UNIVERSIDAD DE ZAMBOANGA SCHOOL OF ALLIED MEDICINE

DEPARTMENT OF NURSING
MAIN CAMPUS, DON TORIBIO ST., TETUAN, ZAMBOANGA CITY

CONTROLLING a. Also known as Evaluating b. Fifth and final step in the management process c. Is an on-going function of management which occurs during planning, organizing, and directing activities. It includes assessing and regulating performance in accordance with the plans that have been adopted, the instructions issued, and the principles established. d. Examples of management controlling functions include the periodic evaluation of unit philosophy, mission, goals and objectives; the measurement of individual and group performance against pre-established standards; and the auditing of patient goals and outcomes e. Opens opportunities for improvement and comparing performance against set standards. It provides information about how well processes and people function so they can be motivated to perform better in the future f. Quality Control, a specific type of controlling, refers to activities that are used to evaluate, or regulate services rendered to consumers Hallmarks of Effective Quality Control Programs Support from top-level administration Commitment by the organization in terms of fiscal and human resources Quality goals reflect search for excellence rather than minimums Process is ongoing (continuous)

1. 2. 3. 4. g.

Health Care Quality, the degree to which health servicers for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (Institute of Medicine). While outcomes are an important measure of quality care, it is dangerous to use them as the only criteria for quality measurement.

REASONS FOR CONDUCTING EVALUATION Evaluation plays an important role in quality and productivity improvement for several reasons. 1. 2. 3. 4. 5. 6. 7. 8. Evaluation ensures that quality nursing care is provided. It allows for the setting of sensible objectives and ensures compliance with them. It provides standards for establishing comparisons. It promotes visibility and a means for employees to monitor their own performance. It highlights problem related to quality care and determines the areas that require priority attention. It provides an indication of the costs of poor quality. It justifies the use of resources. It provides feedback for improvement.

EVALUATION PRINCIPLES In order that employees may be evaluated accurately and fairly, certain principles must be observed. 1. The evaluation must be based on the behavioral standards of performance which the position requires. The goals and objectives are clearly presented to the employee and performance evaluation is based on these. 2. In evaluating performance, there should be enough time to observe employees behavior. Usual and consistent behavior should be evaluated rather than those isolated or typical actuations. 3. The employee should be given a copy of the job description, performance standards, and evaluation form before the scheduled conference. This way, the rater and the employee to be rated can discuss issues from the same frame of reference. 4. The employees performance appraisal should include both satisfactory and unsatisfactory results with specific behavioral instances to exemplify these evaluative comments. 5. Areas needing improvement must be prioritized to help the worker upgrade his/her performance. 6. The evaluation conference should be scheduled and conducted at a convenient time for the rater and the employee under evaluation, in a pleasant surrounding and with ample time for discussion. 7. The evaluation report and conference should be structured in such a way that it is perceived and accepted positively as a means of improving job performance. CHARACTERISTICS OF AN EVALUATION TOOL 1. Evaluation tool should be objective, reliable and sensitive. 2. Objectivity means that the evaluation tool is free from bias. 3. Reliability refers to the accuracy or precision of the tool such that it will produce the same results if administered twice. 4. Validity refers to the relevance of the measurement to the performance of the employee while sensitivity means that the instrument can measure fine lines of differences among the criteria being measured.

