planning is usually longer than 3 or more years. The capital budget is separate from the everyday operating budget, and the funds for these purchases are usually released by the finance department when available for approved purchases. The cash budget predicts expected revenue and payments for resource or cash outflow. An example of cash outflow is the payment of salaries for work performed. This budget, is monitored carefully to ensure adequate cash to pay bills in a timely manner and reduce the necessity to borrow funds to pay bills.

Supply Budget

Supply budget predicts the use of medical-surgical supply costs based on predicted case mix of patients for the upcoming fiscal year. The supply budget includes the expense of all supplies that are utilized on the nursing unit to provide patient care. Supplies are the area of the budget in which managers must be actively involved and can make adjustments to remain within the budget. The supply budget reflects expenses that change in response to the volume of service, above or below the budgeted census, and changes in acuity, requiring more, fewer, or completely different supplies. Controlling the number of supplies used in excess or in a wasteful manner is the responsibility of the nurse manager. This is not an easy task; it requires involvement of all staff members at all levels.

Nurse managers must be thoroughly knowledgeable of the supplies that are stocked on their unit, the amount that each supply costs, and the volume of each supply that is used. Each health-care organization will have a different system to ensure that supplies are available for use as well as for tracking the amount used. The nurse manager needs to control the amount of supplies that are available in her department as well as how these supplies are used. Supplies should be researched to determine their usefulness. Ask the question: is this supply being utilized in the intended manner? Examine supplies that are frequently used and that result in highvolume usage, therefore high cost. Is there a way to decrease the amount of a supply that is used without affecting the quality of care? For example, if the manufacturer recommends applying one incontinence pad to a bed, and an employee applies four incontinence pads, it results in an unnecessary expense that can be prevented or controlled. Perhaps buying one pad of a larger size is cheaper than using two to four pads of a smaller, cheaper vendor. Look at prepackaged supplies. As with many convenience items, these can come with a higher price tag. If prepackaged supplies are being utilized, is every supply item that is included in the package being used? If not, compare cost with convenience; does the expense of the prepackaged supply outweigh the convenience? Monitoring the supply process within the department must be an ongoing effort. This is not a singleperson effort. The nurse manager must educate employees on the importance of utilizing supplies efficiently and encourage them to become actively involved in this cost-saving effort.


Historically, nursing management played a limited role in fiscal planning within health-care organizations. The department of nursing was considered to be non—income-producing; therefore, input was not sought or valued. Today, health-care organizations have recognized the importance of nursing involvement in the budget process. Nursing budgets generally encompass the most personnel expenses and are responsible for the largest share of the total overall expenses in health-care organizations. It is imperative that nurse managers gain expertise in fiscal planning and the budget process. Budgeting is a challenging managerial task because it involves both planning and control functions. A nurse manager must perfect the ability to balance planning skills with control skills. Planning requires an innovative approach to the situation, whereas control can be perceived as restrictive or essentially negative and conservative in nature. In order for a nurse manager to utilize these skills successfully, he must be able to bring balance innovative and conservative view points. A nurse manager could be tempted to request the latest and greatest supplies, furniture, equipment, or increased staffing levels as part of the fiscal planning process for the next fiscal budget. The nurse manager must prioritize what is essential for his unit’s functioning in order to deliver high-quality patient care. The nurse manager must ask for what is really necessary or utilize his planning skills while balancing this with control functions or not asking for what would be above what is necessary. This balance entails the ability to look forward or forecast future activities and anticipate what may be needed as well as the ability to look to the past to reflect upon what has already occurred. The manager needs to model scenarios that can change the forecasted numbers. What if scenarios offer a snapshot of what may happen if change occurs in the projected patient days, the case mix index, the availability of staff, or reduction in services offered. Forecasting is the selection of the scenario that fits the environment best. Success in budgeting requires thoughtful and deliberate forecasting along with the balancing act of planning and controlling. The staff needs to understand how the budget was planned and its role in using the resources wisely to reach successful outcomes for the patients and the organization.


After comparing the budget report, the approved budgeted figure with the actual amount spent, the manager determines if expenses are within, over, or

under the budgeted amount. A deviation from the actual budgeted amount is defined as a variance. Some common reasons for variances are higher- or lower-than-budgeted patient average daily census, higher or lower patient acuity, and staff replacement

or overtime. Variances from the actual budgeted amount (above or below the budgeted amount) should be identified and closely examined and investigated by the manager to determine the cause of the variance. Identified variances can serve as signals in future months to steer the manager away from the cause of the variance. At this point, the manager will do a gap analysis to determine what caused the difference from the budget projections. In other words, the manager will investigate to find an explanation for the gap between planned and actual. An increase in patient days might require more staff and may explain why the total NHPPDs are over budget.

In planning a budget, past variances should be examined to determine any patterns of usage or any areas in which the budget should be adjusted. Figure 16-3 presents some examples of worked FTEs, flexed-budget worked FTEs, and the resulting

PSH Hospital salary expense summary.

variance. The manager in today’s environment must explain why this variance occurred and what corrective action steps will be taken to bring the budget back on target. A solution might be beyond the manager’s jurisdiction and may require a review group for re-adjusting. Variances are experienced in three ways: price, outputs, or inputs. A price variance occurs when the price paid for the resource is different than what was budgeted. An example from a nursing budget is when an agency nurse is used for staffing with the resulting dollar per hour cost being higher. Output variances may be higher or lower than planned amounts and could be more or fewer patient days delivered or change up or down in planned surgical cases. The input variance would entail different resource use than the budget plan. This might be that the budgeted NHPPD was eight NHPPDs and the actual was 10 NHPPDs. Actual NHPPDs become FTEs and salary expense. Figure 16-3 illustrates actual worked FTEs and flexed-budget FTEs. The flexed budget responds to the difference in required FTEs and resulting variance. Nurse managers control expenditures of a major portion of institutional resources. Those resources can be utilized most effectively when the manager takes an active role in preparing and administering the budget. The budget should be a perpetual cycle of examining what has been spent, determining variances within the budget, analyzing causes of variances, and making modifications to correct the causes of the variances.

Cost Containment

Cost containment refers to effective and efficient delivery of services while generating needed revenues for continued organizational productivity. The goal is to deliver the services with high quality at the lowest possible cost. Cost containment is the responsibility of every health-care provider. The viability of health-care organizations today depends on their ability to use their fiscal resources wisely. “In a budget, expenses are classified as fixed or variable and either controllable or noncontrollable” (Marquis & Houston, 2006, p. 217). Fixed expenses do not vary with volume, whereas variable expenses will increase or decrease based on volume. Fixed expenses include a building’s mortgage payment and the payroll of salary employees. Variable expenses

Practice Proof

Practice to Strive

might include supply costs and the payroll of hourly employees. Controllable expenses are those that can be managed or controlled. Controllable expenses include the number of employees working each shift or NHPPD. Uncontrollable expenses, such as equipment depreciation and supplies that are necessary to deliver care, cannot be managed or controlled. In today’s health-care market, the increasing costs of health-care delivery have resulted in a strained health-care system. It is essential for healthcare organizations to operate at the highest level of efficiency and to be acutely aware of cost containment. Nurse managers need to become increasingly aware of the need for cost containment. The old “This is how we have always done it” will not work in today’s health-care market. Cost containment does not have to be thought of in negative terms.  It does not have to mean a deficiency of care; think of it as doing things differently while delivering the same high quality of care, to save money or, even better, so as not to waste money. See Figure 16-4.

All Good Things...

The budget as a plan and management control tool is a “guesstimate” at best. The historical trends, assessment of the environmental changes, projected patient days, and case mix index used to build the budget are not a perfect science. Hence, the management of the budget during its fiscal year is an ongoing activity. Understanding that resources are limited and that each of us is accountable for what we “consume” to provide our product of patient care is a key point for all providers in the health care system.

Creativity and innovation are necessary to deliver our product of patient care within the fiscal limitations of our resources. Whether it’s our own personal budget or that of the organization we work for, resources are finite and as such must always be monitored and carefully utilized. Dashboards as a management tool provide timely opportunities to recoup budget variances and plan new strategies to avoid them in the future. The manager may be the facilitator and monitor of budget compliance, but all of us are the stewards of the financial resources available to provide our product, patient care.

Dashboard calculation.

Staffing and Scheduling

The nurse manager’s  staffing and scheduling goals are to assure the presence of adequate, responsible, qualified, and competent personnel who will provide quality nursing care services in a timely manner and consistent with the Principles for Nurse Staffing of the American Nurses Association (ANA) (1999). Additional goals in staffing and scheduling include sustaining congruence with the mission, vision, values, philosophy, and strategic plan of the organization and its nursing services and maintaining compliance with regulatory guidelines.

Overarching objectives in providing nursing care services include patient safety and patient satisfaction. This chapter will discuss the staffing process with relationship to staffing plan, care delivery models, staffing and scheduling systems, and scheduling outcomes.


The late 1990s brought with them a nursing workforce shortage, which has had a significant effect on nursing care delivery systems. A widespread nursing shortage in the United States translated into demanding and less attractive work environments (Kimball & O’Neill, 2002). Compounding the nursing workforce shortage were the alarming findings by the Institute of Medicine (IOM) in 2000, 2001, and 2004. Based on the IOM quality chasm trilogy series, which provided strong evidence for the need for safer patient care environments in the healthcare delivery system, a redesign of health-care processes became imperative (IOM, 2000, 2001, 2004). To redesign health-care processes, local, state, consumer, professional, and regulatory organizations joined to seek solutions. The redesign would include plans regarding nurse staffing. The IOM reports identified nursing as a pillar of quality and patient safety that must be strengthened to keep patients safe and retain nurses. Transformation of the work environment of nurses requires improving staffing adequacy, administrative support, and good nurse-physician relations (IOM, 2004). Staffing and resource adequacy are systemcentered measurements advocated by the National Quality Forum (NQF) in conjunction with other nurse-sensitive performance measures to achieve an environment of safety (Kurtzman & Kizer, 2005). NQF is a unique public-private partnership of more than 170 organizations, including the ANA. Examples of measurable nursing-sensitive outcomes are satisfaction, burnout, intent to leave, and costs. Examples of patient-sensitive outcomes affected by nursing care are mortality, failure to rescue, complications, satisfaction, and costs. Nurse staffing influences nursing and patient-sensitive outcomes.


In 1999, the ANA published  Principles for Nurse Staffing, which emphasized the nursing work environment to provide safe patient care. Subsequently, the ANA advocated a work environment that supports nurses in providing the best possible patient care by budgeting enough positions, administrative support, good nurse-physician relations, career advancement options, work flexibility, and personal choice in scheduling (ANA, 1999). Staffing, according to the Center for American Nurses (The American Nurse, 2006), refers to job assignments. Job assignments include the following: the volume of work assigned to individuals, the professional skills required for particular job assignments, the duration of experience in a particular job category, and work schedules. The process of staffing begins with an assessment of the current staffing situation. The assessment includes the qualifications and competence of the staff available (ANA, 2004). The next step is to formulate a plan to meet future needs. The staffing process culminates with a schedule (organized plan) of personnel to provide patient care services.

Scheduling variables are defined as:

1. The number of patients, complexity of patient condition, and nursing care required.

2. The physical environment in which nursing care is to be provided.

3. The nursing staff members’ competency levels, qualifications, skill range, knowledge or ability, experience level.

4. The level of supervision required.

5. Availability of nursing staff members for the assignment of responsibilities.

Appropriate allocation of nursing staff for patient-focused care (American Association of Colleges of Nursing [AACN]-Critical Care, 2001) or patient-centered and essential patient safe care (Bleich & Hewlett, 2004) is the desired goal of nursing staffing levels.

The ANA  Principles for Nurse Staffing (1999) offer standards to incorporate and balance the needs of patients, nurses, and organizations committed to positive patient outcomes. The principles recognize that providing nursing care services can be multivariate and complex. The ANCC Magnet Recognition Program (2004) is an example of a quality recognition organization that has incorporated the ANA Principles for Nurse Staffing as a program foundation.

The ANA patient care unit-related principle of “appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs” (ANA, 1999) is aligned with current research findings. Appropriate staffing concentrates on a higher proportion of patient care hours provided by registered nurses as compared with patient care provided by licensed practical nurses or unlicensed personnel for better patient outcomes. An appropriate staffing system incorporates patient needs, staff member skill sets, and staff mixes (ANCC, 2004). The  2004 University HealthSystem Consortium Nursing Work Environment Benchmarking Survey (2005) of 59 academic medical centers found better patient outcomes and improved nurse satisfaction when registered nurses deliver a higher proportion of care.

Another nursing quality recognition program, the Texas Nurses Association Nurse-Friendly Hospital Criteria (TNA, 2005), has incorporated the ANA principle of staff-related “clinical support from experienced RNs should be readily available to those RNs with less proficiency” (ANA, 1999). TNA Nurse-Friendly Hospital Criteria are 12 essential elements identified as an ideal practice environment for nurses. One of the essential elements is “nurse orientation.” The facility must demonstrate that it has a nurse-specific orientation program that considers the education, experience, and identified strengths and weaknesses of the nurse being oriented (TNA, 2005). The ANCC Magnet Recognition Program (2004), a quality-focused organization, advocates that the organization has a function and productive system of shared decision making among the nursing staff members. An example of a shared decisionmaking process is a decentralized nurse staffing and scheduling system that provides staffing throughout

Practice Proof

the nursing operations of the organization. The organization’s personnel policies and programs need to reflect minimal rotating shifts and creative and flexible staffing models. The staffing system adapts and flexes internal and external factors such as staff illness, shift changes in workload, and other uncontrollable variables. Trending data are to be used to formulate the staffing plan and to acquire necessary resources to make staffing adjustments in response to fluctuating patient workload and acuity (e.g., agency staff, float pool staff, overtime). In contrast to appropriate staffing is inadequate staffing. Inadequate staffing came to the forefront of the nursing profession in the early 21st century with such national published and publicized reports as the IOM (2000, 2001, and 2004). In response to the nursing shortage, nurse working condition studies reported nurses’ dissatisfaction with inadequate staffing conditions (Unruh, 2005). For example,

Staffing process.

inadequate staffing conditions are reported in acute-care (Aiken et. al., 2002) and long-stay nursing home (Horn et. al., 2005) studies as well as in national nursing (Stanton & Rutherford, 2004) and health-care standardization organization (JCAHO, 2004) studies. The goal of nursing care is to provide patientcentered and essential patient-safe care (Bleich & Hewlett, 2004). The purpose of nurse staffing is to ensure patient care needs are met. The staffing process starts with a staffing plan and ends with positive patient outcomes and acceptable nursing workloads.


The staffing process is the linear incorporation of the staffing plan, the scheduling and staffing system, and the scheduling outcomes into a systematic flowing process. The following discussion describes the various components of each step of the process, beginning with the staffing plan.

Staffing Plan

The staffing plan consists of four different elements that must be addressed: the health-care setting, care delivery model, patient acuity, and nursing staff. They are then incorporated into the next step in the process, the scheduling and staffing system. A staffing plan can also be referred to as the staffing matrix.

Health-Care Setting

The health-care setting is where the patient care services are provided. It is the first consideration in developing the staffing plan. Geographical location and architectural design of the health-care facility will determine the accessibility of the nursing staff to the patient, which has ramifications regarding the work allocation and provision of the patient care services. Specific examples in the development of the staffing plan are the consideration of the location of the patient care supplies in relation to the point-of-use at the bedside and the walking distances between the patient bedside and the nursing station. The impact of the design of the health-care setting on system metrics was addressed by Gabow et. al. (2005). This study illustrated that nursing turnover and vacancy rates are influenced by efficiency, workforce development, and architectural effects on the work environment.

Care Delivery Models

Care delivery models, also referred to as nursing care delivery systems or patient care delivery models, can vary from one nursing unit to another, depending on the type of patients, the care requirements, and available resources. The focus of care delivery models is on the patient and how nursing care services are developed and provided. Nurse clinical decision making, work allocation (workload), communication, and management are included in care delivery models. The choice of model used is dependent on these factors, combined with the differing social and economic forces (Tiedeman & Lookinland, 2004). A care delivery model needs to address four components:

1. Patient needs

2. Patient population demographics

3. Number of nursing staff members

4. Ratio of nurses serving various roles and levels (ANCC Magnet, 2004, p. 46).

Care delivery models are classified into three main types: traditional, nontraditional, and emerging.

