Professional Adjustment Levels of Nursing Professionals

Professionalism Theoretical basis: Patricia Benner’s Levels of Skills Acquisition (Novice to

 Holistic process of growth and development of an individual Expert) – claims that experience is the best teacher; higher the level of
towards achieving a professional status experience = higher level of professionalism
 First stage or point of entry: EDUCATION
 A process of maturation – able to discern right from wrong and 5 Levels of Skills Acquisition (NACPE)
make decisions Novice No professional experience yet; a rule-bound
practitioner; no initiative and inflexible; full supervision
Who is a professional? needed since nurse is prone to mistakes; “tell me what
Sims, Price & Ervin (2000) Criterion to be a Professional (ABALACA) to do and I’ll do it”.
 Autonomy – the most important characteristic. Includes self- Shadowing – following an expert or competent nurse
determination, self-decision making, self-regulation, able to with higher experience
perform independent functions Ex: fresh graduates, newly oriented nurses, neophyte
 Body of knowledge – utilizes the scientific method through nurse
experimentation and research. Begins with a problem  Advanced 1st year at work; with marginally acceptable
hypothesis  data gathering  experiment  results  Beginner performance; a mediocre or average practitioner; with
conclusions little experience; practices with less supervision
 Academic level of achievement – with a college degree Competent 2-3 years at work; may start assuming positions Ex:
 Long-term commitment – loyalty and fidelity to the profession; from staff nurse to head nurse or unit manager;
promise-keeping independent practitioner practices without any
 Association – a group of people with a common goal supervision; “I can do things on my own now”
 Code of ethics – source of guidance for ethical dilemmas Proficient With 3-5 years of experience; holistic practitioner that
 Altruism – selflessness via service; to discipline oneself which is a considers all aspects of care; delivers comprehensive
mark of a professional approach; able to discern and prioritize; “sees the big
*ALL REQUIREMENTS MUST BE MET TO BE A PROFESSIONAL picture”
Occupation – without a college degree Expert More than 5 years at work; a fluid practitioner; flexible
and intuitive; with an air of arrogance BUT DASURV; “I
Is the nurse a professional? did it because it felt right”
 Autonomy – independent nursing actions; with RA 9173, Article 6 Ex: Chief nurse - requires 5 years of experience as a unit
which states the scope of practice: collaborative role in the manager and a master’s degree. Mentors – teach to
health-care team and independent practitioner share knowledge to make students a better version of
 Scientific – use of the nursing process (ADPIE) which was themselves. Includes dean and chairperson positions
established by Lydia Hall *Transfer to a new department or unit will mean return to the novice stage p
 College degree is required to be a registered nurse.
o CHED - regulates the nursing curriculum and able to Route to RN in the Philippines
open or close nursing programs 3 basic requirements:
 Loyalty – with the Nightingale Pledge for oath-taking. License as 1. Physically and mentally fit or competent
proof of loyalty to the professions 2. BSN Degree – bachelor or baccalaureate degree with a duration of 4
 Association – Philippine Nurses Association (PNA) established in years and 8 semesters. Purpose is to instill preparation for a profession
1922 founded by Anastacia Giron Tupas by learning.
 Code of Ethics – BON Resolution # 220 series of 2004
 Altruism – nursing care offered to patients which should be Core values of nursing education:
patient-centered a. Love of God
b. Love of country
Negative images of nursing portrayed in the media: which gives doubt on c. Love of people
the nurse as a professional d. Caring – foundation of nursing profession
 Handmaiden image – seen as a helper or maid; seen as assistant
of the physician; unable to function unless there is a physician’s Head of nursing education – DEAN. Qualifications include:
order. Affects autonomy criteria of professionalism  Registered Nurse
 Angel of mercy – looked upon as sources of miracles; affects being  Master of Arts in Nursing (MAN) – with thesis; oriented in
scientific. Miracles and science are two worlds apart jawards administration. Note: MSN is more oriented in research (not
 Naughty nurse – sexualized, bordering pornographic image of the qualified for dean’s position)
nurse. Affects code of ethics criteria  With 5 years of teaching experience in the academe
 Collective bargaining – “hangyo”; negotiation between employer  A member of the PNA
and employee. When employee conditions are not met (wages,  Good moral character – absence of conflict of interest
workload, working conditions), a strike may happen (fighting for Implementers of BSN program: FACULTY
ourselves). Affects altruism criteria – can be misinterpreted as  General Education – minor subjects that are not directly related to
selfishness the profession; mandatory by law (ex: Life and Works of Rizal)
 Professional Education – major subjects directly related to the
To improve the image of nursing: (EPAL) profession
 Educate the public that we are professionals, especially when you Qualifications:
have a platform  RN + Master’s Degree (MAN, MSN, MPH, MBA, PhD in Philosophy)
 Participate in public activities that show nursing as a profession –  At least 1 year of clinical experience
activities of the PNA. October is the official month of nursing in  A member of the PNA
the Philippines declared by Pres. Gloria Macapagal Arroyo  Good moral character
 Advocate for laws that support the welfare of the nursing
profession 3. License – a privilege bestowed upon an individual granted by the state as
o Congress – legislative department that creates laws. represented by the government (PRC)
Congressmen and senators vote to register an act.  Purpose: to protect the public from malpractice
 Lobby for laws that support nursing practice and for better  Can be revoked when there are violations to the law
working conditions  Lifetime validity; does not expire. License ID expires and needs to
be renewed and updated every 3 years.
Procurement of license: president of the Phils.