BASIC COMPONENTS OF THE CONTROL PROCESS The control process may be divided into the ff basic components: 1. Establishment of standards, objectives, and methods for measuring performance; 2. Comparison of results of performance with standards and objectives and identifying strengths and areas for correction and/or improvement; 3. Action to reinforce strengths or successes; and 4. Implementation of corrective action as necessary ESTABLISHMENT OF STANDARDS FOR MEASURING PERFORMANCE 1. A standard is a predetermined level of excellence that serves as a guide for practice. 2. Standards have distinguishing characteristics; they are predetermined, established by an authority, and communicated to and accepted by the people affected by them. Because standards are used as measurement tools, they must be objective, measurable, and achievable. 3. Is a desirable set of conditions and performance necessary to ensure the quality of nursing care services which are acceptable to those instrumental to or responsible for setting and maintaining them. THREE TYPES OF PERFORMANCE STANDARDS 1. STANDARDS ON STRUCTURE a. Are those that focus on the structure or management system used by the agency to deliver care b. They include the number and categories of nursing personnel, their education, personal and professional qualities and proficiencies, their function, physical abilities and equipment 2. PROCESS STANDARDS a. Refer to decisions and actions of the nurse relative to the nursing process which are necessary to provide good nursing care b. These include assessment, plan of care and nursing intervention 3. OUTCOME STANDARDS a. Are designed to measure the results of care provided in terms of changes in the health status of clients served, changes in the level of their knowledge, skills and attitudes, and satisfaction of those served including the members of the nursing and health team ACTUAL PERFORMANCE MEASUREMENT 1. Is an on-going, repetitive process with the actual frequency dependent on the type of activity being measured. For example, a nursing care to patient is continuously monitored, whereas, a formal performance appraisal may be done only twice a year 2. Measurements may be scheduled in advance, may be done at periodic unannounced intervals or may occur at random. The purpose of measurement should be clarified and the staff should be informed about the tasks and levels of care that need attention. REINFORCING STRENGTHS OR SUCCESSES AND TAKING CORRECTIVE ACTION AS NECESSARY 1. Positive feedback stimulates motivation, consistently high performance and growth of the employee. 2. Corrective actions are applied to improve performance. RESPONSIBILITY OF THE HEAD/SENIOR NURSES 1. Being at the first level of supervision, the Head or Senior Nurses are in the best position to know whether their staff nurses perform satisfactorily at work. Their influence has an impact on promoting quality care to patients. 2. They have the responsibility to instruct subordinates regarding the appropriate methods and procedures in providing nursing care. 3. They should inform the staff of the likely causes of errors or defects and the preventive measures as necessary. 4. They should initiate and/or facilitate any steps as necessary to improve methods, equipment, materials and conditions in the work area for which they are responsible. PERFORMANCE APPRAISAL 1. An effective managerial controlling responsibility is determining how well employees carry out the duties of their assigned jobs. 2. Performance appraisals let employees know the level of their job performance as well as any expectations that the organization may have of them. 3. Performance appraisals also generate information for salary adjustments, promotions, transfers, disciplinary actions and terminations. 4. A control process in which employees performance is evaluated against standards. It is the most valuable tool in controlling human resources and productivity. 5. It reflects how well the nursing personnel have performed during a specific period of time.