Traditional nursing care models are referred to as total patient care, functional, team, and primary nursing. Tiedeman and Lookinland (2004) found studies of traditional models of care delivery lacked the necessary methodological rigor. They were not able to draw conclusions about the impact of the model of care delivery on quality of care, cost, and satisfaction. Subsequently, nontraditional models of care delivery have been developed to address the changing needs of health care. Nontraditional models of care delivery came about during the 1990s managed-care era. They reduced the professional staff in the skill mix and became a major cost-saving strategy in many organizations (Hall, 1998). Nontraditional models reviewed by Lookinland, Tiedeman, and Crosson (2005) used various combinations or skill mix of licensed nurses (registered nurses and licensed vocational nurses) and unlicensed assistive personnel (UAP). They found weak research evidence for the nontraditional models. They recommended that future studies must be rigorous and include nursing-sensitive outcomes such as nursing productivity; patient, staff, and physician satisfaction; and cost and quality indicators to allow comparisons across studies (Lookinland, Tiedeman, & Crosson, 2005, p. 79)

The traditional and nontraditional models are composed of division of labor, efficient use of time to perform nursing care tasks, cost, and training. These models use a mix of licensed and unlicensed personnel. Most traditional and nontraditional models are patient-centered. In specific patient populations such as adult critical-care and pediatrics, a family-centered care model is used. In the familycentered care model, family members with the patient are active participants in planning the care of their loved ones, including a role as direct caregivers. Nursing care activities are organizing care around the patient and the patient’s family (Henneman & Cardin, 2002). In a redesigned model for providing professional nursing care for psychiatric patients, Allen et al. (2006) found the relationship-based nursing model provides an integrated network of relationships based on the values of caring: between nurses and patients, nurses and nurses, nurses and mental health workers, nurses and physicians, and nurses and the organization. Hall and Doran (2004) studied three care delivery models in Canada: total patient care, team nursing, and primary nursing. The term “regulated nurse” is the Canadian equivalent of the U.S. RN, and in the total patient care model only regulated nurses provide patient care services. Their findings indicated that an all-regulated nurse staffing model has better quality outcomes for patients. They also determined that staffing models that include professional and unregulated staff may pose a challenge for unit-based communication and the coordination of care. Donley (2005) advocates that care delivery models should emphasize radical redesign instead of incremental layering of tasks that are quickly becoming unmanageable. Summarily, the AACNCritical-Care (2005) found that health-care organizations have systems in place that facilitate team members’ use of staffing and outcomes data to develop more effective delivery models. Emerging models are concepts that are being developed and implemented. One emerging model of care delivery is the acuity-adapted room model. The acuityadapted room model is patient-focused care that brings care to the patient rather than bringing the patient to the care. In this model, the room changes around the patient instead of the patient changing rooms. This is possible because each private patient room is equipped to treat all levels of care. From a joint research project conducted by a product manufacturer and a university health-care system, a cardiac universal bed was used in the acuity-adapted rooms (Johnson, Brown, & Neal, 2003). The acuityadaptable rooms (also called universal bed or cardiac universal bed model) are appropriate for specific patient populations, such as coronary critical care and step-down units combined into acuity-adaptable rooms (Advocate Good Shepherd Hospital, 2005;AIA, 2001; Dunton et al., 2004; Hendrich, Fay, & Sorrells, 2004; Moody, 2005; and Pricewaterhouse Coopers, 2004). Thus, the time-consuming and costly patient transferring activities are eliminated. The nursing staff works as a team and is adaptable in scheduling to correspond to the patient acuities (personal correspondence with C. Gallaher, RN, MS, April 2005). The staffing plan is based on patient needs by patient classification level.

■ Level 1 patient classification: one nurse for four to five patients

■ Level 2 patient classification: one nurse for one to three patients

■ Level 3 patient classification: one nurse for one patient

A new variation of the acuity-adapted room model has been developed. In this model, the acuityadapted room within the health-care setting is designed for the patient to be physically closer to the nursing staff (Fig. 17-2). The diagram shows that well-designed units lead to increased efficiency, elevate the quality of patient care. and improve the job satisfaction among the nursing staff. The objective of this model is to increase vigilance by the professional nursing staff, thereby enhancing patient safety (Meyer & Lavin, 2005). Each patient room is furnished with state-of-the-art medical equipment and a private bath. There is a nursing station for every two patient rooms. This arrangement allows the patient to be closely monitored without undue disturbance. Internet access is available in each of the rooms so the nursing staff can do their charting at the bedside. The rooms can accommodate family members who stay overnight.

Acuity-adapted room models offer the following:

■ Reduce the need to transfer patients to different hospital units as their status improves or worsens

■ Assist with the continuity of care

■ Increase patient satisfaction

■ Provide isolation for infectious diseases

■ Protect patient privacy

■ Provide personal patient environment of comfort and reduced disturbances

Additionally, nursing satisfaction can be positive (Anderson, 2003).

Another emerging model is the Partnership Care Delivery Model. The AACN (AACN-Colleges, 2004) has advanced the role of clinical nurse leader, which requires the unit nurse leader to be prepared as a generalist at the master’s level. The clinical nurse leader (CNL) provides care in the model. The CNL understands and interacts with the whole continuum and in partnership with all the disciplines (Tornabeni, Stanhope, & Wiggins, 2006). Smith, et al. (2006) reported a successful 6-month pilot using the model in an acute care setting. Another emerging model example is the Transforming Care at the Bedside (T-CAB). T-CAB focuses on achieving outcomes associated with work reliability, patient centeredness, increased value (including reducing paper work), and work force vitality (Bleich and Hewlett, 2004). The T-CAB model pulls together an interdisciplinary team to assess problems, to develop, and to evaluate creative approaches for addressing the problems. The interdisciplinary team then disseminates solutions to other areas within the facility (Mason, 2006). For critical care delivery in intensive care units, a practice model (Brilli et al., 2001) has emerged that is based on multidisciplinary group practice using the team approach. The team is led by a fulltime critical care–trained physician in the intensive care unit 24 hours per day. This model is based on its ability to minimize mortality and to optimize efficiency while preserving dignity and compassion for patients. Nursing workloads in this model are defined by hours per patient day or the nurse-topatient ratios.

Needleman et al. (2006) examined three approaches to increasing nursing staffing in hospitals and the cost of those approaches, without considering care delivery models. In an earlier study they analyzed data from 799 nonfederal acute care general hospitals in 11 states. In this study using the earlier data, they simulated the effect of three options to increase nurse staffing. They concluded that for hospitals using both RNs and LPNs, greater use of RNs appears to pay for itself in fewer patient deaths, reduced lengths of hospital stay, and decreased rates of hospital-linked complications, such as urinary tract infections, pneumonia, and cardiac arrest.

Regardless of what model of care is used, the nursing education and practice must be client(patient)-centered, generate quality outcomes, and be cost-effective (AACN-Colleges, 2004). Outcome system-centered measures are skill mix (RN, LPN, UAP, and contract), nursing care hours per patient day (RN, LPN, and UAP), and practice environment measures that include staffing and resource adequacy (Kurtzman & Kizer, 2005). The quality and safety of the nursing services provided are tied to the professional nurse and patient ratios and/or the nurse/patient index.

Patient Acuity

Patient needs are summarized in patient acuity systems. Patient needs are specific to each patient, and conditions may change from hour to hour, shift to shift, day to day, and so on. Thus, staffing plans need to be modified constantly. In patient acuity or severity systems, patients are assigned a location in a hospital based on an acuity system and/or admitting diagnoses. For example, patients can be assigned to an intensive care, intermediate care, progressive care, medical-surgical, or obstetrical unit, and by age such as pediatrics versus adults. Medicalsurgical unit patient assignments are often further refined into medical diagnoses or disease systems such as cardiac, oncology, and transplant. Patients are often transferred from one unit to another based on nursing skill levels and/or medical therapeutic and diagnostic procedures needed. Moving patients from one unit to another increases the nursing workload for admissions, transfers, and discharges during a 24-hour period. These activities are not usually accounted for in the daily patient census accountings. Daily patient census counts are done once during the 24 hours, most generally at midnight. The admission, transfer, and discharge activities of patient care add to the overall unit workload. A benchmarking study of U.S. critical care units found the number of nurses needed for basic staffing plans involves expected patient census, special ized skills for patient-care technologies (e.g., balloon pumps, dialysis), and the skill mix of the staff (Kirchhoff & Dahl, 2006, p. 20). A formal patient acuity system has the lowest priority for staff planning. Patient activity is determined by services (nursing, medical, and pharmacy interventions) delivered and not by patient demographics. In a simulated model using actual data provided by Titler et al. (2005), the cost is related to the nurse staff using Nursing Interventions Classification (NIC) data captured in an electronic documentation system from 11,756 hospitalizations from 8988 patients. Titler, et al., analyzed the effects of staffing, treatment, pharmacy, and nursing intervention over cost. They found increased costs with higher nurse-to-patient ratios. The Titler study also found, however,  that RN staffing below the unit’s average (RN/patient dip proportion variable) also costs money. It is interesting to note that this finding (low RN staffing) had not been previously examined (p. 304).

Nursing Staff

The work activity of the nursing staff includes direct care, indirect care, unitelated, personal time, and documentation (Urden & Roode, 1997). Staff members refer to all personnel reporting to the nurse administrator (ANCC, 2004, p. 84). Staff nurse refers to an RN responsible for the direct and indirect care of patients in the hospital (McClure and Hinshaw, 2002, p. 7). Staff members, as defined by Mosby (2005), are people who work toward a common goal and are employed or supervised by someone of higher rank, such as the nurses in a hospital. Staffing is the process of assigning people to fill the roles designed for an organizational structure through recruitment, selection, and placement. According to the ANCC 2004 Magnet Recognition Guidelines, direct patient care nurses (staff nurses) are responsible for patient-centered nursing activities carried out in a patient’s presence (e.g., admission/transfer/discharge, patient teaching, patient communications). Nursing staff categories for direct patient care nurses include those counted in the staffing matrix or plan, assigned greater than 50% to direct care responsibilities, and replaced during a shift if they call in sick (ANCC, 2004, p. 118).

Staff competencies and qualifications are outlined in job or position descriptions and measured through continuing educational activities, mandatory education, and personnel evaluations. Those who require licensure or certifications to perform their job must keep up to date, with no lapse. Qualified nurses with disabilities can be successful practitioners with reasonable accommodations in the workplace (Gatens, 1972). Historically, nursing has been seen as a career requiring considerable physical function and strength. However, much of what the modern nurse accomplishes is done through cognitive function. Such cognitive functions are assessment, problem solving, deduction, counseling, and evaluation (Pischke-Winn, Andreoli, & Halstead, 2004).

A unit staffing plan needs to take into consideration specific patient dependency levels, high-risk patient handling tasks, and the nursing staffs’ physical abilities. Nurses are working less in acute care settings as they get older, choosing instead employment in areas not as physically demanding (Norman et al., 2005). Work-site accommodations aimed to prevent potentially career-ending back, neck, and musculoskeletal injuries in nurses are considerations. Staffing for patient handling and nursing staff safety is determined by patient handling and lifting needs and institutional lifting policies and resources (Nelson & Baptiste, 2004). For example, the nurses face challenges in caring for morbidly obese patients in the acute care setting (Drake et al., 2005). A patient-handling resourceexample is the HoverMatt System for patient transfer using a lateral transfer and repositioning device (Barry, 2006).


Once the variables of health-care setting, care delivery models, patient acuity, and nursing staff have been determined, the staffing process continues into the development of the schedule. Scheduling is defined as the process of making the personnel work assignments for a specific period. Nursing schedules are communicated to the staff in a manual format (paper and pencil) or by computer. Computer software by traditional client server application is available. Online tools—partly or exclusively on the Internet—give personnel access to and responsibility for self-scheduling (Sabet, 2005). Automated nurse scheduling operational systems are commercially available. Using techno-solutions for staffing and scheduling systems will increase efficiency and improve patient care (Forte, 2004; Simpson, 2004). Technological advancements such as Flexestaff offer eShift and applications for computerized scheduling and staffing. Another, Per-Sé Technologies’ ANSOS One-Staff, provides resource management capabilities that include enterprise scheduling with shift bidding and self-scheduling capabilities. Depending on the organization, the period of the schedule can be determined from a matter of weeks up to a year in advance. Staffing refers to the filling of open shifts, or time periods, on the work schedule. A scheduling system pulls all of the variables together. The nurse manager’s goal is to uphold standards to organize and schedule the nursing staff to provide quality patient care services. Consideration and variables needed to plan and implement a nurse-staffing schedule are drawn from institutional policies, regulatory agencies, and professional organization standards. Legislatively mandated minimum staffing ratios, public postings, and collective bargaining agreements also help direct scheduling. In conjunction with budgetary guidelines and staff vacancies, the nurses’ employment status of seniority, probationary, in-orientation, fullor part-time, and career ladder classification along with vacation, sick leave, and leave of absence benefits are also variables for consideration. Nursestaffing schedules are multifaceted and complicated by seasonal changes, planned and unplanned lifechanging events, and disasters.

Unlike manufacturing facilities where standard shifts and days off are the rule, hospitals and longterm health-care facilities operate 24 hours a day, 7 days a week, and face widely fluctuating demands. Hospitals primarily have five shifts: three 8-hour shifts (7 a.m. to 3 p.m., 3–11 p.m., 11 p.m. to 7 a.m.) and two 12-hour shifts (7 a.m. to 7 p.m.; 7 p.m. to 7 a.m.). Some hospitals utilize other shift times such as 4- and 10-hour shifts. Work schedules can be 4-hour, 8-hour, 10-hour, 12-hour, longer than 12-hour, or a combination. The 40-hour work week typically constitutes fulltime employment. However, a 36-hour work week ьis considered full-time in some organizations. Parttime employment status can vary by organization. Shift rotation systems vary by start time and have permanent designation or rotation combinations. Actual time scheduled for a nurse to work centers around a normal working schedule of 40 hours to be worked in a 7-day period. Shift, weekend, and holiday rotations are considerations. For example, a nurse cannot be scheduled to rotate more than two different shifts in any 4-week scheduling period. Other considerations (Ohio Nurses Association, 2005) for scheduling nursing staff can be as follows:

■ Staff should have at least two shifts off duty during the transition from the completion of working one shift or 8 hours to the starting time of a different shift (referred to as recovery time)

■ 4-week schedules shall be posted at least 14 days prior to the beginning of the schedule

■ Staff should be scheduled to be off duty two out of every four weekends

■ No nurse will be required to work more than 6 consecutive days without a day off

■ Flexible scheduling of 12 hours will be in agreement with affected nurses and on particular units

■ Holiday time is rotated based on seniority Scheduling and staffing models can be centralized, decentralized, or mixed (modified centralized staffing) (Lauw & Gares, 2006; Sabet, 2005). Centralized staffing involves a system whereby a master plan is developed as the top level of the organization in a centralized location, frequently the central nursing office. This system offers the opportunity to oversee the entire organization’s nursing services activities. Decentralized staffing is a unit-based plan with corresponding schedules managed by the unit nurse manager. Mixed staffing combines centralized and decentralized to offer a comprehensive overview of a facility while offering individualization for unit and staff members. Scheduling methodologies are rotational or cyclical scheduling, self-scheduling, and preference scheduling, which is a combination of the first two. Scheduling plans with various methodologies can be centralized, decentralized, and mixed, depending on management and staff nurse participation.


Cyclical staffing is a centralized system in which workdays and time off for personnel are repeated in regular cycles, such as every 6 weeks (Howell, 1966). Centralized staffing involves a system whereby a master plan is developed at the top level of the organization. A centralized system works well in large organizations where management oversees strategy, budget, resources, and process (Sabet, 2005). A centralized system offers management a broader overview and closer control of the entire scheduling and staffing system. An obvious disadvantage of the centralized system is that individual considerations are minimized.


In decentralized staffing, the managers of individual nursing units have more control over the budget, resources, and process. For example, unit-based staffing and utilization committees can develop schedules. Membership consists of the nurse manager and staff members to oversee unit-specific staffing utilization, providing safe patient care on appropriate, efficient, and cost-effective bases. Staffing levels would be monitored on an ongoing basis (Texas Nursing, 2001). Under a decentralized scheduling and staffing system, a nursing unit can be accountable for outcomes and would be selfreliant for resources.