1. Citizen or Dual Citizen – pass the NLE; 75% passing rate with no  1 term = 3 years. Term can be extended for up to 2 terms
grade lower than 60%. only (6 years)
2. Foreigner – priority check: should have reciprocity based on the
principle of “do ut des” or mutual granting of opportunities. Can Powers of the BON:
apply for 2 types of licenses: 1. Executive – creates board exams
a. Temporary License – given by BON; no NLE needed but 2. Quasi-legislative – creates resolutions. Ex: requirements for
with specific amount of time to practice. Should be and board exam
RN in his/her own nation before application of 3. Quasi-judiciary – issue subpoenas (a summon from the
temporary license. Ex: medical missions, volunteer court), hold court trials, hold litigation process
work, exchange programs
b. Permanent License – acquire for Filipino citizenship 2 types of subpoenas:
FIRST to take and pass the NLE. 3 ways to be a Filipino 1. Duces tecum – to bring documentary evidence in court
citizen: 2. Ad testificandum – called to be a witness and testify in court.
 “jus soli” - by place of birth Priority: state the truth
 “jus saguini” – by blood; parent/s are
Filipinos  3 - # of years of validity of PRC ID
 Naturalization – give up foreign passport to
DFA and be a resident for 10 consecutive Identification Card Certificate of Registration
years in the Philippines.  Card form which is carried  A paper document for
anywhere. safekeeping. Request for 2
Nursing Law (RA 9173)  With logo of the PRC. copies.
 RA 9173 - Philippine Nursing Act of 2002  With signature of PRC  Indicates NLE grade. Needed
 RA 7164 – previous nursing act chairperson for job application
 Non-transferable  With seal of the PRC.
Legislative track:  Validity: 3 years during the  With signatures of officials of
 Must have at least 2 versions of the bill before signed into law birthday of applicant BON.
o Upper house – senate. Authored by Hon. Sen. Juan Flavier,  Validity: no expiration date
also a previous DOH secretary. Campaigns: HIV program and
iodized salt Violations which lead to revocation of license:
o Lower house – house of representative (representatives of  Gross negligence and malpractice
districts and party lists). Authored by Rep. Carlos Padilla  Fraud– ex: falsification of ID, signature (forgery), identity and
o Signed into law/ratification by Pres. Gloria Macapagal educational attainment (misrepresentation). Possible criminal
Arroyo charges may apply for fraudulence.
 Acts of moral turpitude – should be a guilty criminal (ex: murder,
BON Resolution No. 425 Series of 2003 – implementing rules and regulations arson)
of RA 9173  Practicing while under suspension

RA 7164 RA 9173 Return of revoked license:

 BON: 5 members, no chair  BON: 1 chairperson with 6  4 years has passed since revocation
 BSN: college applicant must members  reason for revocation has been resolved.
be part of upper 40% of  BSN: no requirement if high  Note: NOT all licenses can be returned, it will depend on the
graduating high school class school graduate reason for revocation. Ex: murder – reclusion perpetua or lifetime
 NLE: limited to 3 takes only.  NLE: no limit to NLE imprisonment
Refresher course (1 semester) attempts, no refresher
is required for 4th attempt. course needed Ethics
 About moral philosophy, the study of norms, standards, rules, and
* RA 9173 is more lenient since 2002 was the boom era of nursing due to the principles to help determine right from wrong
increased demand for nurses all over the world  A source of guidance rather than a solution itself

Salient Features of RA 9173: Morals vs Ethics

 9 - # of units in masters required to be a nurse manager. Not  Morals – depends upon individual or specific beliefs, culture, and
necessary to finish your master’s degree. This is reflected in the religion
clinical ladder (hierarchy of positions in nursing)  Ethics – depends upon societal or general beliefs

Clinical Ladder Metaparadigms of Ethics

Staff nurse 9 units of master’s degree + 2 1. Metaethics – study of the origin of words or terms. Provides
years of experience to upgrade to vocabularies and establish its definitions.
unit manager 2. Normative ethics – establishment of ethical principles; what is
Unit manager or head nurse upgrade depends upon facility normal, standard, fundamental; should be followed
Supervisor not present in all institutions 3. Applied ethics – application of the ethical principles into real life
Chief nurse or Nurse VII with MAN and 5 years of situation
managerial experience Ex:
 Meta: truth - what is right; a fact
 1 - # of accredited professional nursing organization (PNA).  Norm: veracity – principle of truth-telling
Membership is not mandatory but is compulsory for practice.  Applied: patient had Western blot test and results were positive.
 7 – # of officials in the BON (members + chairperson) Principle of veracity is applied when the nurse tells the real
diagnosis
Board of Nursing
 AKA “alter ego of the president” when it comes to nursing Branches of Ethics: (according to application)
issues in the country 4. Bioethics – application principles concerning issues about life
 Members are nominated by the PNA and appointed by the
 5. Healthcare ethics – application of principles concerning human 2. Consent proper – asking for permission
healthcare  Consent – permission from an adult
6. Nursing ethics – application into nursing care  Assent – permission from a pediatric client/minor
7. Descriptive ethics – a bottom-up approach wherein society *In acquiring consent for a pediatric px, consent is more
defines what is ethical via applications (applied ethics  important
normative ethics  metaethics). There should be caution in Ex:
applying this method. Ex: homosexuality  MCN = In a vasectomy or BTL for a married person, the couple
should BOTH sign the consent. If not married, whoever goes
Common Ethical Issues through the procedure signs the consent.
Ethical Issue Bioethics Healthcare Nursing  Psych = For voluntary admission, the patient signs the consent.