PURPOSES OF PERFORMANCE APPRAISAL 1. Determine salary standards and merit increases; 2. Select qualified individuals for promotion or transfer; 3. Identify unsatisfactory employees for demotion or termination; 4. Make inventories of talents within the institution; 5. Determine training and developmental needs of employees; 6. Improve the performance of work groups by examining, improving, correcting interrelationships between members; 7. Improve communication between supervisors and employees and reach an understanding on the objectives of the job; 8. Establish standards of supervisory performance; 9. Discover the aspirations of employees and reconcile these with the goals of the institution; 10. Provide employee recognition for accomplishments; 11. Inform employees where they stand FACTORS CONTRIBUTING TO AN EFFECTIVE PERFORMANCE APPRAISAL SYSTEM 1. The controlling process is used to promote positive and favorable activity. 2. Nurse managers have the responsibility to maintain a favorable climate that will lead to job satisfaction a. Compatibility between the criteria for individual evaluation and organization goals. The elements of the performance evaluation system should have been agreed upon at each level of management. Involvement of personnel at all aspects of the evaluation process increases beliefs in its fairness and accuracy, establishes a commitment to the evaluation and increases motivation to utilize the results for improvement. b. Direct application of the rated performance to performance standards and objectives expected of the worker. Predetermined roles for each member of the health team and the set goals in terms of behavioral objectives and success criteria (job description and procedure manual) should be established c. Development of behavioral expectations which have been mutually agreed upon by both the rater and the worker. Participation in the formulation of goals motivates workers to work toward their accomplishment d. Understanding the process and effective utilization of procedure by the rater. Training in the appraisal process should be provided by the employer through in-service education. e. Concentration on the strengths and weaknesses to improve individual performance. Reinforcement of strengths in performance encourages the worker to further improve. Weaknesses are noted only if these are perceived as threats to safety or if they provide significant deterrents to goal achievement. Encouragement of feedback from the rated employees about their performance needs and interests. The immediate supervisor is better equipped to understand each worker. She does this by observation, questioning and listening. f. Provision for initiating preventive and corrective action and making adjustments to improve performance. The primary goal in the performance of all workers should be to provide quality service to all clients. Performance can be enhanced and maintained at a high level through staff development programs, motivation and self-discipline. METHODS OF MEASURING PERFORMANCE 1. Methods of performance may be done formally or informally 2. Informal appraisal may consist of incidental observation of performance while the worker is engaged in performing nursing care by responses made by worker during conferences 3. Interaction of worker with clients, their families, visitors and co-workers should also be noted. 4. Formal appraisal is accomplished regularly and methodically by collecting objective facts that can demonstrate the difference between what is expected and what was done. a. ESSAY i. The appraiser writes a paragraph or more about the workers strengths, weaknesses and potentials. ii. In most situations, particularly in managerial positions, essay appraisals carry significant weight on the presumption that an honest statement from someone who knows the person well is valid. b. CHECKLISTS i. Is a compilation of all nursing performances expected of a worker. ii. The appraisers task is to mark the appropriate column whether the worker does or does not show the desired behavior. iii. A quick glance at the completed form would reveal the over-all quality of the nurses performance. c. RANKING i. In simple ranking, the evaluator ranks the employees according to how he or she fared with co-workers with respect to certain aspects of performance or qualifications. d. RATING SCALES i. A rating scale includes a series of items representing the different tasks or activities in the nurses job description or the absence or presence of desired behaviors and the extent to which these are possessed. Example: On a scale of 0 to 5, indicate the degree of the nurses skill in assessing the patients condition where each of the corresponding number means: 5 Excellent 4 Very Satisfactory 3 Moderately Satisfactory or Average

2 1 ii.

Minimally Satisfactory Unsatisfactory

A descriptive graphic rating scale may be used to describe punctuality in reporting for duty such as; 1 Oftentimes late 2 Sometimes late 3 Always reports on time

e. FORCED-CHOICE COMPARISON i. The evaluator is asked to choose the statement that best describes the nurse being evaluated. ii. The items are grouped that the evaluator is forced to choose from favorable as well as unfavorable statements and to counter the tendency towards leniency by some evaluators. Example: Select the statement that best describes the nurse being evaluated and the statement that least describes him/her: 1 2 3 4 5 Respects the ideas of others Communication ability limited Even-tempered Capable of enduring long hours of hard work Tends to be a loner