Mixed or Preference Scheduling

Mixed staffing combines centralized and decentralized staffing by offering individual units the ability to manage regular schedules with assistance from the central staffing office for shift coverage or other clinical resources for patient activity changes. Mixed staffing can accommodate nursing personnel’s need for flexible or preference scheduling. Flexible scheduling is one of the advantages of working in health care because many facilities are open 24 hours a day, but this also means some health-care professionals have to work on holidays. Flexible scheduling is a strategy aimed at improving retention and offers balance and enhancement between professional and personal-life activities. Flexible scheduling can be combined with  selfscheduling. Self-scheduling offers increased autonomy and job satisfaction. Nursing staff is able to enjoy the ability to participate in self-scheduling as well as being able to work shifts that are in 4- to 12- hour increments. Many organizations now offer flexible schedules to accommodate the needs of both practicing nurses and students (Kimball & O’Neil, 2002), and have thereby improved the work environment.


The implementation of the planned schedule culminates in the daily activities of the patient care team and the subsequent results of that care: the outcomes.

Daily Staffing

Daily staffing, or activation of schedule, is the outcome of the scheduling and staffing system for a specific date and time. It dictates who specifically will interact with which patient and when. Daily staffing, the implementation of the staffing schedule, is affected by the actual assigned nursing workload to the scheduled nursing staff. Daily staffing changes can be warranted for various reasons such as call-ins, patient care needs, patient census changes, and internal and external disasters. Often, staffing adjustments are needed hour-to-hour depending on the patient care activities and needs. Balancing the staff scheduled and the daily staffing workload is a major challenge to the nurse manager. Daily staffing adjustments can be managed by the following options: using other clinical resources and hiring overtime and temporary staffing. Examples of clinical resources for making staffing adjustments include STAT, float pool or admitting nurses, and a rapid response team. STAT nurses are a pool of nurses, usually with critical-care experience, who respond to crisis situations such as sudden cardiac arrests (“codes”) or traumas or who provide assistance with special procedures (e.g., conscious sedation, transport critically ill patients) (Scalise, 2005). STAT nurses may also be the skin and wound assessment team (Lancellot, 1996) to assist bedside nursing staff with prevention of hospital-acquired pressure ulcers. Float pool nurses are experienced generalist or specialized staff available to be assigned as needed to any nursing unit. Often, these nurses can work 2 to 4 hours and move on to the next unit in need. Some providers have created in-house nursing agency pools to help meet seasonal demands. Admitting nurses are an integral part of the patient throughput process in acute-care settings and intake process for home-health care. They complete databases, initiate consults (e.g., skin care and pain management) and falls protocols, initiate medical orders, and generally ease the patient’s transition into hospital or home-care settings. Rapid response team, also known as the medical emergency team, is a team of clinicians who bring clinical expertise to the patient bedside (Scholle & Mininni, 2006). Similarly, a multidisciplinary system-wide action team (SWAT) coordinated by nursing leadership in response to increasing patient census and acuity has been found to be effective for diagnostic testing and scheduling, expediting the admission process, reducing discharge delays, and staffing to hospital census demands (Tachibana & Hardy, 2001).

Temporary/supplemental staffing nurses come from agencies often referred to as “rent-a-nurse” providers, which, although not currently regulated, can apply voluntarily for JCAHO certification. Traditionally, these temporary nurses are paid per diem and are reimbursed for traveling expenses. Use of temporary staffing personnel has great patient safety implications because, often, credentials and experiences are not easily verified. The fatigue factor becomes an issue as, in some cases, agency nurses also work at another institution and do temporary staffing for extra income. There is a national trend to reduce dependency on temporary staffing options (Kovner et al., 2002; Morse et al., 2005).


Overtime, or extended hours, is defined as continuing to work beyond or before one’s scheduled hours. Nurses can work extended hours undermandatory and voluntary overtime scheduled conditions. Collective bargaining contracts often address the issue of overtime by setting the terms for mandating or requiring overtime work. An example contract (Ohio Nurses Association, 2005) defines mandatory overtime as no nurse will be required to work overtime for a period of more than 4 hours. No nurse may be mandated to work more than 16 hours of overtime in any 4-week schedule. A nurse will have a minimum of 8 hours off between shifts, when one such shift is a mandated shift. Overtime work can leave nurses fatigued and affect their ability to provide adequate clinical judgments and care. Gaines and Carter (1989) offer a decisionmaking framework in which to analyze the overtime situation by examining individual rights and responsibilities as a professional nurse. Mandatory overtime should not be a “routine” staffing backup plan and should reflect staff nurse input (Shirey, 2005). Working long hours has caused nurse illness and injury, fatigue and safety problems, workplace violence, and depression (Mason and Kany, 2005). Major national and state efforts are under way to eliminate mandatory overtime (Unruh, 2005). Currently, because there are no governmental regulations restricting overtime, nurse overtime is not federally limited. No state or federal regulations restrict the number of hours a nurse may voluntarily work in 24 hours or in a 7-day period (IOM, 2004, p. 388). Several states have laws that protect patients by limiting hospitals’ use of forced overtime. In states with these laws, however, nurses can voluntarily work overtime, and the laws do not apply in the case of a government-declared state of emergency. Jacobsen et al. (2002) polled the nursing staff on their opinions about both voluntary and mandatory overtime and identified conditions that influence the nursing staffs’ decisions and perceptions about overtime. This study enabled the nursing staff to develop strategies and policies to avoid mandatory overtime and improve staff satisfaction and quality patient care.

Patient Outcomes

The nurse staffing variables used to measure patient outcomes are daily average hours of care, ratio of RNs to  average patient census, workload, and skill mix. Patient outcomes most generally are basedon adverse occurrences such as unit rates of patient falls, pressure ulcers, respiratory and urinary tract infections, and family-patient complaints. Other nursing-sensitive indicators for outcomes are RN job satisfaction, RN education and certification, pediatric pain assessment cycle, pediatric intravenous infiltration rate, and patient assault rate. Since 1994, a national database program, the National Database of Nursing Quality Indicators (NDNQI), has been available to provide comparative information to health-care facilities for use in quality improvement activities and to develop national data on the relationship between nurse staffing and patient outcomes (NDNQI 7/m, 12/05, In the Commonwealth of Massachusetts for public disclosure, health-care consumers can go on line to access staffing plans for comparisons with actual staffing numbers when hospitalized (Scalise, 2006).

Nursing Workloads

Daily staffing is affected by the workload assigned to the scheduled nursing staff, as evident in research studies. Carayon and Gürses (2005) identified the assigned workload as the situation-level workload. Situation-level workloads are real-time performance obstacles and facilitators that contribute to daily workloads. For example, Tucker et al. (2002), in a qualitative study, observed 22 nurses in 8 hospitals for a total of 197 hours and documented 120 problems that prevented patient-care task completion. The problems ranged from missing or incorrect information, missing or broken equipment, waiting for a resource, and missing or incorrect medications. Similarly, Potter et al., (2005) found omissions in patient care due to interruptions in an ethnographic study involving seven staff registered nurses. Nurses were frequently interrupted during interventional work such as administrating medications, problem-solving intravenous infusions, and teaching patients. Interruptions pose risks for medical errors. Daily staffing continues to be influenced by workload predictor/tools. More extensive research and development of intensive care unit (ICU)–specific nursing workload predictor/tools are needed to determine the numbers of ICU nurses and their educational backgrounds (Robnett, 2006).

All Good Things...

The staffing and scheduling process incorporates professional nursing standards and accounts for the health-care setting, the care delivery model, patient acuity, and the nursing staff. Scheduling and staffing systems can be centralized, decentralized, or mixed. The outcomes of scheduling are the daily staffing, patient outcomes, and nursing workloads. The challenges faced by nurse managers in providing adequate staffing are the nurse shortage, the advances in patient care technology, the high patient acuity levels, and the health-care industry’s continuous evolution. For the appropriate allocation of nursing staff for patient-focused care, staffing is both a process and an outcome (AACN-Critical Care, 2001).

Maximizing Employee Performance

Providing safe, high-quality patient care is the goal of health-care organizations. To accomplish this goal, the organization depends on the teamwork of its personnel. The nursing administrator is responsible for planning, organizing, directing, and coordinating the activities of the nursing personnel. Team building is a critical part of this process. The objective of team building is to develop a group that is committed to the work and each other (Creasia & Parker, 2001, p. 171). Another important responsibility of the nurse manager and the focus of this chapter is monitoring and evaluating the performance of personnel, a function called controlling. According to Creasia & Parker (2001), controlling includes personnel evaluation, discipline, and behavior modification. For nurse managers, this function requires interactive contact with employees that is unlike any of their other responsibilities. Successful nurse managers require knowledge and skill in interpersonal relationships to enhance the performance of employees. This chapter will focus on the role of the nurse manager in motivating employees to achieve their professional performance goals within the organization.

Performance Appraisal

Performance appraisal, as the term implies, is a formal evaluation of an employee’s performance. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires regular performance appraisals, and most health-care organizations offer them annually. Regular oversight and evaluation of performance are the responsibilities of nursing administration, whether or not they are required annually. The purpose of a performance appraisal is to provide opportunities for personal and professional growth and to ensure the quality of nursing care (Creasia & Parker, 2001, p. 172). Generally, the process is intended to clarify how well the employee is performing the requirements of the job. A job description often provides the baseline or minimal performance criteria. Additional standards may be used to evaluate employees, depending on the setting. For example, nurse educators in a university setting would be held to university standards for annual merit and/or promotion. These standards generally include guidelines for performance in instruction or teaching; scholarly pursuits, such as research; and service activities to the community and the university. In a clinical setting, the standards or benchmarks for job performance often include the American Nurses Association (ANA) clinical standards and the JCAHO patient safety guidelines.

Typically, upon hire, the individual will receive a copy of the appraisal tool and the criteria that will be used in the evaluation process. The type of tool used will vary from organization to organization. YoderWise (1999, p. 273) described some of the most commonly used tools for performance assessment as either structured or flexible. The most commonly used structured tools are the forced distribution scales and the rating scales. The low and high values found on these types of scales may lead to problems in evaluation.

Forced distribution scales are one of several comparative methods that can be used alone or in conjunction with other tools to evaluate employees. A common practice in many organizations requires the evaluator to place a certain percentage of employees into equally divided categories. For example, each employee would be placed into one of three categories. In a forced distribution scale, these three categories might be labeled: (a) above average, (b) average, and (c) below average. To many employees this seems unfair as any comparative differences in their overall performance may be ever so slight. When this method is used to determine merit raises, it frequently lowers the morale of employees who were found to be average or below (Fig. 18-1). Most rating scales are constructed to evaluate the performance of employees. They usually include a


Sample performance evaluation tool

variety of measures that are common to nursing practice in general. The biggest problem with these scales is that the behavior to be evaluated may not actually be observed by the evaluators, leaving them to make assumptions about the individual’s behavior. For example, an item like “provides safe nursing care” is rather ambiguous and perhaps even circumstance-specific. The individual may be rated low or high on that item depending on when she is evaluated and whether previous evaluations were low or high. Figure 18-2 is an example of a rating scale.

Flexible tools like the behaviorally anchored rating scale (BARS), management by objectives (MBO), and peer review give a better picture of the individual’s performance and are less open to bias.

A variety of tools will be discussed later in this chapter.

For staff members, the performance appraisal process provides feedback about their progress toward career goals and changes in performance and provides an opportunity to review their last evaluation. For the nursing administrator, the performance appraisal process provides opportunities to review the quality of patient care, identify those staff members with the potential for advancement, identify problem employees, and make decisions about the overall operation of various units within the facility. For example, when a number of employees are not performing at optimum, this may indicate problems within the organization, such as high acuity rates and low staffing numbers. If only one or two individuals are having problems, it could indicate a need for further training, coaching, or counseling. In most organizations, individuals will be evaluated using both formal and informal procedures. Formal evaluations may occur only once or twice a year (Tappen, 2001, p. 273). In most cases, formal evaluation is required by accrediting agencies or is part of the organization’s policy. With a formal evaluation, there is usually a written procedure ortimetable to be followed. Forms that must be completed by the nursing supervisor and/or administrator are also part of the typical process. All employees should be aware of the procedure, the timetable, the tools, and their own role in the process. According to Tappen (2001, p. 274), informal evaluation is commonly thought of as individual feedback or information regarding one’s performance. The organization may or may not have a procedure for conducting informal evaluations. In most cases, the individual collects data from various sources to document her performance during the year. The wise administrator and/or supervisor should being doing the same with each staff member. For example, the supervisor should make a point of observing staff members in action and keep anecdotal records, noting the date, time, circumstances, and employee performance. During these periods, feedback should be honest so that any employee who is not performing as expected can take corrective action. Conversely, those employees who are doing well should be told so. According to Barnum and Kerfoot (1995, p. 256), feedback and correction should be ongoing, spontaneous, and to the point. The employee should not be made to wait for an official evaluation date to receive this type of feedback. Ongoing feedback can help motivate the employee toward outstanding performance.


Federal guidelines have stipulated that performance appraisal of employees be based on a valid job analysis. Because a job analysis is used for recruiting purposes as well as for evaluation and promotion guidelines, it should be current. A job analysis generally describes the tasks, characteristics, skills, knowledge, and abilities required to perform a specific job. As such, it serves as a basis for career development, in-service training, job forecasting, and performance appraisals. In most cases, the job analysis helps determine the value of a job in terms of compensation while ensuring that pay equity is maintained. A job analysis includes a job description and the job specifications. Job specifications generally describe the qualities and characteristics of the person needed to perform the job. A job description specifies the duties and responsibilities of a particular role. The job analysis is often used by administration to determine recruitment needs and to make forecasting decisions for staffing within the organization.

Employees are generally given a job description when they are hired or promoted. Job descriptions are not as comprehensive as a job analysis because they list only the basic requirements of the job (Fig. 18-3).

Job Description

The employee’s job description details the basic skills and abilities needed to fulfill the job’s responsibilities; it serves as the starting point for a performance appraisal. Ellis and Hartley (2004, p. 461) defined job descriptions as written statements stipulating the duties and functions of various jobs within the organization and the scope of authority, responsibility, and accountability involved in each position. Job descriptions should define minimum standards for effective job performance and employment and should not be too detailed (Swansburg & Swansburg, 2002, p. 600). A comprehensive job description should describe what is to be done, not how to do it. For example, each nurse would be expected to use aseptic technique when doing a dressing change, but the dressing Nurse A applies may not look like the dressing Nurse B applies, even though both have maintained a sterile field while doing the procedure.

Most organizations have written job descriptions in their policy manuals. As job responsibilities and performance requirements for employees are constantly changing, job descriptions should be reviewed and updated on a regular basis. Employees should have an opportunity to provide input with regard to their job descriptions.

ANA Standards and Guidelines

Contributing to job descriptions and to performance evaluation criteria for nurses are the standards of clinical practice established by the ANA and the guidelines for patient safety established by JCAHO. The standards and guidelines proffer the measurements to be used by hospitals and a variety of healthcare agencies when evaluating their employees. They can also provide additional information about job requirements for the nursing staff. Nursing is guided by these ANA standards of practice and standards of professional performance (ANA, 2004, p. 12). The ANA standards provide a framework for the evaluation and improvement of nursing practice

It makes sense, therefore, to include these standards developed by the profession when evaluating the performance of the practicing nurse. Most agencies will incorporate many or all of these standards as part of their performance appraisal process. For instance, the first six standards articulated by the ANA are directly related to the practice of nursing. These standards should be quite familiar to nurses and are more commonly known as the nursing process. Beginning with the assessment of clients, the nurse is expected to proceed through a series of steps that include diagnosis, outcomes identification, planning, implementation, and evaluation. The nursing process is based on a critical thinking process and provides the foundation for evidence-based nursing practice. The standards of professional performance, on the other hand, reflect the commitment of nurses to the profession and the clientele they serve. These standards include:

■ Quality of practice

■ Education

■ Professional practice evaluation

■ Collegiality

■ Ethics

■ Research

■ Resource utilization

■ Leadership

These standards are also included as part of most performance appraisal tools. Quality of practice typically means that the nurse engages in activities to improve nursing care and nursing practice. This might include serving on committees to update or improve policies and procedures or documentingoutcomes of practice. Continuing education can be formal or informal. Most state boards require periodic continuing education for relicensing. Ideally, nurses will seek educational opportunities to enhance or improve the knowledge and skills needed for their practice area. Lifelong learning is a professional commitment.