Abortion of fetus Yes Yes Yes For involuntary admissions, the guardian signs the consent. DAMA
Animal cruelty Yes No No is only applicable for voluntary admissions.
Medical Malpractice Yes Yes No  Research = A participant can withdraw from the study even if they
*All nursing issues are healthcare issues. But not all healthcare issues are have signed the informed consent. Priority action when a
nursing issues. participant withdraws is to respect the patient’s right to refuse.
*All healthcare issues are bioethical issues. But not all bioethical issues are o Attrition – decreased amount of data due to the
healthcare issues withdrawal of a participant from the study
 CHN = Courtesy call during the entry phase is a form of consent.
Two Methods of Applying Ethical Principles:
Teleological Method Deontological Method Veracity
 “telos” – results. The ends will  The action/means itself will  Principle of truth-telling or honesty (an attitude). It is the patient’s
justify the means make the nurse ethical basic right to know the truth.
 Action is ethical based on the regardless of the results  Violation: Lying. Types include:
results regardless of the means  The means will justify the ends o Intentional lying – purposeful lying despite knowing
to achieve it  Proponent: Immanuel Kant the truth
 Proponent: Aristotle  Idealisms: o Incomplete information – the truth should always be
 Idealisms:  Kantianism whole
 Consequentialism  Principalism o Lying by omission – lying by not saying anything about
 Utilitarianism Ex: Emergency triage, Catholic the truth despite knowing the truth
Ex: Robin Hood, placebo effect to church  In the case when family requests that patient will not be informed
maintain internal validity of health information for their benefits, the nurse can participate.
Nurse applies both methods since patient care is DYNAMIC. Nurse can withdraw from patient-care if they cannot tolerate
lying for the benefit of the patient.
Ethical Principles:
Autonomy Confidentiality
 Self-determination and self-regulation; ability to decide on one’s  The principle of honoring privacy
own without coercion  All individuals have a right to privacy
 Foundation: respect for human rights which universal. Article 3 -  Confidentiality transcends death
Bill of Rights found in the Philippine Constitution  Avoid talking about patient data in public areas.
 Autonomy is subjective to:
1. Age Two types of privacy:
o Age of majority - > 18 y/o 1. Solitude – right to be alone. In the case of invasion of privacy,
o Age of minority - < 18 y/o; with the right to decide apologize first.
o Legal basis: RA 6809 – Emancipation Law 2. Data privacy – right to secrecy of personal information to keep the
o Minors can decide when they are emancipated (minors patient safe
who are orphaned, pregnant, marriage)
2. Mental capacity Beneficence and Non-maleficence
 Diminished capacity - cannot decide for their own  “Twin sisters” of ethics
Beneficence Non-maleficence
Advanced Directives – preserves autonomy; instructions made in advance  To do good  Do no harm
about health care and are implemented once patient is unable to decide on  Priority: client’s best interest  Priority: safety of the patient
his own. This is recommended for all people, not only those who are Examples:
terminally ill or dying. Includes: 1. Nurse instructs patient with COPD to stop smoking – NON-
 Living Will MALEFICENCE since smoking is harmful to the patient
 Durable Power of Attorney – person appointed by the patient to 2. Vaccines outweigh the risks by its benefits – BENEFICENCE
decide on their behalf
 DNR – reversible do not resuscitate order which expires within 24 Restraints – object given to the client to prevent movement of a body part or
hours; but can be requested to have it permanent. Doctor the entire body which can only be used upon a standing order of the
discusses DNR order with patient. physician. Order expires within 24 hours. Types:
1. Physical – siderails (prevents ambulation). Complication: impaired
Informed Consent skin integrity. Prevent this by releasing the restraint q2h for 30
 Obtaining permission from a client by means of explanation about mins per extremity
a certain procedure 2. Chemical – sedatives and major tranquilizers. Complications: falls.
 Applicable in all fields of nursing. Nurses CAN obtain informed Prevent by assisting when ambulating. Anticholinergic effects
consent include (BUCO PANDAN):
2 parts in obtaining informed consent:  Blurred vision
1. Full disclosure - elements include:  Urinary retention
 Purpose  Constipation
 Methods  Orthostatic hypotension
 Benefits  Photosensitivity
 Risks and Complications  Amnesia – temporary
 Right to refuse  Dryness of mouth
  Ataxia under your direct care. If partner asks, tell them to ask
 Nighttime disturbance of sleep – insomnia the patient themselves (lying by omission). Violates
veracity
Justice
 Principle of fairness and equality HIV diagnostic test: Western Blot
 Fair distribution of burdens and opportunities which is usually HIV Screening test: ELISA (at least 2 tests)
tested when there is scarcity of resources Mode of transmission: sex and body fluids (except saliva)
 Violation: discrimination (prejudice or a pre-formed notion) or AIDS Dx: CD4 test (< 200 cells) with at least 2 opportunistic infections
bias. Ex: sexism or bigotry, racism, ageism
 Justice vs Beneficence
o Organ Donation (RA 7170) – scarcity of resources leads to
Fidelity unfair distribution of organs (violates justice). donation process
 Principle of loyalty and keeping true to one’s oath should involve 2 teams:
 Nurse’s oath – Nightingale’s Pledge. No oathtaking, no initial  Donor – either live or cadaver. Donation should not lead to
registration the disability of the live donor. Most common donated
 Violation: client abandonment organ: KIDNEY. Most common donated tissue: BLOOD.