f. SELF-APPRAISALS i. Employees are asked to submit written summaries or PORTFOLIOS of their work-related accomplishments and productivity as part of the self-appraisal process. ii. Portfolios often provide examples of continuing education, professional certifications, awards and recognitions. iii. The portfolio also generally includes the employees goals and action plan for accomplishing these goals. g. MANAGEMENT BY OBJECTIVES (MBOS) i. Is an excellent toll for determining an individual employees progress because it incorporates both the employees assessments as well as the organization. 1. The employee and supervisor meet and agree on the principal duties and responsibilities of the employees job. 2. The employee sets short-term goals and target dates in cooperation with the supervisor or manager. 3. Both parties agree on the criteria that will be used for measuring and evaluating the accomplishment of goals. 4. The employee and supervisor meet regularly to discuss progress. 5. The managers role is supportive, assisting the employee to reach goals by coaching and counseling. 6. During the appraisal process, the manager determines whether the employee has met the goals. 7. The entire process focuses on outcomes and results, and not on personal traits. h. PEER REVIEW i. When peers rather than supervisors carry out monitoring and assessing work performance ii. Provides feedback that can promote growth. iii. It can also provide learning opportunities for the peer reviewers. i. ANECDOTAL RECORDING i. The anectodal record describes the nurses experience with a group or a person, or in validating technical skills and interpersonal relationships. ii. The anecdotal record should include; (1) a description of the particular occasion, (2) a delineation of the behavior noted including answers to the questions who, what, why, when, where and how (3) the evaluators opinion or assessment of the incident of behavior. STRATEGIES TO ENSURE ACCURACY AND FAIRNESS IN THE PERFORMANCE APPRAISAL 1. 2. 3. 4. 5. The appraiser should develop an awareness of his or her own biases and prejudices. Consultation should be sought frequently. Date should be gathered appropriately. Accurate record keeping is another critical part of ensuring accuracy and fairness in the performance appraisal. Collected assessment should contain positive examples of growth and achievement and areas where development is needed. When a nurse does her job well, it can go unnoticed because its expected that shell meet the requirements of her job description. But if she makes a mistake, were sure to let her know about it. 6. Some effort must be made to include the employees own appraisal of his or her work. 7. The appraiser needs to guard against three common pitfalls of assessment: the halo effect, the horns effect, and central tendency. The halo effect occurs when the appraiser lets one or two positive aspects of the assessment or behavior of the employee unduly influence all other aspects of the employees performance. The horn effect occurs when the appraiser allows some negative aspects of the employees performance to influence the assessment to such an extent that other levels of job performance are not accurately recorded. The manager who falls into the central tendency trap is hesitant to risk true assessment and therefore rates all employees as average. These appraiser behaviors lead employees to discount the entire assessment of their work. 8. Reviewers need to safeguard against a bias known as the Matthew Effect. The Matthew Effect is said to occur when employees receive appraisal results, year in and year out. That is, their appraisal results tend to become

self-fulfilling: if they have done well, they will continue to do well; if they have done poorly, they will continue to do poorly. Past appraisals prejudice and employees future attempts to improve. Effective Performance Appraisals Appraisals must be based upon a standard that all employees are held accountable to and this standard must be communicated at the time of hire. Employees must know in advance what happens if standards are not met.

Influenced by the following: Employees must know how information will be obtained to determine performance level. Appraisers should be those who directly supervise the employee. Positive outcomes are more likely if the appraiser is looked upon with trust and professional respect. The employees past experiences with performance appraisals (negative or positive) will affect the outcome. Coaching as Part of the Performance Appraisal Process The effective manager and astute leader are aware that day-to-day feedback regarding performance is one of the best methods for improving work performance and building a team approach. QUALITY ASSURANCE 1. ASSURANCE means achieving a sense of accomplishment and implies a guarantee of excellence. 2. QUALITY is the degree of excellence and assurance means formal guarantee of a degree of excellence. 3. Quality gives people with different functions in the organization a common language for improvement. It enables all people with different priorities and abilities to communicate with each other in pursuit of a common goal. 4. QUALITY OF CARE is the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with the current professional knowledge. It is the balance of benefits and harms to a client, of effectiveness and efficiency and appropriateness of care. Quality exists to the degree that service is efficient, well-executed, effective and appropriate. It meets the customers satisfaction. 5. QUALITY ASSURANCE is a process of evaluation that is applied to the health care system and the provision of health care services by health workers. It promotes collegial and sharing relationships among workers instead of a feeling of threat when observed and evaluated. 6. QUALITY IMPROVEMENT PROGRAM in an organization is the umbrella program that extends the many areas for the purpose of accountability to the consumer and the payor. The program is a continuous, on-going measurement and evaluation process that includes structure, process and outcome. 7. INDICATORS are valid and reliable quantitative measures of structure, process and outcome that are related to one or more dimensions of performance. Clinical indicators related to clients. Indicators may be focused on service, practice or governance. 8. SENTINEL EVENT INDICATORS measure a low-volume but serious undesirable and often avoidable process or outcome such as falls and medication errors. BENCHMARKING is a tool to assist in quality of care decision making. It is a continuous process of measuring what exists against the best in search for industry best practices. 9. TOTAL QUALITY MANAGEMENT (TQM) is a way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service. TOTAL QUALITY MANAGEMENT PRINCIPLES a. Create a constancy of purpose for the improvement of products and service. b. Adopt a philosophy of continual improvement c. Focus on improving processes, not on inspection of product. d. End the practice of rewarding business on price alone; instead, minimize total cost by working with a single supplier e. Constantly improve every process for planning, production and service f. Institute job training and retraining g. Develop the leadership in the organization h. Drive out fear by encouraging employees to participate actively in the process i. Foster interdepartmental cooperation, and break down barriers between department j. Eliminate slogans, exhortations, and targets for the workforce k. Focus on quality and not just quantity; eliminate quota systems if they are in place l. Promote teamwork rather than individual accomplishments. m. Educate/Train employees to maximize personal development n. Charge all employees with carrying out the total quality management package 10. CONTINUOUS QUALITY IMPROVEMENT (CQI) is a process of continuously improving a system by gathering data or performance and using multi-disciplinary team to analyze the system, collect measurements, and propose changes. The four main principles are CUSTOMER FOCUS, THE IDENTIFICATION OF KEY PROCESSES TO IMPROVE QUALITY, THE USE OF QUALITY TOOLS AND STATISTICS, AND THE INVOLVEMENT OF ALL PEOPLE IN PROLEM SOLVING. PRINCIPLES UNDERLYING QUALITY ASSURANCE EFFORTS There are certain principles upon which effective quality assurance programs are based. 1. 2. 3. 4. All health professionals should collaborate in the effort to measure and improve care. Coordination is essential in planning a comprehensive quality assurance program. Resource expenditure for quality assurance activities is appropriate. There should be focus on critical factors such as functions and activities that promise to yield the greatest health and financial benefit to reveal significant findings. 5. Quality patient care is accurately evaluated through adequate documentation.