Professional practice evaluation is a process. It implies that nurses should seek feedback actively on their performance as it relates to standards, guidelines, and job descriptions. Feedback can come from a variety of sources such as patients, peers, and superiors. Nurses have a responsibility to evaluate the care they give. Soliciting input from others is one way to determine the effectiveness of care given. For example, nurses understand the importance of checking the patient’s response to medications and treatments. This can either be by observing the response of the patient or asking the patient how he is doing after receiving the said medication or treatment. Today’s nurses must continually assess their strengths as well as areas needing improvement. Peer evaluation, for example, is one means for ongoing self-assessment. Peers generally have similar goals and experience. New nurse graduates often seek advice from their superiors with experience when they take on new responsibilities. Ongoing self-evaluation by nurses makes the performance appraisal process seem less threatening. Periodic informal feedback should prepare nurses for the more formal process when it occurs. Nurses constantly interact with other health team members. Collegial relationships serve several purposes. For one, they provide a learning forum for the nurse and enhance the outcome of the patient’s situation. During the course of patient care, the nurse collaborates with patients, families, and colleagues. Collaboration through communication and documentation is one way to ensure continuity of care for the patient. Patients and their families have a right to expect nurses to engage in ethical practice, which is why it has become a component of performance evaluation. Patients expect confidential handling of information about them and to be treated with dignity and respect. Today’s nurse is also expected to participate in research at some level. This may include helping to collect data, implementing new procedures based on research, sharing research findings, or serving on research committees. This type of activity may be new to many nurses, but it can often be very rewarding. Many of the practice guidelines that nurses take for granted are based on research findings.

The term “resource utilization” may be somewhat misleading but refers to keeping patients (as consumers) informed about their options. Many nurses have been doing this for some time. If there is a less costly but safer treatment available, nurses have usually discussed it with their clients. For example, soap and water might work as well as an expensive hand cleanser.

An additional component here is delegation

of patient care to unlicensed personnel. Delega-

tion requires finding the right person for the

right job. The five rights of delegation identified

by the National Council of State Boards of Nurs-

ing are:

■ Right task

■ Right circumstance

■ Right person

■ Right direction

■ Right supervision

In short, using nursing judgment and following these standards of delegation, nurses are able to assign tasks to other caregivers safely. This is often difficult for new nurses, who may not be familiar with the job responsibilities of other health team members. It is critical, however, that nurses use delegation appropriately to save themselves time and energy and to distribute the workload better.

Leadership implies that the nurse assumes a larger role in the community or outside of the practice setting. This may mean, for instance, teaching first-graders about hand washing or spreading germs. Nurses are expected to participate in committees within the practice setting either as a member or a leader. They are also expected to take an active role in advancing their profession, usually by joining a professional organization. One purpose of performance appraisal is to make good employees better. According to Ash (1984), good employees are a company’s number one asset. Management usually describes a good employee as one who is loyal to the organization and/or one with good work ethics. Additionally, management has indicated that these individuals seem satisfied with their work and have low rates of absenteeism. Ash believes that one way to make good employees better is for management to help them reach their potential.


Management by objectives (MBO) systems indicate a two-way communication process of evaluation (Houston, 1995). This implies that both management and employee establish goals to be discussed during the evaluation process. Encouraging employees to set their own goals is often a good way to enhance performance and behavior. Whereas there is a sense of self-satisfaction derived from achieving goals, there may also be some extrinsic reward as well. Achieving one’s goals could result in a salary increase or a promotion. This idea for setting one’s own goals is based on McGregor’s theory of management and is often referred to as MBO. Many health-care organizations have included MBO as part of the performance appraisal process. For the nursing staff, MBO offers an opportunity to do a self-assessment and set goals that are realistic and meaningful to career aspirations. Some details on developing goals as part of the MBO process follow:

■ The staff should limit their goals to two or three.

■ Goals should be meaningful and realistic.

■ Strategies for achieving the goals should be included as well.

■ An in-service session on writing goals and strategies may be helpful when introducing the idea of MBO.

■ The nurse manager and nursing supervisor should review goals with staff members.

■ Before the goals are submitted, all parties should agree on them.

Working with the nursing supervisor and/or administrator, the performance appraisal process can become a meaningful and  rewarding experience. When one’s superior shows an interest in his or her career goals and aspirations, the employee may be motivated to reach his potential. This is a win-win for both parties because the success of the administrator is often measured by the success of her subordinates.

The job description and standards of performance provide the starting point for assessing employees. Performance appraisal, however, should make use of additional data sources depending on the requirements of the organization. Standardized tools may be used to evaluate employees in some organizations, while others may opt for the use of tools developed in-house. In any case, the responsibility for data collection rests with the nursing supervisor.


The employees’ immediate supervisor usually carries out data collection for evaluations at various points during the review period. The employee should be aware of the methods and have a copy of the tool or tools that will be used to evaluate performance. Data collection methods might include:

(a) making notations on the tool based on observations, (b) keeping anecdotal notes, (c) reviewing charting, (d) interviewing patients, (e) attending staff meetings, (f) talking with the employee’s coworkers, and/or (g) reviewing the employee’s skills or competency evaluations. Any or all of these may be used.

Performance Appraisal Tools

Input from nurses working in different settings suggested that organizations are using a wide variety of tools. Sophisticated, standardized tools are used in some organizations while others use simple checklists. There seemed to be little consistency in the type of tool used from area to area. Checklists, ratings, rankings, anecdotal records, peer reviews, and self-appraisals have their place in health-care organizations. Several of these methods are described below in detail.

Peer Reviews

Peer reviews are one means of evaluating staff, especially in a decentralized organization. Peer review is a process of assessing, monitoring, and evaluating the quality of patient care provided. Acceptable standards of practice are often used to determine the quality of care. The process of peer review may vary from organization to organization. Each institution should establish guidelines for conducting peer reviews. These guidelines should describe who, what, when, how often, and under what circumstances. A method that is commonly used in many institutions is critiquing patient records. Generally, this involves a group of peer reviewers. One or more of those individuals might randomly review patient records with attention to specific criteria. The same criteria should be used when reviewing any patient records. Because patient records are legal documents, certain criteria should apply from institution to institution, such as assessing the patient’s level of pain and documenting the patient’s response to any pain medication that may have been administered. Other methods of peer review may require one or more of the peer reviewers to observe an employee giving patient care. Here again, the criteria should be specified and the same for each person being observed. Despite its increasing popularity, employees may see peer review as intimidating.

Parks and Lindstrom (1995) reported that the potential rewards for instituting unit-based peer review included increased trust, communication, and job satisfaction. In the situation they described, performance appraisal was one of three reasons for instituting peer review. Quality assurance and professional development were the other reasons given. The peer review groups consisted of senior nurses who were experienced in mentoring and adept at group process skills.

Peer reviews can provide informal feedback to the nursing staff. If used properly, peer evaluation can provide a powerful incentive for personal and professional development. According to Marquis and Huston (2000, p. 427), peer review has the potential to increase the accuracy of performance appraisal. The idea of having colleagues or peers evaluate each other makes sense from the standpoint of similarity of experiences, knowledge, and familiarity with skill requirements. This practice is becoming more widely accepted in health care and lends more credence to the overall performance evaluation of employees. Although peer review offers some benefits, it cannot be entered into lightly, and it is unrealistic to think peers can be involved with evaluations without extensive training (Barnum & Kerfoot, 1995, p. 256).


Kelly-Heidenthal (2003, p. 558) described checklists as the most commonly used type of performance evaluation tool. Checklists are easy to use and only require the rater to determine whether the person being evaluated falls below the standards, meets the standards, or exceeds the standards of the organization. The problem with checklists is that they often lead to rater errors, especially central tendency. Central tendency occurs when the evaluator rates nearly everyone the same. Most often this happens when the evaluator is not familiar with the persons she is evaluating or because she has not actually observed them in the performance of certain activities. In organizations where this type of tool is used, employees often complain that they really have no idea of whether they are doing well or improving because their evaluations vary little year after year.

Rating Scales

Rating scales are also used to evaluate performance. The rater selects a number (usually between 1 and 5) that best describes the individual’s performance (see Fig. 18-2). While rating scales are only slightly more illuminating than a checklist, the rater does have more options from which to choose. Although ratings and rankings are intended to be applied subjectively, any rating or ranking could reflect the rater’s bias (Houston, 1995).

Ranking Employees

Rankings are sometimes used to determine how an individual performs in relation to others in a similar situation. Nursing administrators are sometimes required to rank subordinates based on a variety of criteria. This method is one that is often used when decisions have to be made about promotion or merit raises. Typically, ranking requires assigning numerical points rather than narrative descriptors when totaling data.

When ranking systems are used, the performance of individual employees is compared with those of other employees, usually those at the same level. Rankings should not be used alone, however, because they do not address the quality of the performance. A ranking system is generally used in organizations where performance is used to determine merit increases or promotions.

For example, in a recent merger at Central Hospital, two staff nurses were being considered for a newly created position in pediatrics. The nurse manager was unable to determine which nurse, Janet or Joyce, should be given the position. Both of them had worked on the pediatric unit for 5 years, and both of them had earned a bachelor’s degree in nursing. Using the outcomes from the performance appraisal data, the supervisor was able to differentiate between the two individuals in terms of their overall performance for the past 3 years. On the 10 items listed on a rating scale similar to the one in Figure 18-2, Janet had scored 35, 43, and 45, respectively, for the past 3 years. Joyce, on the other hand, had scored 35, 40, and 40 during the past 3 years. Their scores on several other tools also reflected a similar pattern. As a result, Janet received the job offer.

Anecdotal Records

Anecdotal records are generally written records of observations. If used to evaluate performance, criteria should be established for the evaluator. For example, the evaluator might observe the individual’s behavior in a given situation to ascertain whether or not he has explained the side effects of a client’s medications. When the behaviors to be observed are clearly defined, the evaluator knows what to look for, and the individual knows the criteria by which he is being evaluated.

Skill Testing

Many organizations are now evaluating the skills of their employees. Testing skills in working with specialized equipment or performing specific procedures is one way to evaluate the employee’s performance in areas that are unlikely to be observed in all situations. Skill testing may be part of the orientation of new nurses in a given agency to bridge the gap between education and practice. When skill testing is involved, nurses are often required to demonstrate expertise in such areas as cardiopulmonary-resuscitation, handling the crash cart, preparing and/or starting intravenous medications, isolation techniques, tracheostomy care, dressing changes, removing staples (sutures), and other skills as deemed necessary by the agency. Some agencies have ongoing in-service programs whereby the staff are tested on a regular basis to maintain their expertise. Brykczynski (1998) recommends identifying and describing levels of nursing skills into the performance evaluation.

Those demonstrating exemplary skills or the expert nurses could then serve as role models for the staff.

Patient Surveys

Most health-care agencies use some form of patient survey. Whereas supervisors often depend on patient surveys to evaluate the productivity and performance of the agency itself, they may also be used to assess patient satisfaction with care received. Unfortunately, it is difficult to collect information about individual employees in an acute care setting using a patient survey form. There are some rehabilitation centers and nursing care facilities that do provide opportunities for the residents and family members to evaluate the staff. In some cases, employees may be given a bonus for positive comments on these surveys. Reviewing patient satisfaction data is part of the administrator’s responsibility. Client care is the focus; when clients are dissatisfied, something is amiss. Consumer satisfaction continues to be a major concern of health-care agencies. Several tools have been used, most of which only describe the patient’s overall satisfaction or dissatisfaction with the experience. For example, patients may be asked if someone explained the treatments and medications they received and then how satisfied they were with the explanations they received. Because most patients are not required to give their names, there may be no way of knowing who took care of them or perhaps even when they were hospitalized. This kind of general information serves as a starting point, but the current thinking is that more relevant patient satisfaction measures should be used, based on patient outcomes or evidencebased practice.


The more examples of behavior that the nursing administrator has to work with, the less biased the appraisal will be. Performance appraisal is an interpersonal process containing an element of subjectivity (Huber, 2000, p. 335). Regardless of the tool used, someone must evaluate the employee. In most instances, the employee’s immediate supervisor is the person who does this. To guard against subjective attitudes and values influencing the appraisal, the appraiser should develop an awareness of her own biases and prejudices, according to Marquis and Huston (2000). How can this be accomplished? The nurse manager could consult with other managers when questions of personal bias exist, gather data appropriately, and keep notes on observations, others’ comments, chart reviews, and care plans (p. 417).

Try as they might, raters are likely to be less objective than the ideal. This could result in one or more evaluator rating errors (Nauright, 1987). Some of the most common rater errors include: (a) central tendency, (b) “halo effect,” and (c) “horn effect.” Central tendency occurs when the rater, unsure of how persons are performing, ends up rating them as good or average on most items listed. The “halo effect” occurs when the employee has recently shown exceptional performance in one or more areas. If this behavior is apparent to the rater during the last few observations, the rater may rate the employee as above average in most areas listed, regardless of the actual performance in some of those areas. The “horn effect” is the opposite of the “halo effect.” In other words, an employee who has recently displayed less than satisfactory behavior in one or more performance areas may be rated as per

Rater Errors

forming below average in many other areas. This may not be a fair reflection of the individual’s usual behavior (Table 18-1)

The Appraisal Meeting

Once all the data are compiled, the nurse manager sets aside time on her calendar for employee appraisal meetings. As a rule, these are conducted at about the same time each year for all employees. The purpose of the meeting is to discuss the employee’s performance for the year. At the conclusion of the meeting, both parties should reach an agreement as to the employee’s overall performance status, areas for improvement, and plans for maximizing performance.


In preparation for performance appraisals, employees should collect their own data. They can begin by listing their strengths, especially contributions to the organization, as well as to patient safety and welfare. In addition, they will want to identify any accomplishments since their last review that indicate progress toward their stated goals. If little or no progress was made, they should be able to explain why. In most organizations, employees would have been required to submit goals for the upcoming appraisal meeting well in advance, perhaps at the last meeting. The employee should be prepared to address the goals they established at the time of their performance appraisal meeting. Some of the long-term goals may be ongoing, while short-term goals may be completed or nearing completion by the time of the meeting. Employees should identify any problems encountered with reaching their goals and ascertain why. For example, an employee may have determined that she would have become a certified nurse midwife this year. The employee might first look at the needed resources and/or strategies she identified in relation to the stated goal. Next, the employee needs to ask herself a series of questions about failure to meet the goal. Was it due to time constraints? Was it a matter of finances, or was it a lack of adequate experiences or preparation? Was there anything the organization or the supervisor could have done to assist the employee? The employee should be as honest as possible when identifying the reasons the goal was not accomplished.


Self-appraisals are commonly used to address whether or not employees have met established goals and if not, why not. Self-appraisals can also be used in conjunction with any of the other tools as can anecdotal records. In fact, self-appraisals should relate to performance of the job as defined by the job description, according to Swansburg and Swansburg (2002). When all parties are using like criteria or standards, there ought to be no surprises at the time of the appraisal interview. The goals established by the employee should therefore have relevance to the goals and mission of theorganizations as well as to her own career goals. For example, a staff nurse who would someday like to be the team leader would need to determine what that job entails. Her goals should be defined clearly with that idea in mind. When meeting with her supervisor, the discussion should center on her career goals as well as on her capabilities as a staff nurse.

Before the performance appraisal meeting, the employee would be expected to submit self-appraisal materials to the nurse manager, including the goals developed for the coming year. This information will be added to the data that have already been compiled by the nurse manager.


Prior to meeting with her subordinates, the nurse manager should organize materials for the upcoming meeting. This begins with reviewing the employee’s past performance and goals established for the past year. Next, the manager would review data from tools, peer evaluations, self-evaluations, and any anecdotal records. The benefits of prior planning cannot be overemphasized. The manager should be in charge and prepared for all contingencies. According to Rondeau (1992), successful performance appraisal sessions require a wellconceived and well-executed plan of action. To evaluate subordinates better, the manager needs to know as much about the person being evaluated as possible. For example, knowing the current position held by the employee and how long she has held that position could make a difference in terms of how the person is evaluated. When looking at records of any critical incidents, the manager should remember that a single critical incident might not represent a true picture of the individual. A date and time for the meeting should be established well in advance, and the manager should make certain the date and time for the meeting are satisfactory for both parties. It is important that the meeting be free of interruptions. The employee should believe that the manager considers this time to be important.