Examples:  Recipient – either willed or non-willed (waiting list)
 Client advocacy – speak and act on their behalf, especially the
most vulnerable ones (e.g., referring the patient to social workers,  Veracity vs Beneficence
NGOs, or foundations when unable to pay). o Placebo effect in research – to maintain internal validity; giving
a false medication or telling a lie to the patient to find a cure
Solidarity or answer
 “solid” – being united; the principle of unity
 Collaboration and teamwork results to something good Steps in Solving Ethical Dilemmas: (Follow Nursing Process)
1. Assess the situation and gather data about the dilemma.
Totality 2. Diagnosis – identify the problem and establish the dilemma
 Principle of preserving human dignity by keeping the physical (which principles are at conflict)
body parts together 3. Planning – perform values clarification (self-awareness)
 Prioritize the good of the entire person including physical a. Choose the value that you resonate with
psychological, and spiritual factors b. Cherish the value
 Also applies to elimination of a diseased body part to preserve the c. Act based on the chosen value
whole (e.g., amputation) 4. Intervention – recommend action
5. Evaluate if the action solves the dilemma
Stewardship
 Principle of caretaking (supervision or assistance); taking good Other Resources to Solve Ethical Dilemmas (Counseling):
care of God’s creations  Immediate superior
 Related to:  Ethics committee – last resort; refer problems that are
o Beneficence complicated. Also involved in research as the institutional review
o Non-maleficence board by evaluating research proposals for approval
o Fidelity
Jurisprudence
Ethical Dilemma Law – rule of the land as mandated by the state; policies or norms set to
 A problem/situation wherein ethical principles in conflict with keep the peace and order in a jurisdiction
each other; a universal experience Jurisdiction – a particular place where a particular law is implemented
 Nurse is torn between two or more ethical principles or beliefs
(intrapersonal conflict) Why do nurses study the law?
 No clear solution but requires a choice between two principles.  Ignorantia legis neminem excusat – ignorance of the law excuses
Outcome scenario is WIN-LOSE. no one; leniency can lead to violations
 To protect the patient’s rights
Examples of ethical dilemmas:  To protect the self from injustice
 Autonomy vs Beneficence
o Medical Paternalism – “behaving like a parent”; results to Classifications of Law
coercion in terms of decision-making for medical A. According to Source:
procedures; pressuring the patient to choose the nurse’s Divine Human
preferred choice (violates client’s autonomy)  From an omnipotent and  Created by legislators to
omniscient being (all keep peace and order
 Beneficence and Non-maleficence knowing, all powerful)  “statutes” – pieces of
o Euthanasia – mercy-killing. Violates  “Mandate of the heavens” legislation
 Active euthanasia – deliberate ending of patient’s life.  Supreme source of laws
Patient is functional but with a terminal condition. Ex:
assisted suicide with high doses of sedatives (Dignitas
in Switzerland)
 Passive euthanasia – dies a natural death by not B. According to Statutes (ranked)
performing any life-saving measures. Ex: DNR, 1. Constitutional Law – highest form of law in the land. All
removing patient from life-support machines other laws are based on the constitutional stipulations
o Therapeutic Abortion – for cases of ectopic pregnancies (abortion and divorce are not supported in the Philippine
(teleological method) constitution). Changing the constitution will require 2/3 vote
from the senate and president’s confirmation
 Veracity vs Confidentiality 2. Statutory/Regulatory/Legislative – all republic acts (ex: RA
o HIV diagnosis – right to keep the diagnosis confidential 9173)
but sex partners should be aware of the diagnosis 3. Administrative – with local or exclusive clout; small
Follow the patient’s confidentiality since they are coverage. Ex: Administrative order 2009-0025 – Unang
Yakap campaign, city ordinances
 Preponderance of Evidence for Civil Liability: (4Ds)
C. According to Relationships Governed/Application 1. Duty – under the scope of practice
2. Dereliction or breach of duty – neglect, failure to act, breach of
Civil Law Criminal standards
 Involves private relationships  Public relationship with the 3. Damage – physical, emotional, mental injury, harm, or death
with another individual or state as represented by the 4. Direct causation or proximation – direct relationship of dereliction
group government (involves the and damage
 Nurse-patient, nurse-peer society)
relationships  People of the Republic of the Ex: A nurse administers Propofol (anesthetic) instead of Propranolol (beta
 Civil Code: RA 386 Philippines vs Criminal (public blocker) which results to comatose.
enemy)  Duty = rights of drug administrations
 Revised Penal Code: RA 3715  Dereliction = failure to give the right drug
Tort – civil violation. Evidence Crime – violation of the criminal  Damage = comatose condition
required: Preponderance of law. Evidence required: Proof  Direct causation = administration of Propofol results to comatose
evidence – burden of proof; beyond reasonable doubt condition of the patient
greater weight of evidence is Ex: Murder – death  Therefore, nurse is guilty of MALPRACTICE.
more likely than not to have
Ex: A nurse administers Vit C instead of Vit D. No untoward effects happened.
occurred.
Both can be grounds for revocation of license, but criminal violations  Duty = rights of drug administrations
has severe consequences.  Dereliction = failure to give the right drug
 Damage = NONE
Civil Law Violations  Direct causation = No damage but mistake has been made.
Intentional Unintentional  Therefore, nurse is NOT GUILTY but has to make an incident
 with evil, malicious intent  without evil intent but results report within 24 hours from the period of the event and
 “dolo” – deceit to harm submitted to the supervisor (private document). Do not put in the
 With heavier consequences;  “culpa” - fault chart that IR has been written. Do not place a copy of the IR in the
may be a criminal act chart. IR can be used for research for quality improvement.
Types of Intentional Torts:
Respondeat superior – superior is liable to the action of the subordinate.