6. The ability to achieve nursing objectives depends upon the optimal functioning of the entire nursing process and its effective monitoring. 7. Feedback to practitioners is essential to improve practice. It perpetuates good performance and replaces unsatisfactory interventions with more effective methods. 8. Peer pressure provides the impetus to effect prescribed changes based on the results of assessment and needed improvements on the quality of care. 9. Reorganization in the formal organizational structure may be required if assessment reveals the need for a different pattern of health care. 10. Collection and analysis of data should be utilized to motivate remedial action. QUALITY IMPROVEMENT 1. A systematic process to improve outcomes based on customers needs 2. A proactive approach that emphasizes doing the right thing for the customer 3. Became a part of health care in the 1980s when competition as well as pressure from managed care organizations and other payers to reduce cost and improve quality of care increased 4. Is more of an overall management approach rather than a single program

DIFFERENCE BETWEEN QUALITY ASSURANCE AND QUALITY IMPROVEMENT I. FOCUS ON QUALITY ASSURANCE (ALSO CALLED DOING IT RIGHT) a. Assess or measure performance b. Determine whether performance meets standards (goal in manufacturing, for example, is zero defects) c. Improve performance when it does not meet standards FOCUS ON QUALITY IMPROVEMENT (ALSO CALLED DOING THE RIGHT THING) a. Meet the customers needs b. Build quality performance into the work process c. Assess the work process to identify opportunities for improved performance d. Employ a scientific approach to assessment and problem solving e. Improve performance continuously as an ongoing management strategy, not just standards are not met f. Performance integrates processes and outcomes and continually seeks a better way to accomplish desired outcomes

II.