When employees are performing well, the meeting should go fairly smoothly for both parties. The purpose of planning for the meeting is to review the employee’s job-related behaviors and the available evaluation materials. The focus of the meeting is always on the performance level of the individual past and present and the progress she has made toward the established goals. The manager should also review and be prepared to discuss any positive comments from peers, patients, or the person’s immediate supervisor. Anecdotal records can be discussed if needed, but the employee deserves an opportunity to discuss his self-analysis and career aspirations as well.

When evaluating others, the nurse manager engages in active listening and assertive communication. Assertive communication means being open and honest but treating others fairly and with respect. This means giving criticism when needed and handing out praise when deserved. The focus of performance appraisal should be on the individual’s performance, not on personal characteristics or problems. The manager needs to think through what he needs to discuss with the employee while making every effort to put the person at ease.

According to Ash (1984), there is a gender difference in responses to criticism. Although many societal changes have occurred for working women in general, nursing has always consisted primarily of women. In general, women are much more sensitive to criticism than men. In other words, women take it much more personally and tend to react more negatively to criticism.

Difficult as it may be, the nurse manager must decide how to approach an employee who has demonstrated an unsatisfactory performance. The nurse manager’s role is to encourage and motivate employees toward excellence in performance. None of the manager’s roles is as personal as appraising the work performance of others (Marquis & Huston, 2000, p. 414). This aspect of the process is considered extrinsic motivation. Because most employees are sensitive to comments about their performance, good interpersonal skills are as important as good leadership and managerial skills. At the beginning of this chapter was a quote from Ash (1984), “Sandwich every bit of criticism between two layers of praise.” In short, this means that managers should start by focusing on the person’s good points, then bring up the problems identified, and end by discussing how these can be resolved. Rondeau (1992) advocates using criticism sparingly as it tends to build up individual resistance and shut down communication. Leaming (1998) described several improvement pointers for academic leaders engaged in evaluation of their subordinates. Many of these pointers would work well for the nursing administrator in any setting. In general terms, it is important to:

■ Keep channels of communication open

■ Let people know they are appreciated for their contributions to the organization

■ Involve your subordinates in departmental governance

■ Be positive and encourage an attitude of cooperativeness

■ Treat people fairly and with respect

■ Spread the workload around

■ Create a supportive culture in the workplace

■ Tolerate differences among subordinates (pp.131–134).


Once all the data are collected, the nursing manager or supervisor can begin to summarize the findings. A good rule of thumb is to list the strengths first and then to list the areas in need of improvement. If the

employee submitted goals for the year and provided documentation, assess these as well. Although the nursing manager can list a few strategies for improving performance, the employee should take the major responsibility for this. According to Smith (2003), the appraisal meeting should be scheduled at a convenient time for the employee so the meeting can proceed uninterrupted for at least 45 minutes. She also recommends that the environment be nonthreatening and relaxed and that managers be prepared for the meeting. Lack of preparation is a time-waster and sets a poor example for subordinates. It may also display a lack of concern or interest in the employee. The meeting is a very personal, face-to-face interaction and should not be taken lightly by either party (Box 18-1).

The focus of the meeting should be to review the employee’s performance and explore with him ideas for being successful within the organization. The manager sets the tone for the meeting by first explaining the purpose for the evaluation, which may vary from organization to organization. When merit raises or promotions are dependent on the outcome of the appraisal, the employees are likely to be somewhat nervous, so the manager should make every effort to put the employee at ease. The nurse manager should initiate the evaluation process by reviewing with employees their goals for the year. From there she should proceed to discuss her findings based on data collection. Next,

the manager can move on to the periodic observations or input from others, such as patients or peers. Employees should have an opportunity to respond to these findings and to discuss their performance and accomplishments.

By the conclusion of the meeting, the manager and the employee should mutually agree on a plan of action for the professional or career development of the individual. Both long-term and short-term goals should be addressed. A preprinted form can be used for this purpose. Such a form should include a space for a narrative summary and dated signatures of both the supervisor and employee. This plan of action might also include the employee’s future goals with the organization.


Implementing the plan of action may require longterm intervention by the supervisor, such as motivating, coaching, or counseling the employee. If, at the conclusion of the meeting, the manager is convinced that none of those approaches would be beneficial to the employee, she may need to resort to disciplinary measures.


The nursing manager/leader is in the best position to motivate employees to achieve their goals because managers set the tone for an environment that encourages productivity and success. When the employees look good and perform well, the nursing manager/leader looks good and, in turn, the organization looks good. A large part of motivation involves feelings related to self-worth and satisfaction. According to Swansburg and Swansburg (2002), a motivating environment is one in which the nurse leader/manager:

■ Establishes a career development program

■ Helps employees to meet their career goals

■ Communicates the organization’s goals and priorities

■ Involves the staff in the development of department and organizational mission and goals

■ Encourages teamwork

■ Rewards teamwork, innovation, and creativity

While the above list does not cover all aspects of motivation, the list specifies those environmental factors that would encourage excellence in employee performance.


In assisting employees to reach their goals and develop professionally, the nurse manager often assumes the role of a coach. According to Donner, Wheeler, and Waddell (1997), coaching is an ongoing, face-to-face, collaborative process. The purpose of coaching is to assist the employee in carrying out job responsibilities or gaining knowledge and skills required for the job. The immediate supervisor often has ongoing contact with the employee and is in the best position to evaluate progress and identify areas for improvement. Coaching might be likened to on-the-job training or teaching. The employee on the receiving end of the coaching has the advantage of immediate application of learning in the real world. This is a common practice in many organizations when new hires or individuals being considered for promotion have no educational experience related to the requisite knowledge or skills the job requires. Loveridge and Cummings (1996, p. 368) described coaching as informal counseling that can be used for the short term or over the

long term. Short-term coaching is generally spontaneous, brief, and open. Long-term coaching can be used to correct performance deficiencies. This type of coaching is usually planned and behavior-specific (Loveridge & Cummings, 1996, p. 200). Coaching also might involve providing opportunities for the employee to attend workshops or conferences or serve on committees.


The nurse managers may also find themselves counseling employees. According to Hecht, et al. (1999, p. 111), this process provides the nursing administrator with an opportunity to demonstrate genuine interest in subordinates. Deciding if an employee would benefit from counseling requires interpersonal contact between the nurse manager and the employee. Counseling is one of the most productive functions to improve employee performance (Loveridge & Cummings, 1996, p. 368). Counseling generally occurs in a private session where the focus is on helping the employee solve a problem. Generally, these are personal problems that may be interfering with the employee’s performance. Frequent absenteeism is a good example. While frequent absenteeism can be due to many other factors, it is a common symptom of substance abuse. Other problems that require counseling might include disputes or conflicts with other employees. In counseling sessions, the nurse manager should help employees get to the bottom of problems and adjust their attitude if necessary. Sometimes this means separating the employees, putting them on different shifts or on different units. If the problem is potentially life-threatening or requires therapeutic intervention, the employee should be directed where to seek help. Because nurses are not always equipped or trained as therapists, the problem employee may need referral to another agency or a professional counselor for support.


Managers may also be required to mete out discipline. Although discipline is generally thought of as some form of punishment for negative behavior, Gillies (1994, p. 557) stated that its purpose is to improve job performance. According to Webster’s Dictionary (1995), disciplining can mean taking corrective action or bringing about self-control through instruction or training. The definition also includes conformity to rules and regulations. Marquis and Huston (2000, p. 442) stated that when employees continue undesirable conduct, either in breaking rules or in not performing their job duties adequately, disciplinary action must be taken. This approach may seem a little extreme, but in any organization there are standards and guiding principles. Employees are expected to conform and perform accordingly. In health-care systems, many of these standards exist to protect the patients and others. One good example is universal precautions. JCAHO (2005) published its list of disease-specific care national patient safety goals, one of which was to reduce the risk of health-care–associated infections. One of the strategies listed was compliance with the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Nurses learn early on that aseptic technique is essential to preventing the spread of organisms from person to person. But how often have nurses been observed rushing from one situation to another without taking the time to wash their hands between patients? Most health-care agencies have begun to post signs in plain sight in every patient room and anywhere that hand washing is considered essential. Some nurses might view this as a form of discipline simply because somewhere, someone did not take the time to wash his hands. When considered in a broader perspective, however, most nurses realize that this is a reminder for everyone who might transmit organisms: nursing staff members, physicians, other health-care workers, family members, and even the patients. Few responsibilities of the nursing manager are as personal and time-consuming as performance appraisal. The manager’s job includes a number of other personnel responsibilities, including working with new employees, probationary employees, and problem employees. Although most health care organizations have personnel departments, the nursing manager is generally involved whenever the nursing staff is the focus of attention. New Employees and Probationary Employees In this era of nursing shortages, new employees and probationary employees rarely have the luxury of a long orientation period. Agencies should take care with new employees and develop an evaluation procedure for determining their ability to succeed. When the organization shows an interest in the employee and is willing to spend time teaching him, he may be more likely to stay. Metcalf (2001) stated that it is crucial for newly graduated nurses that the process of staff development begin at the commencement of and continue throughout their employment. A collaborative environment is a motivating environment where the nursing administration provides ongoing support and encourages the professional development of each employee. Conversely, any new or probationary employee who demonstrates problematic behavior in one department is likely to have difficulty on other units in the same facility. Documenting behavior and evaluating abilities from the beginning of employment provides the agency with information about performance in general. New hires and probationary employees who do not measure up, especially with coaching and counseling efforts, may need to be terminated.


Once an employee is a part of the organization, the administration has a responsibility to assist that person. A variety of personal difficulties can lead to

poor performance in the workplace. Most notable would be problems related to chemical impairment. Chemical impairment refers to impairment due to drug or alcohol addiction (Marquis & Huston, 2000, p. 459). Some common problems resulting from these impairments are excessive absenteeism, decreased quality of work, errors in judgment, work-related accidents, and high rates of turnover. When evaluating employees, the manager should note when these problems occur with regularity. Excessive absenteeism, tardiness, and sick leave can create a serious staffing deficiency unless guidelines or policies exist. Most unionized settings address these problems, and nonunionized settings would do well to address them as well (Box 18-2). In many states, nursing organizations or boards of nursing sponsor programs for the impaired nurse. Many agencies and health insurance plans also cover the cost of such programs. The nurse manager needs to be familiar with the policies existing in the organization and in the state. For example, in Ohio, employers are required to report employees for conduct

requiring disciplinary action, such as a positive drug screen, even if that employee has been referred to an employee assistance program. Ohio sponsors two programs for problem employees: a program for nurses with substance abuse problems and a program that requires nurses to obtain additional education to improve their practice skills. Nurses in these programs are monitored by the state board of nursing and are able to remain employable with minimal threat to the public. Other states as well as most professional organizations and many health-care organizations offer similar programs.

Although most organizations have a personnel department to deal with all kinds of issues that develop during corporate changes such as reorganization and downsizing, the nurse manager may find herself called upon for input when the nursing staff is involved. Nurse managers may also be involved at the decision-making level when it comes to transferring or terminating nursing staff.

Transfers and Termination

Transfers and termination within an organization can lead to increased productivity and success. Good employees may be transferred to other areas within an organization as part of a promotion package or to make better use of their potential. In someinstances problem employees may be transferred to other areas where they may be more successful. When an employee exhibits problem behavior that is unlikely to change and may be detrimental to the organization, she should be terminated. Restructuring within an organization may result in the termination of employees, even those with good performance records.


Transfers are common in the corporate world; they often involve moving an employee to a new location, often with a promotion and an increase in salary. In health-care organizations, this may not be the case. Many employees, especially the nursing staff, are place-bound and unwilling or unable to move to another location. When mergers or acquisitions occur in the health-care industry, it is often necessary to eliminate positions. Mergers occur when two or more organizations join together to form a single new organization (Lancaster, 1999, p. 99). When one organization buys another, the acquired organization no longer carries its original identity (Lancaster, 1999, p. 99). In either of these situations, for example, there may be no need to have two evening supervisors for the intensive care unit (ICU). One of them could, if willing, be transferred to another unit as a supervisor, if they were unwilling to take a staff position in the ICU. One type of transfer is the  lateral transfer, meaning the individual would be moved to a position with a similar scope of responsibilities within the same organization (Marquis & Huston, 2000). Another type of transfer is the downward transfer, which occurs when someone takes a position within the organization that is below his or her previous level (p. 539). If the transfer is unrelated to performance, the individual may be able to select a position that best relates to her career goals. A person who eventually wants to be a nurse educator may opt to switch to the education department. If this is not in her future, she may decide to take the open position as relief supervisor for the emergency department. Downsizing refers to reducing the number of positions within an organization, normally done to reduce organizational costs and often accompanied by changes in job design to enhance the productivity of the remaining staff (Lancaster, 1999, p. 93). Two personnel issues related to downsizing are transfers and termination of employees. Usually, a transfer is no reflection on the employee’s performance because the person’s salary often remains the same. With downsizing, this is becoming a fairly common practice.


While termination is certainly possible with restructuring, the shortage of nurses makes it unlikely that nursing personnel would be let go. More often, it is the unlicensed personnel whose jobs are in jeopardy. Termination should be the final step in the performance appraisal process, when other measures have failed to bring about improvement of the employee’s performance. As with other policies in the organization, it is critical that a well-defined procedure for termination be in place. The guidelines should be followed strictly by the nursing administrator, after efforts at coaching, counseling, and disciplining have proved unsuccessful. When an employee is a member of a collective bargaining unit, the contract delineates the steps leading to termination. In many organizations, outplacement services are available for employees who have been terminated. This might be a comprehensive program that helps individuals to prepare résumés and applications and work with counselors as they search for another job. This type of program may also be instituted when an organization is going through a major transition, such as downsizing or closing. When valued employees must be terminated, they may be recommended to other facilities within the corporate system.

All Good Things...

The purpose of performance appraisal is to improve the quality and productivity of the employee and enhance career aspirations. The nursing administrator has the responsibility for overseeing the performance appraisal and motivating the employee toward excellence in practice. When employees appear to need support or assistance in reaching goals, their supervisors may be able to work with them, coaching and counseling as needed. Performance appraisal should be an ongoing process, which has both informal and formal components. Employees should take an active role in the process by establishing meaningful career goals for themselves and working toward those goals. The outcome of the process should be satisfied employees who realize their aspirations with the support of the nursing administration.


Managing Your Professional and Financial Future

Nursing is regarded as a profession, and its members are expected to demonstrate evidence of professional characteristics. These characteristics have developed from the study of professionalism by Greenwood in 1957, which proposed five characteristics or attributes of a profession. These attributes can be applied to any functioning profession to defend its status, including nursing. The attributes are:

1. Systematic knowledge base, including a theoretical foundation unique to the profession as well as those adapted from other disciplines

2. Authority, which occurs through education and experience and gives the nurse knowledge and skill to make professional judgments

3. Community sanction, which occurs through statutes, rules, and regulations defining practice and role expectations

4. Code of ethics applicable to the practice area

5. Culture, which consists of formal and informal groups representing the profession Individuals in nursing must demonstrate a high level of personal, ethical, and skill-related characteristics and career orientation to be considered professional. Performing the responsibilities should not be considered “just a job.” To become a professional, one has to be appropriately qualified, licensed, credentialed, committed to lifelong learning, and career-oriented. To achieve this goal requires financial means, time, commitment, and caring.

The challenge of making the right educational choice begins now. Once licensed, many avenues exist for professional advancement. Examples include formal coursework that would lead to another degree, certification following a specialized study in an area, and continuing education. Continuing education involves updating knowledge needed for an individual’s work environment or certification maintenance.

Education is only one element of a nurse’s career, however. Learning how to function as a professional is also critical. By being involved in professional and community organizations and sharing information through scholarly activity such as making presentations, writing for publications, and/or performing research to help build the evidence based scientific foundation for nursing practice, a nurse comes to realize that nursing is more than just “a job.”

This chapter is meant to help readers plan their careers. It includes levels of nursing education, certifications after graduation from a formal program, pursuit of scholarship in nursing, and financial planning to secure a comfortable retirement for the nurse professional.

Nursing Education

Nursing is unique in that it has multiple related educational paths that lead to licensure and professional status. These paths, however, have led to a great deal of public consternation and confusion about the profession.