1. Assault – an actual threat that results to anxiety; either verbal or
Grounds include:
non-verbal. Ex: “If” statements, cussing, body language, insulting
 Culba in eligiendo – fault in delegation
gestures
 Culba in vigilando – fault in supervision
2. Battery – actual physical contact without consent resulting to harm.
Liability: vicarious liability – more than one person is liable for the breach of
Ex: CPR on a DNR patient, blood transfusion on Jehovah’s witness (in
duty.
emergency, exercise protocol by verifying identity first then
document). Prevention: Ask for consent!! Ex: Operating Room = Surgeon as captain of the ship doctrine. When one of
3. False imprisonment – a form of battery wherein restraints and the members of the OR team commits a mistake (e.g., instrument or sponge
isolation procedures result to harm. Ex: restraints without order left in the body cavity), the captain is also held liable.
(most common). Prevention: always check order and its validity (24
hrs) Res ipsa loquitor – “the thing speaks for itself”; evidence speaks for itself
4. Illegal Detention – unlawful non-discharging of a patient despite
signing appropriate forms (ex: promissory note, DAMA). A violation Force majeure – natural occurrences that are beyond one’s control
to the right of habeas corpus (right to lawful admission and
detention in the hospital) Borrowed servant doctrine – employer is held liable for acts of a temporary
5. Oral Defamation or Slander–malicious intent of destroying one’s employee
reputation (what people think you are). Requires witnesses to the
act. Criminal Law Violations
6. Published/Written Defamation or Libel – requires published  Crime – violation of the law of the land which destroys
evidence of calumny (ex: broadcasted interviews, posts, relationships with the state (criminal = enemy of the state)
7. Invasion of Privacy
2 Basic Elements of a Crime:
8. Fraud
1. Mens rhea – criminal intent; a dangerous mind
2. Actus reus – the criminal act
*both should be present for it to be considered a crime. You cannot sue for a
criminal intent alone.
Types of Unintentional Torts:
3 Degrees of a Crime
Negligence Malpractice
Degrees Mens rhea Actus reus
 Carelessness  professional violation; breach
Consummated Present and Successful and Heaviest
 Failure of a nurse to act in the in professional duty
fulfilled executed punishment
same manner a  overstepping beyond one’s job
given
prudent/careful nurse would description resulting to injury,
Frustrated Present Executed but
do, resulting to damages or harm, or death
unsuccessful (I
injury  exclusive to professionals
did my best, but
 can happen to anyone (ex: (nurses, physicians)
it wasn’t enough

☹ = frustration)
nursing aid, UAP)  legal context: the name of the
 legal context: wrongful act or lawsuit
failure to act
Attempted Present but Unsuccessful and Least
Ex:
unfulfilled stopped punishment
 Giving a wrong medication. The act itself is negligence. When
Ex:
patient files a lawsuit, it is called professional malpractice – since
 Homicide – murder without intent to kill
it is the direct fault of the nurse
 Parricide – murder of a family member
 Failure to report a possible case of sexual abuse -Negligence since
 Infanticide – murder of an at least 3-day old newborn
the abuse is not the direct fault of the nurse
  Abortion – murder of a fetus; worst form of killing since the victim 2 main sources of power:
is defenseless 1. Positional – derived from politics and hierarchy. Higher position =
 Arson – intentional burning of property higher power
 Robbery – stealing with force (holdup with a gun to the head) 2. Personal – derived from possession of a unique set of talents and
 Theft – stealing without force; lack of or late awareness skills; indispensable source; may assume the role of a consultant
 Burglary – breaking into a property; can be both theft and robbery
 Simulation of birth – switching the identity of infants 5 types of power:
 Rape – RA 8353 (Anti-rape Law). With 3 elements: no consent, 1. Legitimate power – authoritative power of those who are in
carnal knowledge (criminal intent), penetration or attempt to position/rank (ex: chief nurse, head nurse, chairperson, dean)
penetrate an orifice (actus reus) 2. Expert power – with unique skills, knowledge, and attitudes. Best
o Statutory rape – consensual rape with a minor role: mentor
3. Reward power – ability to give people’s wants and needs. Ex:
o Marital rape – rape between couples. 3 attempts of
giving of salaries and promotion
refusal to engage in sexual activity = RAPE
4. Coercive power – derived from fear. When people are afraid, they
o 3 degrees of rape: consummated (with penetration),
are on their best behavior (follows you). Should be limited and
attempted (no penetration)
used only on delinquent staff members. Wrong motivation for
o Grave Coercion – rape of a male without penetration
staff to do good.
o Incestuous rape – worst form; rape by a family
5. Referent power – derived from being associated with someone
member powerful, power from connections. Ex: joining powerful
organizations. Negative use: backer system
Conspiracy of a Crime – 3 characters:
1. Principal – mastermind; with primary gain if crime is committed. 3 levels of skills required to be a leader:
Receives highest form of punishments 1. Technical skills – most basic element; ability to perform
2. Accomplice – partner in crime procedure innate in the organization
3. Accessory – hides or destroys the body of evidence 2. Conceptual skills – ability to create systems and approaches that
improve services. Includes planning, project ideas, strategies
Circumstances affecting Criminal Liability (JEMA)
3. Interpersonal skills – ability to interact well with people
1. Justifying circumstance – to rationalize the criminal act. Case will
be dissolved. Ex: self-defense, defense, or protection of the
Styles of Leadership
patient
3 styles according to Kurt Lewin in Contingency Theory:
2. Exempting circumstance – absence of criminal intent. Ex: too
young (< 9 y/o; considered juvenile delinquency) and too old (<70 Autocratic  Dictatorial or authoritative
y/o; like Juan Ponce Enrile), diminished capacity (mentally  Main activity: leader alone performs decision making;
ill/psychotic) with high control
3. Mitigating circumstance – reduced amount of punishment. Ex:  Staff’s degree of freedom is low to nonexistent
ages 9-18 y/o, crimes d/t obfuscation resulting from passion  Responsibility assumed by the leader only
(crime of passion)  Output quantity is high. Faster decision = faster output
4. Aggravating circumstances – heightened amount of punishment.  Output quality is good or average (one idea only)
Ex: crime performed at night since most victims are vulnerable,  Best used in times of crisis (emergency or disasters).