AUDITS AS QUALITY CONTROL TOOL WHEREAS STANDARDS PROVIDE THE YARDSTICK FOR MEASURING QUALITY CARE, AUDITS ARE MEASUREMENT TOOL. 1. An audit is a systematic and official examination of a record, process, culture, environment, or account to evaluate performance. 2. Auditing in health organizations provides managers with a means of applying the control process to determine the quality of services rendered. 3. Auditing can occur retrospectively, concurrently, or prospectively. RETROSPECTIVE AUDITS ARE PERFORMED AFTER THE PATIENT RECEIVES THE SERVICE. CONCURRENT AUDITS ARE PERFORMED WHILETHE PATIENT IS RECEIVING THE SERVICE. PROSPECTIVE AUDITS ATTEMPT TO IDENTIFY HOW FUTURE PERFORMANCE WILL BE AFFECTED BY CURRENT INTERVENTIONS. 4. The audits most frequently used in quality control include the outcome, process and structure audits. OUTCOME MEASURES The end results of medical care. The changes in the patient's health status that can be attributed to the delivery of health care services. What happened to the patient in terms of palliation, control of illness, cure, or rehabilitation. What results (if any) occurred as a result of specific interventions. Examples of outcomes traditionally used to measure quality of hospital care include mortality, morbidity, and length of hospital stay. PROCESS MEASURES Process measures are used to measure the process of care or how the care was carried out. They assume that a relationship exists between the process used by the nurse and the quality of care provided. They tend to be task-oriented and focus on whether practice standards are being fulfilled. Process standards may be documented in patient care plans, procedure manuals, or nursing protocol statements. A process audit might be used to establish whether fetal heart tones or blood pressures were checked according to an established policy. In a community health agency, a process audit could be used to determine if a parent received instruction about a newborn during the first postpartum visit. Critical pathways and standardized clinical guidelines are examples of efforts to standardize the process of care. They also provide a tool to measure deviations from accepted best-practice process standards. Clinical pathways; predetermined courses of progress that patients should be making after admission for a specific diagnosis or a specific surgery. Are one method of planning, assessing, implementing, and evaluating the cost-effectiveness of patient care.

STRUCTURE MEASURES Structure measures assume that a relationship exists between quality care and appropriate structure. Structure measures include resource inputs such as the environment in which health care is delivered. It also includes those elements that exist prior to and separate from the interaction between the client and the healthcare worker. For example, staffing ratios, staffing mix, emergency department wait times, and the availability of fire extinguishers in patient care areas are all structure measures of quality of care. Problem Employees: Rule Breakers, Marginal Employees, and the Chemically or Mentally Impaired 1. Part of the controlling process in management is discipline. In the past, discipline meant rigid obedience to rules and regulations, the violation of which resulted in punitive actions. 2. Today, discipline is regarded as a constructive and effective means by which employees take personal responsibility for their performance and behavior. 3. Two types of employees with special needs: a. Marginal employees are those employees who disrupt unit functioning because the quantity or quality of their work consistently meets only minimal standards. b. Impaired employees refer to employees who are unable to accomplish their work at the expected level as a result of chemical or psychological disease. CONSTRUCTIVE VERSUS DESTRUCTIVE DISCIPLINE 1. 2. 3. 4. 5. Discipline involves training or molding of the mind or character to bring about desired behaviors. Discipline is often considered a punishment but is not the same thing as punishment. Punishment is an undesirable event that follows unacceptable behavior. Although discipline can have negative consequences, it can be powerful motivators for positive change. Moreover, discipline has an educational component as well as a corrective one. Scientific Management theory viewed discipline as a necessary means for controlling an unmotivated and selfcentered workforce. Because of this traditional philosophy, managers primarily focused on eliminating all behaviors that could be considered to conflict with organizational goals. Although this approach may success on a short-term basis, it is usually demotivating and reduces long-term productivity because people will achieve only at the level that they believe is necessary to avoid punishment. Use of threats and fear to control behavior. Employee always alert to impending penalty or termination. Arbitrarily administered and either unfair in the application of rules or the resulting punishment. This approach is destructive because discipline is often arbitrarily administered and is unfair either in the application of rules or in the resulting punishment. A more effective approach being used currently by many businesses encourages employee commitment by showing workers the discrepancy between actual and expected performance and putting the burden on the employee to change. (Encyclopedia of Business 2007) Discipline is called CONSTRUCTIVE DISCIPLINE when it assists employee growth. Helps the employee to grow. Is carried out in a supportive, corrective manner. Employee is reassured that punishment is given because of actions and not because of who he or she is as a person. Primary focus is to assist the employee to behave in a manner that allows him or her to be self-directed in meeting organizational goals. Punishment is frequently inferred when defining discipline, but discipline also can be defined as training, educating or molding. (Latin term DISCIPLINA, which means teaching, learning and growing) In constructive discipline, punishment may be applied for improper behavior, but is carried out in a supportive, corrective manner. Employees are reassured that the punishment given is because of their actions and not because of who they are.

6. 7. 8. 9.

10. 11.