“The origins of the present diversity in education stem from its historic roots” (Catalano, 1996, p. 68). Starting as an apprentice-like system in early society, nursing was further developed by religious orders during the Middle Ages in Europe. These programs were independent in nature and varied by culture. The student learned what was believed to be of importance for practice in the culture. No formal plans for content or study existed. It was under these religious influences that Florence Nightingale obtained her education. She was also influenced by the secular health-care practices of her native England. From her work in the Crimean War, the earliest “best practices” were set for a formal systematic education in both the theoretical and practice arenas.

From the beginning of nursing education (hospital-based diploma schools) to its current status (in college settings), the scope of knowledge required for practice has grown continuously. This growth includes the development of standardized nursing curricula with variations by individual colleges. In the educational community, there was a belief as early as the early 1900s that nursing education should be housed in an academic environment, such as a college. The earliest nurse training school in America was started in 1871 (Worcester, 1927).

In 1949, the National Nursing Accrediting Service, working with the National League for Nursing Education, became the licensing body for all nursing schools. The first formal accreditation of schools came about in 1952. The accreditation of a school of nursing required that specific criteria, standards, and curricula be adopted and followed.

From the 1950s through the 1970s, an increased awareness of nursing as a profession was evident. During that time, nursing strove to align public perception of nursing with its reality. The events of a growing society after World War II—the population explosion during and after the war; the need for more health-care workers (especially nurses); political, economic, and educational changes—contributed to the development of the multiple entry levels into the profession (Bullough & Bullough, 1984; Schorr & Kennedy, 1999). Table 25-1 shows the various levels of nursing education. Diploma programs have been phased out in many parts of the country. Most nurses today initially become licensed attending associate degree or baccalaureate degree programs and work in a variety of clinical settings. Presently, advanced practice nurses acquire their license through graduate study and passing certification examinations. Many nurses with this degree work as nurse practitioners, teach, and serve as administrators in hospitals or as clinical nurse specialists at the bedside. The highest level of education available is the doctorate. Many nurses prepared at this level perform research, teach, or continue in clinical practice. Choosing the path of nursing study requires examining many factors in planning for the longterm goal. These factors include length of program, cost of education, distance learning, travel and selection of clinical sites for use in the program, pass rate of the students of the program on the National State Board for Nursing examination,

Nursing Educational Programs

personal and work time commitments needed, and student financial needs.


Certification has been utilized in many professions and is the process to acquire formal recognition as having expertise in a given area. It signifies knowledge beyond the minimum required for licensure. The process is believed to determine and maintain specific standards, knowledge, and skills to ensure the safety of the clients in a specified area of practice. Becoming certified helps to build confidence professionally and serves as a testimonial to one’s dedication and accountability to a profession. Health-care consumers are familiar with this process when they seek physicians; however, that is not necessarily the case when working with nurses.

Educating the public on this issue is one mechanism to help the public understand that certified nurses are available for consultation and care management/teaching.

Organizations that provide certification status usually do so on a voluntary basis and are not controlled by the government. Therefore, the certification credential may have a more professional than legal value. Individuals acquiring a credential are believed to be good for consumers by protecting the public and enabling the public to identify competent practitioners more readily.

Registered nurses (RNs) seeking certification must present evidence of an RN license, appropriate education, and experience in the area of specialization for which certification is requested. Requirements vary with the level of certification requested. The roles and responsibilities for advanced practice nursing, for example, are determined through many sources, beginning with each state’s nurse practice act. The RN must contact the American Nurses Credentialing Center (ANCC) and the specialty practice organization of interest to determine the requirements for certification for both the basic and advanced practice levels. On September 1, 2004, ANCC began providing certification candidates with a handbook: the General Testing Information booklet, which includes key information on planning for certification and scheduling the computer–based examination. The test is administered by authorized testing agencies. Manual paper-and pencil examinations can also be taken and are generally given twice a year. Examination dates are provided by the authorized testing agencies when an individual registers for the examination. A test content outline and sample examination questions may be obtained through the ANCC Web site. Making and following a plan of action for the examination process will assist the individual in assessing, implementing, and completing the certification process. Table 25-2 provides information regarding certification opportunities. Professional Organizations The existence of professional organizations is considered to be a defining characteristic of a profession, as noted earlier in the chapter. Professional organizations are developed to meet the needs of their members and their common interests. Whereas state governments have legal control over licensure issues, these organizations provide professional standards of practice and ethical conduct to ensure the public of the availability of high-quality services (Mancino, 2001). Governed by members through bylaws and protocol derived from a board of directors and approved by members, professional organizations work to fulfill varied missions for nursing service in society. It is through organizations that the power of the professional can be recognized and consolidated to perform a variety of services and to provide leadership development opportunities. Nursing associations have three major constituents: the public, the nursing profession, and the individual members (Mancino, 2001, p. 102). The public is served by the development of standards for

Examples of Certification Opportunities

practice and education and by ethical codes to ensure protection of human rights in practice. Professional organizations serve their members collectively to help define the role of the nurse and politically by helping to define actions of the nurse. This can be accomplished through continuing education courses and certifications to keep the nurse up to date with theory and research in caring for clients. In addition, the organizations provide leadership opportunities, such as serving as an officer, performing as an accrediting surveyor, assuming the role of project director on a local or national issue, becoming a board member, working with or becoming a lobbyist, or serving as a volunteer. These opportunities are available at the national, state, and local level.

Nurses have a responsibility to join professional organizations, to serve in a professional capacity, and to help define and better the profession. In general, there are three types of associations available: broad-purpose, specialty practice, and special interest. Deciding on the association that will best serve you may be difficult. Review the purpose, opportunities for involvement, benefits of membership, cost-effectiveness of membership, success of the political arm and issues it covers, and your personal goals before making a choice.


The American Nurses Association (ANA) was established in 1896 by a group of nurses. In its early years, it focused primarily on standardizing nursing education and licensure. Today, the welfare of nurses and the public they serve is a cornerstone of the organization. The Code of Ethics helps guide practice and research policy, and clinical standards guide care and practice measures. This is evidenced in all settings by professional nurses. Public policy plays an integral role in monitoring and lobbying for measures to be adopted for practice, leading to quality and safe care. Membership is open to all nurses in each state of the country and in U.S. territories. Membership dues are used to maintain the organization and its programs. Joining and participating are carried out through national, state, and local district avenues. The ANA offers its members major programs and services, including legislative involvement, standards setting, formal and continuing education, and maintenance of quality practice. In 1992, an International Nursing Center was established to collaborate with nurses internationally and to work for the common good.


Created in 1952 through the ANA, the National Student Nurses’ Association provides a means for all students in RN programs to develop as responsible, accountable, and career-oriented members of the profession. This organization allows students to have a voice in nursing. This is accomplished by working with faculty and students who network with each other and the ANA. The main purpose is to “help maintain high standards of education in schools of nursing with the ultimate goals of educating high quality nurses who will provide excellent health care” (Catalano, p. 180).


Established in 1952, this organization claims to be the oldest nursing organization in this country (Mancino, 2001). The NLN is concerned with the quality of all nursing education, from practical nursing through master’s degree programs. In 1917, the precursor to this organization drafted and disseminated the first standard curriculum for nursing schools. In 1952, the National Organization for Public Health Nursing and the Association of Collegiate Schools of Nursing joined to establish the NLN. This organization is utilized by all levels of nurses in practice today Membership is open to all nurses interested in the purpose of the organization—professional and public—at the state and national levels.


Sigma Theta Tau (STT) was established in 1922 by six students from Indiana University Training School for Nurses. STT has become the national honor society of nursing and recognizes the value of scholarship and excellence in nursing practice, technology, and research, striving to improve nursing care and health worldwide. Programs involved in this organization include mentoring programs in leadership, encouraging members to become involved in chapter, regional, and international efforts of study, task forces, and work. Membership in STT is acquired through organized chapters within accredited schools of nursing that grant baccalaureate and higher degrees. Students usually enter the organization through their college chapter. Community leaders are also eligible and can apply through these same chapters. They must also meet requirements of a baccalaureate degree in nursing, and they must demonstrate marked achievement in education, practice, research, administration, or publication for membership. Being a member of this organization is considered an honor and creates many new opportunities in professional development, scholarship, and leadership.


There are multiple specialty organizations available for nurses to join: the American Association for Critical Care Nursing, the American Heart Association, the Emergency Nursing Organization represent a few. The area of nursing in which the RN practices might be of assistance when determining the most appropriate specialty organization. Every possible specialty in the nursing profession is represented by an organization. The work setting, the Internet, or a library search will help you locate the most appropriate organization. Dues are expected in most.


Scholarship is the culmination of activities that advance teaching, research, and the practice of a profession through rigorous study (Boyer, 1990). Nursing scholarship, like scholarship in other disciplines, also includes presentations and service. Even though the practice of nursing has been in existence since before Florence Nightingale, it was not considered to be a profession until much later. Concept, theory, and knowledge development continue today, as they must if nursing is to maintain its relevance and achieve its purpose. For some, nursing is too practical, too pragmatic, and too ordinary to be paired with the ancient, lofty, traditional, and self-disciplined idea of scholarship (Kitson, 1999). According to a position statement by the American Association of Colleges of Nursing: “Scholarship in nursing can be defined as those activities that systematically advance the teaching, research, and

practice of nursing through rigorous inquiry that 1) is significant to the profession, 2) is creative, 3) can be documented, 4) can be replicated or elaborated, and 5) can be peer-reviewed through various methods” (AACN, 1999, p. 373)

Nursing practice is rooted in the scientific principles of scholarly research. Nursing education, certification, and organizations, as described in the earlier sections of this chapter, rank nursing as a profession among its peers. It is important to understand that, until recently, scholarship was measured by the following:

■ Significance of research questions asked

■ How productively the results of the investigation are communicated

■ Strictly followed research methods; how answers are found

■ The soundness of the theoretical base

■ How significant the answers are to the field and to humanity (Meleis, 2001).

The competition to obtain grant funding for research is stringent. Research is now being measured by the standards of grant funding, “indirect cost returns, evidenced-based practice, and outcome measures” (Meleis, 2001). Scholarship is a means by which the registered nurse’s career can be advanced while advancing the profession of nursing. The nurse engaging in scholarship gains the opportunity to delve into areas of nursing science of interest to the nurse as well as share those areas of interest as they apply to others and the field of nursing. There is also motivation for the RN to engage in scholarship through the monetary and promotion incentives maintained by colleges and universities that employ nursing professionals.


Nursing, along with other disciplines, is in the process of redefining scholarship as it relates to itself as a discipline (Edwards, et al., 2000). Scholarship is pertinent to the individual members of the profession, whether faculty, administrator, or practitioner. Publishing, which includes writing articles, editorials, and books; integration and application of knowledge; curriculum development; and teaching methods and techniques, is another vital aspect of scholarship.

General Writing Guidelines

A shopping list of errors exists for which a work might be rejected. Many authors submit their work before they have closely scrutinized it for errors. Authors of any type of scholarly work—print, computer, or film—must make sure they have chosen the appropriate medium and ensure that the material will meet the needs of their audience. Some media will appeal to a limited clinical audience, whereas others will have a larger, more general audience. In some cases, the work may be well written, but the content may be too old, or the material does not supply new information, or the work does not make a specific point. Sloppy work does not represent scholarship.


Presentations may be made in on-unit in-services, hospital grand rounds, case studies, classroom lectures, professional meetings, and the community. There are several methods by which scholarship can be presented. Two methods discussed here will be speaking and poster presentations because they are the methods used most often at conferences and workshops. When the professional nurse has developed a specific idea or conducted research, it is the responsibility of the nurse to share that new knowledge with the discipline of nursing and/or other interested parties.

Speaking Presentations

Presenting papers and projects to large and small audiences, from national conferences to unit meetings, is a skill learned by doing and is perfected over time. After deciding the broad area of focus for the presentation (e.g., in-patient psychiatric care) and narrowing the focus to something manageable (comparing care for eating disorders—anorexia nervosa and bulimia), it always helpful to develop an outline (Strickland, 1999). The outline will serve two functions: it will guide the writer by delineating specific sections and details to be covered, and it will provide the conference attendees with a guide to follow at the actual presentation (Gregg & Pierce, 1994).

Walker prepared a “Survival Guide” to assist the professional with presentations. It includes the development of a title, an abstract, and audiovisual materials (Walker, 1997). The title of the presentation introduces the attendees to the session and tells them what it will be about. The title should be well considered. Clever titles are usually not informative and should be avoided in lieu of a clear and concise title that will invite people to attend the presentation.

An abstract is a concise statement that introduces and summarizes the work. The abstract should be accurate, comprehensive, and self-contained. It is used to present the pertinent information about the work to the reader. The conference committee will use the material to determine the suitability of the work for presentation at the conference. Unless otherwise specified, an abstract should be only up to 250 words; if it is more, it might be shortened by the service requiring the abstract (APA, 2001). Much of what is read, seen, or heard is forgotten; however, when visual and audio media are combined, 70% is retained (Rawlins, 1993). Even in today’s world of the computer and PowerPoint presentations, it continues to be important that all audiovisuals be prepared with care and thought to the material they will represent. Audiovisual materials include everything from PowerPoint slides, charts, posters, videotapes, and clips from movies to handouts. Overhead transparencies continue to be used as well. The type of media chosen is at the discretion of the presenter and should be determined by size of the room and audience, availability of equipment, availability of resources to develop the media, type of presentation, and time available for presentation (Gregg & Pierce, 1994). Depending on resources and ability, the presenter may decide to personally develop the media or to have it professionally developed. No matter how the media are developed, they must represent and support the presentation. It is important to note here that slides/media should never be read to the audience. The speaker should highlight the presentation—points that can help the audience recall details long after the presentation has ended. The media can be considered an annotated outline, making points upon which the presenter will expound. When parts of videos or films are used, they must be chosen and prepared carefully. Only a specific portion of these media will be of importance to the presentation, and it must be absolutely pertinent (Gregg & Pierce, 1994). It is better to have too little than too much of a film because the presenter can always add what might have been omitted. See Table 25-3 for helpful hints when preparing and making presentations.

Presenting a Poster

Posters are the other main type of presentations used to disseminate information at conferences.


Helpful Hints for Presentations

Poster presentations are less formal than oral presentations and usually require less discussion from the presenter. Posters are primarily visual and are expected to “stand alone” in their ability to depict the message of the researcher or presenter (Ryan, 1989). The poster might include photographs, bullet points, and tables and graphs because these methods allow much information to be communi cated quickly. Even though there is no formal verbal presentation, the researcher may be expected to remain in the vicinity of the poster during poster sessions. As attendees enjoy the posters, the researchers will be available to present specific information about the poster and research and to answer any questions the attendees might have. Poster sessions are also prime opportunities for professional networking with clinicians and researchers (Polit & Beck, 2006: Ryan, 1989). Poster presentations generally follow the IMRAD format—Introduction, Methods, Results, and Discussion (Polit & Beck, 2006, p. 68). The introduction presents the rationale for the study by describing the research problem, its significance, and the framework in which it was developed. The literature review is usually included in the introduction section. The method section gives a detailed description of how the researcher conducted the research, facilitating another researcher to be able to replicate the work. The method section will usually include a description of the research design, the setting and sample, how data were collected and instruments used, and how data were analyzed and/or processed. In a quantitative study, results of the study give a factual summary of the statistical analysis. Results in qualitative studies may include the emergence of themes and new theory; the report of data and the interpretation of the data may be intertwined. Actual edited quotes of the participants may also be included to tell the story of the research. The discussion section allows the presenter to include the main findings and what those findings mean, the validity of the results and the interpretations, comparison of results with prior knowledge, and implications of the finding to nursing and nursing research. The name and institution of the investigator and a brief abstract would also be included on the poster (Burns & Grove, 1993).

The appearance of the poster is very important because it must stand alone and draw spectators. The conference committee will determine the size of the poster and whether it will have one, two, three, or four panels. The title must be descriptive of the research as well as large enough to be seen easily from a distance. Keep in mind that some colors do not promote clarity and visibility of the poster. It is important to make a mock poster before completing the final copy; finances of the presenter determine whether the poster is produced by a professional artist. Some of the helpful hints in Table 25-3 may also be applicable with poster presentations.

In the process of making a name for yourself in the professional nursing community, you must consider financial planning for the future.