crime performed during a disaster or in a place of worship Used in high-risk areas (ER, OR, ICU, PACU)
o Crisis – cry for help; coping mechanisms are not
Process of Litigation – holding a court trial functional anymore
Plaintiff or Complainant Defendant or Accused Democratic  Participative or consultative
 On the side of the  On the side of the defense  Leader with the group performs decision-making
prosecution  Named in the lawsuit and through consultation, with medium control
 Files the lawsuit accused of a tort or crime  Staff’s degree of freedom is moderate
 Tort case: Individual  Responsibility assumed by the leader and the group
 Crime: State  Output quantity is lesser since consultation takes time
 With the burden of proof  Output quality is better d/t consultation from the
(evidence) since they filed the group (brainstorming of leader and group)
case  Best used in stable situations – with time to think and
consult. Used in the ward
Steps of Litigation: Laissez Faire  “let others do” or lazy leadership, ultra-liberal style
1. Filing of a lawsuit. Ex: blotter in the barangay  police (crime) or  Allows others to decide, with low control
municipal trial court (civil)  Staff’s degree of freedom is high
2. Summons (civil) or warrant (crime)  Responsibility assumed by the group or no one
3. Pre-trial – lawyers represent the plaintiff and defendant. Case can  Output quantity and quality are variable – depends on
be dismissed if plaintiff settles with money (civil). If it is a crime, the characteristics of the staff
bail can be done.  Best used with competent to expert staff
4. Trial proper in court (professionally mature and motivated) members.
5. Verdict – final decision of the judge or arbiter. No jury system in Dangerous to use in novice or beginner staff.
the Philippines. Can file for an appeal if conditions are *leader must be able to adjust the style of leadership depending on the
appropriate. situation
Leadership and Management Leader vs Manager
Concept of Leadership
 A learned behavior: a form of role modelling to inspire people to LEADER MANAGER
be better versions of themselves
 May or may not have a  Position is required. Source of
2 elements to be a leader: position. Source of power is power is positional
1. Influence – ability to make people follow personal  Output-oriented: disciplinarian,
2. Power – ability to influence people despite their resistance, with  More people-oriented: has control, successful
authority and position inspirational, charismatic (“may  Sticks to the plan; stays within
dating”; can be subjective) the box
Concept of Power  A risk taker – takes chances on  A bureaucrat, planner
 people; thinks outside the box  deciding in advance: what to do, who will do it, how to do it
Nurses in position should be both leaders and managers.  a plan not put into action is useless

2 Types of Planning:
Management Strategic Operational
 A process of getting the cooperation of a group of people to  Purpose: to provide direction  To guide daily activities
achieve a common goal. Required to have an organization; “no  Top level managers are  Low level managers are
man is an island” involved (administrative involved (patient care)
 Most popular theory: General Administrative Theory by Henry functions)  Time frame: < 1 year
Fayol  Time frame: long term planning  Activities: inventory, rotation,
(> 1 year). Done at least once a or scheduling of duties,
3 Levels of Nursing Management: year, either during January or
1. Top level – chief nurse or deans; involved in decision making, December
planning, and setting objectives  Activities: planning hierarchy
2. Middle level – supervisors; removable in some institutions (flat  Should be planned FIRST to
organization); involved in departmental planning and guide operational planning
interdisciplinary problem solving
3. Lower level – head nurse or unit managers; day-to-day planning Steps in Strategic Planning: (use nursing process)
1. Assess the status quo of the organization. Use the SWOT
Principles of Management
technique:
*should be present so that management process is successful
1. Unity of command – one source of instruction. Multiple sources (+) Factors (-) Factors
of instruction can be confusing. Ex: one chief nurse in the hospital
Internal Strengths Weakness
2. Unity of direction - one common goal. Reflected in the
External Opportunities Threats
institution’s mission, vision, and goals
*can also be used for people or staff
3. Subordination – being under a superior to work towards a
common goal, a form of altruism (putting orders of manager 2. Establish/diagnose priorities according to the SWOT findings.
before your own)  Promote strengths
4. Esprit de corps – teamwork; pride in belonging to one’s group
 Eliminate weakness
5. Initiative – ability to start a task automatically
 Exploit opportunities
6. Authority – right to command; not applicable to everyone. Overall
 Remove threats
authority = top level management (chief nurse)
3. Perform planning hierarchy – a set of statements that provide
7. Order – proper chronology or sequence of tasks; being
direction
systematic. Best basis = nursing process
 Mission – a broad statement of action; the reason why the
8. Discipline – self-control; ability to follow rules and abide by them
organization exists
9. Equity – fair treatment at work; no favoritism pls. There should be
 Vision – a broad statement of ambition; what the
no conflict of interest.
organization sees itself in the future. Ex: PHC vision: Health
10. Remuneration – source of motivation for working in an
in the Hands of the People by 2030
organization. Ex: salary
 Philosophy – statement of beliefs and values, where
11. Stability of tenure – non-existence of a threat to one’s job status.
decisions are based on
Illegal dismissal – violation
12. Centralization/Decentralization – distribution of power and  Goals – general actions
authority in an organization  Objectives – specific actions; should be SMART (specific,
a. Centralized – power from the top (autocratic) measurable, attainable, realistic, time-bound). Should NOT
b. Decentralized – power is well distributed to the lower be GLOBE (general, lengthy, out of reach, bogus, elusive)
areas; applied in the Philippines  Policies
13. Scale of Chain/Chain of Command – functions: a method of  Rules and regulations
communication, distribution of authority, delegations. Reflected 4. Implement the planning hierarchy – distribute the plan towards
in the organizational chart. lower-level managers.