SELF-DISCIPLINE AND GROUP NORMS 1. The highest level and most effective form of discipline is SELF-DISCIPLINE. 2. When employees feel secure, validated and affirmed in their essential worth, identity and integrity, self-discipline is encouraged. Some factors that influence self-discipline are: a. A strong commitment to the vision, philosophy, goals and objectives of the institution. Strong commitment results in cohesion and teamwork which in turn encourage greater conformity to expected norms of conduct within the organization. b. Laws that govern the practice of all professionals and their respective Codes of Conduct. For all government employees, the Civil Service Rules and Regulations as provided for in P.D. 807 and the Code of Conduct for Public Officials, R.A. 6173, are also to be complied with. c. Understanding the rules and regulations of the agency. All employees are oriented on the rules, regulations and policies of the agency. Some organizations give their employees a handbook containing these and the possible sanctions for their infractions. d. An atmosphere of mutual trust and confidence. Self-discipline thrives best in an atmosphere of trust and confidence between superiors and subordinates. e. Pressure from peers and organization. Social pressures from co-workers and the organization demand that workers perform their jobs to the best of their abilities. 3. Ideally, all employees would have adequate self-control and be self-directed in their pursuit of organizational goals; however, this is not always the case. Instead, groupsnorms often influence individual behavior and make self-discipline difficult. 4. Group norms are group-established standards of expected behavior that are enforced by social pressure. 5. The leader, who understands group norms, is able to work within those norms to mold group behavior. This modification of group norms affects individual behavior and thus self-discipline. 6. Although self-discipline is internalized, the leader plays an active role in developing an environment that promotes self-discipline in employees.

7. It is impossible for employees to have self-control if they do not understand the acceptable boundaries for their behavior, nor can they be self-directed if they do not understand what is expected of them. 8. Managers must discuss clearly all written rules and policies with subordinates, explain the rationale for existence of the rules and policies and encourage questions. Strategies to Create an Environment of Self-Discipline 1. 2. 3. 4. Clearly written and communicated rules and regulations. Atmosphere of mutual trust. Judicious use of formal authority. Employee identification with organizational goals.

FAIR AND EFFECTIVE RULES McGregors (1967) Hot Stove Rule Four elements must be present to make discipline as fair and growth-producing as possible: 1. Forewarning a. All employees must be forewarned that if they touch the hot stove (break a rule), they will be burned (punished or disciplined). They must know the rule beforehand and be aware of the punishment. 2. Immediate consequences a. If the person touches the stove (breaks a rule), there will be immediate consequences (getting burned). All discipline should be administered immediately after rules are broken. 3. Consistency a. If the person touches the stove again, he or she will again be burned. therefore, there is consistency; each time the rule is broken, there are immediate and consistent consequences 4. Impartiality a. If any other person touches the stove, he or she will get burned. Discipline must be impartial, and everyone must be treated in the same manner when the rule is broken. DISCIPLINE AS A PROGRESSIVE PROCESS 1. Managers have the formal authority and responsibility to take progressively stronger forms of discipline when employees fail to meet expected standards of achievements. (However, inappropriate discipline (too much or too little) can undermine the morale of the whole team. 2. Discipline is generally administered using a progressive model. 3. Union contracts include provision for disciplinary procedures, which are usually based upon some sort of PROGRESSIVE DISCIPLINE PROCESS. Four Common Steps in Progressive Discipline 1. Informal reprimand or verbal admonishment. a. Includes an informal meeting between the employee and manager to discuss broken rule or performance deficiency. b. The manager suggests ways in which the employees behavior might be altered to keep the rule from being broken again. Often, an informal reprimand is all that is needed for behavior modification. 2. Formal reprimand or written admonishment. a. If rule breaking occurs after verbal admonishment, the manager again meets with the employee and issues a written warning about the behaviors that must be corrected. b. This written warning is very specific about what rules or policies have been violated, the potential consequences, if behavior is not altered to meet organizational expectations, and plan of action that the employee is expected to take to achieve expected change. 3. Suspension from work without pay. a. If the employee continues the undesired behavior despite verbal and written warnings, the manager should remove the employee from his or her job for a brief time, generally a few days to several weeks. b. Such a suspension gives the employee the opportunity to reflect on the behavior and to plan how he or she might modify the behavior in the future.