Practice to Strive

Future Financial Planning

Nursing, a helping profession, is also a traditionally female profession. Helpers and women are not usually the groups that plan for their financial futures. In many instances, nurses tend to neglect their own future financial affairs (La Plante, 2003). According to Bartruff (2003), nurses tend to be too busy with their jobs for financial planning; or they change employment for greater financial benefits before they can build a substantial portfolio with any one employer. Nevertheless (and for these and perhaps other reasons), nurses should plan for their financial futures. In people’s early working years, ages 20–30, nurses, like many other professionals, are concerned with building a career, paying off college loans, and establishing an initial savings plan. The focus shifts toward preparing for retirement when the employee reaches the late 30s and 40s (Hawke, 2000). It has been found that increased salaries and career ladders greatly influence job satisfaction (Bruce, 1990); many health-care organizations are improving their benefits packages in other ways. According to a survey by the American Hospital Association, many health-care organizations are “reworking their retirement plans to recruit and retain healthcare workers,” thus hoping to assist in slowing the trend of nurses changing jobs in search of better benefits, better pay, and better retirement before they can develop a substantial portfolio (The American Nurse, September/October, 2003; Runy, 2003).There is a need for nurses to recognize that retirement plans are necessary. Too large a percentage of nurses do not take advantage of employer-provided retirement plans. Nurses must require of their employers a retirement plan explanation and, with assistance, must develop goals for their financial retirement plans (Cook, 1997). Health-care organizations are increasing their spending on retirement plans and are offering ancillary services such as investment advice and flexible account spending services (Reilly, 2003).

Retirement planning includes planning for finances as well as health care. It also includes psychological adjustment to and acceptance of the aging process, the transition from an active working lifestyle to one which is, in many instances, far less active (Lee, 2003). According to MacEwen, et al. (1995), retirement preparation affects the individual’s anxiety level. Financial savings must begin years before the psychological planning is needed if the individual is to accomplish the emotional state of one Canadian nurse who took an early retirement; she says she is not bored, but pleasantly busy and glad to be retired (Leeson, 2003).


Nurses already multitask, but they must add another task to the list: gaining knowledge of retirement planning. It would simplify the process if all necessary information on retirement planning could be found in one place, but that is not the case. Therefore, nurses must actively search for the knowledge they require (Lewis & Hounsell, 2003). The nurse can also seek advice from the human resources department in the individual’s place of employment.


According to La Plante (2003), each individual must determine what retirement means personally. At retirement, some may want to travel; others may plan to work longer and/or even part-time and do special interest activities. Others may want to pursue more education in areas in or outside of the nursing field. Whatever the retired nurse may do, planning the finances for those activities is a vital part of retirement financial planning.


There are many formulas for determining the finances required for retirement. Lewis and Hounsell (1999) have suggested a general rule of planning for the individual to maintain the same lifestyle in retirement as before retirement. These authors suggest that 65% to 80% of one’s pre-retirement income is needed. Therefore, if the individual earned $50,000 annually, the retirement income would need to be $32,000 to $40,000 annually. It is possible that, given the present state of the economy and the current rate of inflation of about 4%, the same amount of income may be required after retirement as before. They also suggest that nurses know their:

1. Savings on hand

2. Value of Social Security benefits

3. Current pension plan in detail

4. Rights to a spouse’s pension

5. Values of other savings plans. Those plans may include: 401(k), 403(b), 503(c), 401(a), 457(b), and 457(f). See Box 25-2.

La Plante (2003) cautions the reader to maintain insurance, have emergency savings, and live a relatively debt-free lifestyle. Other advice includes changing from saving to investing because of more

rapidly increased returns. When nurses control their future financial plans, they are participating in the control of their destinies.


According to Cook (1997), the 401(k) [the 403(b) in non-profit organizations] plan quickly became the retirement vehicle of choice for financial planning in the 1990s and possibly into the 21st century as well. There are proposals, however, to replace public and private contribution plans with investment savings accounts that are sponsored by the employer (Ward, 2005).

Cook stated that hospital employees will have a greater advantage when choosing financial retirement plans if they understand risk and diversification. Diversification must not be confused with having a number of investment options (Cook, 1997). A clear understanding of risk and return is vital when making investment decisions.

Asset Allocation Strategies

Decisions regarding risk tolerance and the amount of time required to invest before the funds are acquired at retirement are at the discretion of the individual. There are at least four strategies for allocating assets for retirement funds. The conservative strategy is for individuals who have only a few years to invest (fewer than 4) and who cannot tolerate investment risk (experiencing their invested funds increase and decrease as the stock market loses and gains). The balanced strategy is for the individual who can tolerate only a moderate amount of investment risk and has at least 6 years to invest before retirement. The individual’s funds will be distributed equally between rapidly growing investments and safer investments, which grow at a much slower rate. The growth strategy is for the individual who has at least 6 years to invest before retirement and who has a fairly high tolerance for investment risk. In this instance, the rapidly growing, more risky investments will consume more of the person’s funds, and fewer funds will be attributed to the slower-growing safer investments. The last strategy, the aggressive growth strategy, is for the individual who has at least 7 to 10 years to invest, who wants a high rate of return, and who can tolerate greater investment risk. There are specific formulas that delineate this philosophy (Keefe, 2005).

Another concept to consider regarding investment plans is what to do with your funds when you leave one job for another. Nurses tend to change jobs frequently; thus, nurses may have investment funds in several different places. Four choices have been suggested for handling retirement assets in previous accounts. The individual can roll over the invested funds from the previous position into an individual retirement account (IRA), transfer previously invested funds to the new employer’s 401(k) plan, allow the previously invested funds to remain in the former employer’s plan, or take the previously invested funds in cash. One serious problem with “cashing out” investment funds is the considerable amount of taxes due for those funds because they are saved as pretax funds, and there are penalties for early withdrawal (Kohrmann, 2003). Another problem is the temptation to use the funds to pay for present financial responsibilities. This temptation should be resisted in lieu of a brighter financial future in retirement. Changes in society, in nurses, and in the nursing profession are reflected in the way nurses are viewing and participating in financial planning for the future. Although acceptance of the aging process, transitioning from the working lifestyle to a much less active lifestyle, and planning for health care during retirement are extremely important, it is vital that the working nurse plan financially for retirement. The financial retirement once available for individuals through Social Security will no longer meet the needs of a population that is living longer and is more active. Time and risk tolerance might (in some cases) seem prohibitive in financial planning; however, the invested funds are the property of the individual, and the decision about how to manage them is for the individual to plan and make wisely.

All Good Things...

Professions demonstrate five attributes to defend their status. Nursing has declared itself to be a profession. To defend this status, nursing has met the attributes in the following manner: (1) it functions from a systematic knowledge base unique to the profession based on scholarship activities as well as knowledge from other disciplines; (2) it has authority, through education and experience, allowing the nurse to make professional judgments; (3) it demonstrates community sanction through licensing, certification, and defining practice through rules and regulations set at the state level; (4) it has a code of ethics for practice to protect both the nurse and the client; and (5) it has been identified as a culture through licensing, professional organizations, community organizations, and the educational programs in place for students and licensed nurses. Scholarship is a key foundation to the basis for nursing practice. Commonly thought of as purely the research process, this is not scholarship’s only component. Scholarship also includes dissemination of the information gained through study via writing (editorials, articles, books) and presenting (speaking, papers, or posters) related to the information. Guidelines for these activities include reviewing reading/writing level, using visuals (pictures, backgrounds, color schemes), using formats (PowerPoint IMRAD), and monitoring personal appearance (dress, eye contact, voice). Like the research process, time and planning are crucial for any of these activities to have a positive outcome.

Finally, it is never too late for planning one’s financial future in retirement. Although this was not on the minds of many individuals in the past, now is believed to be a good time to start investing, even a small amount, toward this goal. Nurses must consider this fact and educate themselves through their employer’s human resource department or select a financial advisor to assist them in this process, no matter where they are in their career presently.

There are many formulas for determining finances required for retirement. Factors to help determine a plan include one’s savings, the value of Social Security benefits, detailed information on current pension plan, and rights related to a spouse’s pension. Once known, it is important to review other savings plans, such as the 401(k), 403(b), 503(c), 401(a), 457(b), and 457(f), along with their risks and diversification. Based on the understanding of this information, a decision can be made.

Coming onto the unit, Sofia, the evening charge nurse, already knew that a hectic day was in progress. Scattered throughout the unit were clues from the past 8 hours. Two clients on emergency department stretchers were parked outside observation rooms already occupied by clients who had been admitted the previous day in critical condition. Stationed in the middle of the hall was the code cart, with its drawers opened and electrocardiograph paper cascading down its sides. Approaching the nurses’ station, Sofia found Daniel buried deep in paperwork. He glanced at her with a face that had exhaustion written all over it. His first words were, Three of your RNs called in sick. I called staffing for additional help, but only one is available. Good luck!’’

Sofia surveyed the unit, looked at the number of staff members available, and reviewed the client acuity level of the unit. She decided not to let the situation upset her. She would take harge of her own time and reallocate the time of her staff. She began to mentally reorganize her staff and alter the responsibilities of each member. Having taken steps to handle the problem, Sofia felt ready to begin the shift.

Business executives, managers, students, and nurses know that time continues to be a valuable resource. Time cannot be saved and used later, so it must be used wisely. As a new nurse, you may at times find yourself sinking in the “quicksand” of a time trap, knowing what needs to be done but just not having the necessary time to do it (Ferrett, 1996). In today’s fast-paced healthcare environment, time management skills are critical to a nurse’s success. Learning to take charge of your time is the key to time management (Gonzalez, 1996).

Many nurses feel as though they never have enough time to accomplish the tasks that need to be completed. Like the White Rabbit in Alice in Wonderland, they are constantly in a rush against time. Time management is simply organizing and monitoring time so that clientcare tasks can be scheduled and implemented in a timely and organized fashion (Bos & Vaughn, 1998).



How often do you look at your watch during the day? Do you divide your day into blocks of time? Do you steal a quick glance at the clock when you come home after putting in a full day’s work? Do you mentally calculate the amount of time left to complete the day’s tasks of grocery shopping, driving in a car pool, making dinner, and leaving again to take a class or attend a meeting? In our society, calendars, clocks, watches, newspapers, television, and radio all remind us of our position in time. Our perception of time is important because it affects our use of time and our response to time (Box 1).





Webber (1980) has collected a number of interesting tests of people’s perception of time. You may want to try several of these:

Do you think of time more as a galloping horseman or a vast motionless ocean?

Which of these words best describes time to you: sharp, active, empty, soothing, tense, cold, deep, clear, young, or sad?

Is your watch fast or slow? (You can check it with the radio.)

Ask a friend to help you with this test. Go into a quiet room without any work, reading material, radio, food, or other distractions. Have your friend call you after 10 to 20 minutes have elapsed. Try to guess how long you were in that room.

Webber test results interpreted. A person who has a circular concept of time would compare it to a vast, still ocean. A galloping horseman would be characteristic of a linear conception of time, emphasizing speed and motion forward. A fast-tempo, achievement-oriented person would describe time as clear, young, sharp, active, or tense rather than empty, soothing, sad, cold, or deep. These same fast-tempo people are likely to have fast watches and to overestimate the amount of time that they sat in a quiet room (Webber, 1980).

Source: Adapted from Webber, R.A. (1980). Time is Money! Tested Tactics that Conserve Time for Top Executives. New York: Free Press.




Computers complete operations in a fraction of a second, and we can measure speeds to the nanosecond. Time clocks that record the minute we enter and leave work are commonplace, and few excuses for being late are really considered acceptable. Timesheets and schedules are part of most healthcare givers’ lives. We are expected to follow precisely set schedules and meet deadlines for virtually everything we do, from distributing medications to getting reports done on time. Many agencies produce vast quantities of computergenerated data that can be analyzed to determine the amount of time spent on various activities. It is no wonder some of us seem obsessed with time.

Individual personality, culture, and environment all interact to influence our perceptions of time (Matejka & Dunsing, 1988). Each of us has an internal tempo (Chappel, 1970). Some internal tempos are quicker than others. Environment also affects the way we respond to time. A fast-paced environment influences most of us to work at a faster pace, despite our internal tempo. For individuals with a slower tempo, this pace can cause discomfort. If you are a high-achievement–oriented person, you are likely to have already set some career goals for yourself and to have a mental schedule of deadlines for reaching these goals (“go on to complete my BSN in 4 years; an MSN in 6 years’’). Many healthcare professionals are linear, fast-tempo, achievement-oriented people. Simply working at a fast pace, however, is not necessarily equivalent to achieving a great deal. Much energy can be wasted in rushing around and stirring things up but actually accomplishing very little. The rest of this chapter looks at ways in which you can use your time and energy wisely to accomplish your goals.




Nurses are the largest group of healthcare professionals. Because of the number of nurses and the shift variations, attention concerning the efficiency and effectiveness of their time management is needed. The effect of rotating shifts has long been a concern in nursing. Nurses who rotate shifts are twice as likely to report medication errors as those who do not rotate. Night-shift staff members and rotating-shift staff members also report getting less sleep, a poorer quality of sleep, greater use of sleep medication, and a problem with nodding off at work or while driving home after work (Sleeping on the job, 1993).

A new graduate worked the 7 A.M. to 3 P.M. shift and rotated every third week to the 11 P.M. to 7 A.M. shift in a medical intensive care unit, working 7 days straight before getting 2 days off. It was not difficult to remain awake during the entire shift the first night on duty, but each night thereafter staying awake became increasingly more difficult. After the 2 A.M. vital signs were taken and recorded, the new graduate inevitably fell asleep at the nurses’ station. He was so tired that it was necessary to check and recheck client medications and other procedures for fear of making a fatal error. He became so anxious over the possibility of injuring someone that sleep during the day became impossible. Because of his obsession with going over his work, he had difficulty completing tasks and was always behind at the end of the shift (of course, napping didn’t help his time management).

A number of studies have examined how nurses use their time, especially nurses in acute-care settings. For example, a study by Arthur Andersen found that only 35 percent of nursing time is spent in direct client care (including care planning, assessment teaching, and technical activities). Documentation accounts for another 20 percent of nursing time. The remainder of time is spent on transporting clients, transaction processing, administrative responsibilities, and hotel services (in Brider, 1992) (Fig. 6–1). Categories may change from study to study, but the amount of time spent on direct client care is usually less than half the workday. As hospitals continue to reengineer, downsize, and cross-train personnel, nurses are finding themselves more involved with tasks that are not client-related, such as quality improvement, developing critical pathways, and so forth. These are added to their already existing client care functions. The result is that in some cases nurses are able to meet only the highest-priority client needs.

Any change in the distribution of time spent on various activities can have a considerable impact on client care and on the organization’s bottom line. Prescott (1991) offers the following example of this: If more unit management responsibilities could be shifted from nurses to non-nursing personnel, about 48 minutes per nurse shift could be redirected to client care. In a large hospital with 600 fulltime nurses, the result would be an additional 307 hours of direct client care a day. Calculating the results of this timesaving strategy in another way shows an even greater impact: the changes would contribute the equivalent of the work of 48 additional fulltime nurses to direct client care. Many healthcare institutions are considering integrating units with similar patient populations and having them managed by a non-nurse manager, someone with business and management expertise and not necessarily nursing skills. However, as a group, nurses respect managers who have nursing expertise and are able to perform as nurses.





Setting Your Own Goals

It is difficult to decide how to spend your time because there are so many things that need time. A good first step is to take a look at the situation and get an overview. Then ask yourself, “What are my goals?” Goals help clarify what you want and give you energy, direction, and focus. Once you know where you want to go, set priorities. This is not an easy task. Remember Alice’s conversation with the Cheshire Cat in Lewis Carroll’s Alice in Wonderland?

“Would you tell me please, which way I ought to go from here?” asked Alice.

“That depends a good deal on where you want to go to,” said the Cat.

“I don’t care where,” said Alice.

“Then it doesn’t matter which way you go,” said the Cat.