14. Division of labor - delegation  Most important role: middle-level management who bridges
the gap between top and low levels.
Functions of a Manager  Best way to distribute the plan is through a memorandum or
 Planning announcement.
o output = goal setting in the form of a plan 5. Evaluate the understanding of the members of the organization
o the brain of management about the strategic plan.
o most important step/function and the driving stimulus
Budgeting – AKA fiscal planning; not only about money but also includes
 Organizing
multiple resources to realize a plan
o output = group of people to help in carrying out the
 Purpose: proper allocation of resources (justice)
plan
o the backbone of management – the organization as  Duration: budgeting process takes about 3-6 months
 Included in planning phase for proper allocation of resources
the support of the manager
which is important in carrying out the plan
 Directing
o delegation of tasks
 One should be familiar of the total institutional budget elements:
o the heart of management
o Capital budget – starting money; for major
 Controlling
investments and usually a one-time big-time expense.
o ensuring that the activities being done are within
Covers heavy-duty equipment (diagnostic
standards
department), infrastructures, land titles,
o the conscience or super ego of management
documentation software, renovations Able a
Planning o Personnel budget (33%) – allocated for manpower
 a future-oriented activity, a predetermined action (set/bound to (staff). Covers the employees’ salary, wages, benefits,
do it) stipend. Comprises the major (highest) component of
the institutional budget d/t labor-intensive nature of
 a means of preparation for success
nursing
 o Operational budget – allocated for supplies for daily
use (central supply room) which are replenished Tall/Centralized Flat/Decentralized
monthly or weekly. Includes safety and security  vertical in nature;  Horizontal in nature
equipment (CCTV, fire extinguishers, paraphernalia) “pyramidal”  wider span of control
o Utility budget – covers electricity and water bills  with narrow span of control;  shorter chain of command
with better supervision (faster and direct
2 types of expenditures:  with multiple levels of communication)
1. Directs costs – crucial to operate or offer services offered; “must communication (difficult)  with better delegation
buys”. Includes PPEs, medications, staff salary and benefits,  workers may be boss- opportunities
online communication oriented d/t close contact
2. Indirect costs – not related to the main services but has a with supervisor
specific purpose; organization can still function without these
factors. Ex: fire extinguishers and CCTVs 3. Establish and identify organizational relationships
Formal Relationships Informal Relationships
Types of Budgeting:  with a classic command  coordinating or consultative
1. Incremental budgeting – raising the budget allocation based on relationship (superior- relationship
the current inflation rate (affected by internal revenue, import- subordinate pairing) –  may represent temporary
export, investments). Considered as the easiest type of budgeting  symbolized by a solid straight relationships with the
2. Zero-based budgeting – AKA sunset budget; manager needs to line in the organizational organization
justify all budget allocations for the upcoming fiscal year chart  symbolized by a broken or
(presentation and defense of the budget proposal). Budget starts dotted line
from scratch/zero instead of basing it from the previous year
3. Ceiling budget – setting of limits for each allocation of resources.
4. Identify organizational culture based on the philosophy of the
Budget should not go beyond the maximum limit set by the
organization.
source of budget
4. Standard budget – fixed set of budgets; not recommended since
Staffing – a major activity in organizing involved in human resources; the
nursing is variable
process of assigning competent and qualified people to fill in job descriptions
Responsibilities of the manager during budgeting process:
Staffing Considerations:
 Budgeting is done annually 1. Regulatory requirements – supported by the law
 Timeframe for budget-making is 3-6 months  employee must work for 40 hours/week (8 hours/day
 Transparency is encouraged. for 5 days) – 104 days in a year (excluding holidays)
 Prioritize budget monitoring once it is used according to RA 5901
 affects # of employees/unit and the scheduling of shifts
When there is excess money from the budget, inform the source. 2. Benchmarking – seeking the best practice and applying it into the
organization to improve performance
Organizing 3. Patient Classification System – classifying patients based on the
 Formation of a group of people (organization) with the same goals amount of nursing workload
to execute the plan  Patient acuity – measure of nursing workload
 A manager cannot do without an organization and vice versa. generated for each patient (high-acuity = more work)
Manager supplies direction to the org, and the org gives support Classification of Description
to the manager in the actualization of the goal (mutual Patient Care
relationship)
Self-care or minimal Capable of ADLs, usually for discharge. Able and
Steps in Organizing: care ambulatory
1. Choose the type of organization you want to build. 2 types of Moderate care Stable but with special treatment procedures
organization in terms of management (ex: px with colostomy)
Formal Organization Informal Organization Total care Bedridden and lacks strength and mobility to
 with position, title, and job  people do not have positions; perform ADLs
description assignments; built people are together because Intensive care Highest acuity; critically ill and in constant
by the manager the share similarities (e.g., danger of death. Patients in the ICU, PACU, ER,
 communication through a friendly relationships) OR
chain of command – unbroken  communication through a *level of patient acuity dictates the type of staff need. Ex: ICU = expert
like of reporting grape vine (chismis) nurses. DR = female nurses.
 creation of an organizational
chart which depicts the formal 4. Staff support – number of personnel needed for operations to
structural relationship, areas of occur.
responsibility and channel of a. Shifting of staff - 45% staff needed in the AM shift; 37%
communication staff in PM, 18% staff in NOC
Ex: 20 staff in total: 9 in AM, 7 in PM, 3 in NOC.