4. Termination. a. Should always be the last resort when dealing with poor performance. However, if the manager has given repeated warnings and rule breaking or policy violations continue, then the employee should be dismissed. b. Although this is difficult and traumatic for the employee, the manager, and the unit, the cost in terms of managerial and employee time and unit morale of keeping such an employee is enormous. The Disciplinary Conference 1. State problem clearly. 2. Ask employee why there has been no improvement. 3. Explain disciplinary action to be taken. 4. Describe expected behavioral change. 5. Get agreement and acceptance of the plan. The Termination Conference 1. State the facts of the case and the reason for termination. The manager must not appear angry or defensive. Although managers may express that the outcome is termination of employment, they must not dwell on this or give the employee reason to think that the decision is not final. The manager should be prepared to give examples of the behavior in question. 2. Explain the termination process. State the date on which employment is terminated as well as the employees and organizations role in the process 3. Ask for employee input and respond calmly and openly. Termination conferences are always tense; raw, spontaneous emotional reactions into his or her anger or sorrow. Always stay focused on the facts of the case and attempt to respond without reacting.

4. End the meeting on a positive note, if possible. The manager should also inform the employee, what if any references, will be supplied to prospective employers. Finally, it is usually best to allow the employee who has been dismissed to leave the organization immediately. If the employee continues to work on the unit after dismissal has been discussed, it can be demoralizing for all the employees who work on that unit. Rule Breaking Most common reason for discipline. If rule is consistently broken, need to ask: 1) Whose rule is it? 2) Do we still need the rule?

Think back to rule breakers you have known Were they a majority or minority in the group? How great was their impact on group behavior? What characteristics did they have in common? Did the group modify the rule breakers behavior or did the rule breaker modify the groups behavior?

The Formal Grievance Process A grievance is essentially a statement of wrongdoing. The steps of the formal grievance process are generally outlined in union contract or administrative policies. Generally entails progressive lodging of complaints up the chain of command. If differences not settled in formal grievance, it generally proceeds to arbitration. Rights and Responsibilities in Grievance Resolution Both parties have rights and concomitant responsibilities to be heard and to listen. Employee has right to a positive work environment, but also a responsibility to express discontent responsibly. Manager has a right to expect employee to follow the rules, but must make sure employees know and understand the rules.

Performance Deficiency Coaching May be ongoing or problem-centered. Manager actively brings areas of unacceptable behavior or performance to the attention of the employee and works with him or her to establish a plan to correct deficiencies. Marginal Employees These employees disrupt unit functioning because the quantity or quality of their work consistently meets only minimal standards. These employees often make tremendous efforts to meet competencies, yet usually manage to meet only minimal standards at best. Traditional discipline is generally not constructive in modifying their behavior. Substance misuse is defined by Lillibridge et al. (2002) as maladaptive patterns of psychoactive substance abuse indicated by continued use even when faced with recurrent occupational, social, psychological, or physical problems as well as/or use in dangerous situations. Incidence of Chemical Impairment in Nursing The chemical impairment rate of health professionals is generally acknowledged as being greater than that of the general public. The majority of disciplinary actions by licensing boards are related to misconduct resulting from chemical impairment, including the misappropriation of drugs for personal use and the sale of drugs and drug paraphernalia to support the nurses addiction (Cherry & Jacob, 2002). Chemicals Most Commonly Abused by Nurses Demerol opioid analgesic Oxycodone opioid analgesic Oxycontin opioid analgesic (Brand Name) Vicodin Brand Name/ Hydrocodone Generic Opioid Analgesic/ Antitussive Alcohol

Confronting the Chemically Impaired Employee Gather as much evidence as possible of employees impairment. Immediate confrontation is necessary if manager suspects employee may be impaired and thus poses a risk to clients. Denial of the impairment or use of defense mechanisms should be expected from the employee. The manager should not try to nurture or assume the role of counselor to the employee. Others are more qualified to assume this role. The manager must be very careful not to assume the role of counselor or treatment provider for the impaired nurse. Others who have greater expertise and objectivity should assume this role.