How can you get somewhere if you do not know where you want to go? It is important to explore your personal and career goals. This can help you make decisions about the future. This concept can be applied to day-today activities as well as help in career decisions. Ask yourself questions about what you want to accomplish over a particular time period. Personal development skills include discipline, goal setting, management and organizational skills, self-monitoring, and a positive attitude toward the job (Bos & Vaughn, 1998). Many of the personal management and organizational skills related to the workplace focus on time management and scheduling. Most new nurses have the skills required to perform the job but lack the personal management skills necessary to get the job done, and specifically time management. To help organize your time, you need to set both short- and long-term goals. Short-term goals are those that you wish to accomplish within the near future. Setting up your day in an organized fashion is a short-term goal and so is scheduling a required AIDS course. Long-term goals are those you wish to complete over a long period of time. Advanced education and career goals are examples. A good question to ask yourself is, “What do I see myself doing 5 years from now?’’ Every choice you make requires a different allocation of time (Moshovitz, 1993). Eleanor, a licensed practical nurse returning to school to obtain her associate’s degree in nursing, was faced with a multitude of responsibilities. A wife, a mother of two toddlers, and a full-time staff member at a local hospital, Eleanor suddenly found herself in a situation in which there just were not enough hours in a day. She became convinced that becoming a registered nurse was an unobtainable goal. When asked where she wanted to be in 5 years, she answered, At this moment, I think, on an island in Tahiti!’’ Several of her instructors helped Eleanor develop a time plan. First, she was asked to list what she did each day and how much time each task required. This list included basic childcare, driving children to and from day care, shopping, cooking meals, cleaning, hours spent in the classroom, study hours, work hours, and time devoted to leisure. Once this was established, she was asked which tasks could be allocated to someone else (e.g., her husband), which tasks could be clustered (e.g., cooking for several days at a time), and which tasks could be shared. Eleanor’s husband was willing to assist with car pools, grocery shopping, and cleaning. Eleanor had never asked him for help before. Cooking meals was clustered: Eleanor made all the meals in 1 day and then froze and labeled them to be used later. This left time for other activities. Eleanor graduated at the top of her class and has subsequently completed her BSN and become a clinical preceptor for other associate degree students on a pediatric unit in a county hospital. She never did get to Tahiti, though. Organizing your work can eliminate extra steps or serious delays in completing your work. It can also reduce the amount of time spent doing things that are neither productive nor satisfying. Working on the most difficult tasks when you have the most energy decreases frustration later in the day when you may be more tired and less efficient. To begin managing your time, you need to develop a clearer understanding of how you use your time. Creating a personal time inventory helps you estimate how much time you spend in typical activities. Keeping the inventory for a week gives a fairly accurate estimate of how you spend your time. The inventory also helps identify “time wasters” (Gahar, 2000). To avoid time wasters, take control. It is important to prevent endless activities and other people controlling you. Every day, set priorities to help you meet your goals.






One of the most useful organizers is the “things to do” list. You can make this list either at the end of every day or at the beginning of each day before you do anything else. Some people say they do it at the end of the day because something always interferes at the beginning of the next day. Do not include routine tasks, because they will make the list too long and you will do them without the extra reminder. If you are a team leader, place the unique tasks of the day on the list: team conference, telephone calls to families, discussion of a new project, or an in-service demonstration on a new piece of equipment. You may also want to arrange these things to do in order of their priority, starting with those that must be done on that day. Ask yourself the following questions regarding the tasks on the list (Moshovitz, 1993):

• What is the relative importance of each of these tasks?

• How much time will each task require?

• When must each task be completed?

• How much time and energy do you have to devote to these tasks?

If you find yourself postponing an item for several days, decide whether it should be given top priority the next day or dropped from the list as an unnecessary task. The list itself should be in a user-friendly form: on your electronic organizer, in your pocket, or on a clipboard. Checking the list several times a day quickly becomes a good habit. Computerized calendar-creator programs help in setting priorities and guiding daily activities. These programs can be set to appear on the desktop when you turn on your computer and give an overview of the day, week, or month. This calendar acts as an automated “things to do” list. Your daily things to do list may become your most important time manager. Box 2 summarizes ways to determine how to distribute your time.



BOX 6–2


Set goals.

Make a schedule.

Write a to do list.

Revise and modify; do not throw itout.




Tickler Files


Tickler files might be called long-term lists. The basic principle of a tickler file is that you create a system to remind yourself of approaching deadlines and due dates. Today, computerized tickler files can be created by using calendar-creator programs. At the beginning of the semester, students are told the examination dates and when papers will be due. Many students find it helpful to enter the dates on a semester-long calendar so that they can be seen at a glance. Then the students can see when clusters of assignments are due at the same time. This allows for advance planning or perhaps requests to change dates or get extensions.


Schedules and Blocks of Time


Without some type of schedule, you are more likely to drift through a day or bounce from one activity to another in a disorganized fashion. Assignment sheets, worksheets, flow sheets, and critical pathways are all designed to help you plan client care and schedule your time effectively. The critical pathway is a guide to recommended treatments and optimal client outcomes (see Chapter 4). Assignment sheets indicate the clients for whom each staff member is responsible. Worksheets are then created to organize the daily care that must be given to the assigned clients (see Chapters 2 and 4 for examples of worksheets). Flow sheets are lists of items that must be recorded for each client. Effective worksheets and flow sheets schedule and organize the day by providing reminders of various tasks and when they need to be done. The danger in using them, however, is that the more they divide the day into discrete segments, the more they fragment the work and discourage a holistic approach. If a worksheet becomes the focus of attention, the perspective of the whole and of the individuals who are our clients may be lost. Some activities must be done at a certain time. These activities structure the day or week to a great extent, and their timing may be out of your control. However, in every job there are tasks that can be done whenever you want to do them, as long as they are done on time.

In certain nursing jobs, reports and presentations are often required. For these activities, you may need to set aside blocks of time during which you can concentrate on the task. Trying to create and complete a report in 5- or 10-minute blocks of time is unrealistic. By the time you reorient yourself to the project, the time allotted is over and nothing has been accomplished. Setting aside large blocks of time to do complex tasks is much more efficient.

Consider your energy levels when beginning a big task. Start when levels are high and not you find yourself winding down. For example, if you are a morning person, plan your demanding work in the morning. If you get energy spurts later in the morning or early afternoon, plan to work on larger or heavier tasks at that time. Nursing shifts may be designed in 8-, 10-, or 12-hour blocks. Many nurses working the night shifts (11 P.M. to 7 A.M., or 7 P.M. to 7 A.M.) find they have more energy a little later into their shift rather than at the beginning, whereas nurses working the day shifts (7 A.M. to 3 P.M.; 7 A.M. to 7 P.M.) find they have the most energy at the beginning of their shift. Also, learn to delegate tasks that do not require professional nursing skills.

Some people go to work early to have a block of uninterrupted time. Others take work home with them for the same reason. This extends the workday and cuts into leisure time. The higher your stress level, the less effective you will be on the job—so don’t bring your work home with you. You need some time off to recharge your batteries (Turkington, 1996).



Filing Systems


Filing systems are helpful to keep track of important papers. Every professional needs to maintain copies of licenses, certifications, and continuing-education credits as well as current information about their specialty area. Keeping these organized in an easily retrievable system saves time and energy when you need to refer to them. Using color-coded folders is often helpful. Each color holds documents that are related to one another. For example, all continuing-education credits might be placed in a blue folder, anything pertaining to licensure in a yellow folder, and so on.





To set limits, it is necessary first to identify your objectives and arrange the actions needed to meet them in order of their priority (Haynes, 1991). It is also important to stick to these objectives, which can require considerable determination.



Saying No


Saying no to low-priority demands on your time is an important but difficult part of setting limits. Assertiveness and determination are necessary for effective time management. Learn to tactfully say no at least once a day (Hammerschmidt & Meador, 1993). Is it possible to say no to your supervisor or manager? It may not seem so at first, but actually many requests are negotiable. Requests sometimes are in conflict with career goals. Rather than sit on a committee in which you have no interest, respectfully decline and volunteer for one that holds promise for you as well as meets the needs of your unit. Can you refuse an assignment? Your manager may ask you to work overtime or to come in on your scheduled day off, but you can refuse. You may not refuse to care for a group of clients or take a report because you think the assignment is too difficult or unsafe. You may, however, discuss the situation with your supervisor and together work out alternatives. You can also confront the issue of understaffing by filing an unsafe staffing complaint (see Appendix 4). Failure to accept an assignment may result in accusations of abandonment. Some people have difficulty saying no. Ambition keeps some people from declining any opportunity, no matter how overloaded they are. Many individuals are afraid of displeasing others and therefore feel obligated to continuously take on all forms of additional assignments. Still others have such a great need to be needed that they continually give of themselves, not only to clients but also to their coworkers and supervisors. They fail to stop and replenish themselves and become exhausted. Remember, no one can be all things to all people at all times without creating serious guilt, anger, bitterness, and disillusionment. “Anyone who says it’s possible has never tried it’’ (Turkington, 1996, p. 9).



Eliminating Unnecessary Work


Some work has become so deeply embedded in our routines that it appears essential, although it is really unnecessary. Some nursing routines fall into this category. Taking vital signs, baths, linen changes, dressing changes, irrigations, and similar basic tasks are more often done according to schedule rather than according to client need, which may be much more or much less often than the routine specifies. Some of these tasks may be appropriately delegated to others.

• If clients are ambulatory, bed linens may not need to be changed daily. Incontinent and diaphoretic clients need to have fresh linens more frequently. Not all clients need a complete bed bath every day. Elderly clients have dry, fragile skin; giving them good mouth, facial, and perineal care may be all that is required on certain days. This should be included in the client’s care plan.

• Much paperwork is duplicative, and some is altogether unnecessary. For example, is it necessary to chart nursing interventions in two or three places on the client record? The use of charting by exception, flow sheets, and computerized records are attempts to eliminate some of these problems.

• Socialization in the workplace is an important aspect in maintaining interpersonal relationships. When there is a social component to interactions in a group, the result is usually positive. However, too much socialization can reduce productivity in the workplace, so judgment must be used in deciding when socializing is interfering with work.

You may create additional work for yourself without realizing it. How often do you walk back down the hall to obtain equipment when it all could have been gathered at one time? How many times do you walk to a client’s room instead of using the intercom, only to find that you need to go back to where you were to get what the client needs? Is the staff providing personal care to clients who are well enough to meet some of these needs themselves?





Many tasks cannot be eliminated or delegated, but they can be done more efficiently. There are many sayings in time management that reflect the principle of streamlining work. “Work smarter, not harder’’ is a favorite one that should appeal to nurses facing increasing demands on time. “Never handle a piece of paper more than once’’ is a more specific one, reflecting the need to avoid procrastination in your work. “A stitch in time saves nine’’ reflects the degree to which preventive action saves time in the long run.

Several methods of working smarter and not harder are:

• Gathering materials, such as bed linens, for all of your clients at one time. As you go to each room, leave the linen so that it will be there when you need it.

• While giving a bed bath or providing other personal care, perform some of the aspects of the physical assessment, such as taking vital signs, skin assessment, and parts of the neurological and musculoskeletal assessment. Prevention is always a good idea.

• If a client does not “look right,’’ do not ignore your instincts. The client is probably having a problem.

• If you are not sure about a treatment or medication, ask before you proceed. It is usually less time-consuming to prevent a problem than it is to resolve one.

• When you set aside time to do a specific task that has a high priority, stick to your schedule and complete it.

• Do not allow interruptions while you are completing paperwork, such as transcribing orders.

What else can you do to streamline your work? A few general suggestions follow, but the first one, a time log, can assist you in developing others unique to your particular job. If you complete the log correctly, a few surprises about how you really spend your time are almost guaranteed.



Keeping a Time Log


Our perception of time is elastic. People do not accurately estimate the time they spend on any particular task, so we cannot rely on our memories for accurate information about how we spend our time. The time log is an objective source of information. Most people spend a much smaller amount of their time on productive activities than they estimate. Once you see how large amounts of your time are spent, you will be able to eliminate or reduce the time spent on nonproductive or minimally productive activities (Drucker, 1967; Robichaud, 1986). For example, many nurses spend a great deal of time searching for or waiting for missing medications, equipment, or supplies. Before beginning client care, assemble all the equipment and supplies you will need, and check the client’s medication drawer against the medication administration record so that you can order anything that is missing before you begin.

Figure 6–1 is an example of a time log in which you enter your activities every halfhour. This means that you will have to pay careful attention to what you are doing so that you can record it accurately. Do not postpone the recording; do it every 30 minutes. A 3-day sample may be enough for you to see a pattern emerging. It is suggested that you repeat the process again in 6 months, both because work situations change and to see if you have made any long-lasting changes in your use of time.



Reducing Interruptions


Everyone experiences interruptions. Some of these are welcome and necessary, but too many interfere with your work. Interruptions must be kept to a minimum or eliminated if possible. Closing the door to a client’s room may reduce interruptions. You may have to ask visitors to wait a few minutes before you can answer their questions, although you must remain sensitive to their needs and return to them as soon as possible.

There is nothing wrong with asking a colleague who wants your assistance to wait a few minutes if you are engaged in another activity. Interruptions that occur when you are trying to pour medications or make calculations can cause errors. Physicians and other professionals often request nursing attention when nurses are involved with client care tasks. Find out if a nonlicensed person may be of assistance. If not, ask the physician to wait, stating that you will be more than glad to help as soon as you complete what you are doing. Be courteous, but be firm; you are busy also.



Categorizing Activities


Clustering certain activities helps eliminate the feeling of bouncing from one unrelated task to another. It also makes your caregiving more holistic. You may, for example, find that documentation takes less time if you do it while you are still with the client or immediately after seeing a client. The information is still fresh in your mind, and you do not have to rely on notes or recall. Many healthcare institutions have switched to computerized charting, with the computers placed at the bedside. This set-up assists in documenting care and interventions while the nurse is still with the client. Also, try to follow a task through to completion before beginning another.



Finding the Fastest Way


Many time-consuming tasks can be made more efficient through the use of automation. Narcotic delivery systems that deliver the correct dose and electronically record the dose, the name of the client, and the name of the healthcare personnel removing the medication are being used in many institutions. This system saves staff time in documentation and in performing a narcotic count at the end of each shift (Meyer, 1992). Efficient systems do not have to be complex. Using a preprinted color-coded sticker system helps to identify clients who must be without food or fluids (NPO) for tests or surgery, those who require 24-hour urine collections, or those who are having special cultures done. The information need not be written or entered repeatedly if stickers are used.



Automating Repetitive Tasks


Developing techniques for repetitive tasks is similar to finding the fastest method, but it focuses on specific tasks that are repeated again and again, such as client teaching. Many clients come to the hospital or ambulatory center for surgery or invasive diagnostic tests for same-day treatment. This does not give nurses much teaching time. Using videotapes and pamphlets as teaching aids can reduce the time needed to share the information, allowing the nurse to be available to answer individual questions and create individual adaptations. Many facilities are using these techniques for cardiac rehabilitation, preoperative teaching, and infant-care instruction.





Time can be our best friend or our worst enemy, depending on our perspective and how we manage it. It is important to identify how you feel about time and to assess your own time management skills. Nursing requires that we perform numerous activities within what often seems to be a very short period of time. Knowing this can create stress. Learn to delegate. Learn to say, “I would really like to help you; can it wait until I finish this?’’ Learn to say no. Most of all, learn how to make the most of your day. Finally, remember that 8 hours should be designated as sleep time and several more as personal or leisure (“time off’’) time.




1. Develop a personal time inventory. Identify your time wasters. How do you think you can eliminate these activities?

2. Create your own client care worksheet. How does this worksheet help you organize your clinical day?

3. Keep a log of your clinical day. Which activities took the most time and why? Which activities took the least time? What situations interfered with your work? What could you do to reduce the interference?

4. Identify a task that is done repeatedly in your clinical area. Think of a new, more efficient way to do that task. How could you implement this new routine? How could you evaluate its efficiency?




Antonio was recently hired as a team leader for a busy cardiac step-down unit. Nursing responsibilities of the team leader, in addition to client care, include meeting daily with team members, reviewing all admissions and discharges for acuity and length of stay, and documentation of all clients who exceeded length of stay and the reasons. At the end of each month, the team leaders are required to meet with unit managers to review the client care load and team member performance.

This is the last week of the month, and Antonio has a meeting with the unit manager at the end of the week. He is 2 weeks behind on staff evaluations and documentation of clients who exceeded length of stay. He is becoming very stressed over his team leader responsibilities.

1. Why do you think Antonio is feeling stressed?

2. Make a “things to do” list for Antonio.

3. Develop a time log for Antonio to use to analyze his activities.

4. How can Antonio organize and streamline his work?



Oddsei - What are the odds of anything.