*an informal organization can exist inside a formal organization but NOT vice
5. Skill mix – ratio of professionals to non-professionals (aids, UAP,
versa
auxiliary worker)
2. Create an organizational design (blueprint of the organization)
Steps in Staffing:
which reflects the overall look or structure. 4 basic elements:
1. Determine the number and type of personnel needed (job
a. Division of labor
description and staff calculation)
b. Centralization/Decentralization and COC– distribution
2. Recruit personnel – hiring process
of power
a) Advertisement - most efficient is through word of
c. Span of control – pragmatic concern of the manager
mouth
over the subordinates; # of people under the direction
b) Application – applicant passes curriculum vitae with
of the manager
cover letter which presents intention of interest for
 Wide - > or = 4 subordinates
available job vacancy. Includes (contact details, 2 levels
 Narrow - < 4 subordinates
d. Organizational structure
 of educational attainment, NLE rating, job experience,
character references) Delegation
c) Sorting of qualified applicants  main activity of directing characterized by division of labor
3. Interview of applicants – wear business or corporate attire  the process of assigning tasks to competent staff with
 WOMEN: sleek hairstyle with ears exposed, light corresponding ARA:
makeup, simple jewelry, collared blouse with blazer, o Authority
just above the knee skirt, skin-tone stocking, closed- o Responsibility – concerned with accepting and
shoes with heels completing a task
 MEN: sleek and styled hair, clean shave, tie up to the o Accountability – concerned with the results/outcome
buckle of the belt (same color as shoes), tucked in of the completed task
polo, slacks, black socks
 If you do not know the answer to the question: do not Common Errors in Delegation:
pretend. apologize and admit that you don’t know the 1. Overdelegation – too much task given which results to burnout
answer and ask for another question (holistic overexhaustion)
 Tell me about yourself: answer with things not found in 2. Underdelegation – too little task is given which happens when
your CV someone is over delegated. This results to redundancy. A
 Why should we hire you: contribute to the culture of redundant employee is a waste of organization funds
excellence of the company 3. Improper Delegation – delegating to a wrong person. Results to
 Why this company: state mission, vision, goals of the negligence and malpractice.
company
 If you are given a chance to ask questions, do not ask Prevention of Delegation Errors: (5 rights)
HR about the salary. Expected amount of salary – give  Right task
a range, not an exact amount (minimum wage)  Right person
 Upon entering, do not sit right away, wait to be seated.  Right direction
After the interview, stand and offer to shake hands.  Right circumstances
4. Induct or orient the personnel  Right supervision
5. Give the job offering (employment contract)

Directing
 Steps taken by the manager to ensure that tasks are being
distributed appropriately among the members of the organization
in completion of the plan Things you cannot delegate to a nursing aid/unlicensed personnel:
 Main activity: to give good directions  Nursing process activities. Gathering of data can be done but
no interpretation should occur.
Elements of a Good Direction: (4 Cs)  Admission and discharge (rigorous assessment and discharge
 Clear – well understood instructions teaching done by the nurse)
 Concise – less words, lesser mistakes  Health teaching
 Consistent - reliable  Medication administration
 Complete – all required details are given in full  Highly invasive or sterile procedures
 High-risk and unstable patients
 Formal documentation

Elements of Directing: Modalities/Models of Care

Communication method of health care delivery; manner in which the staff and the tasks
 a must; the process of relaying messages from the sender to the available in the unit will be divided; basis of delegation
receiver. Goal: understanding  Total Patient Care or Case Method
o Total patient care: perform all aspects of nursing care are done
Elements of Communication: by one RN to/for a patient or group of clients
 Sender or encoder o considered as the best modality because it is the original as
 Message established by Florence Nightingale
 Medium or channel of communication o Advantage: 1 RN: 1 patient; typically used in nursing school
 Receiver or decoder o Uses: RLE, ICU, OR
 Response or feedback
 Functional Method
o Task-based nursing: tasks available in the unit is divided among
available staff, each performs one task for the whole shift (1
Levels of Communication: nurse: 1 task)
1. Verbal – use of words. Includes oral and written communication o Strengthens the skills of the nurse through repetition
2. Paraverbal – characteristics of speech. Includes tone, sounds, o Ex: Medication nurse administers medications for all patients in
speed, vocabulary. the station
3. Nonverbal – use of kinesics. Includes body language, actions, o Popularized during the 1940’s – World War II
gestures. More powerful than verbal
o Use: high-census patients, emergencies or disasters, mass
*communication is 93% nonverbal, 7% verbal. Managers should always strive
casualties
for congruence of all 3 levels to deliver a good message
 Team Nursing
Directions of Communication:
o “partners in care”; 1 group of RNs (at least 4 members) take
1. Vertical – between superior and subordinate; a formal command
care of a patient/s
a. Upward – subordinate to superior
o Composed of a team leader (TL) who delegates the tasks to the
b. Downward – from superior to subordinate
members
2. Horizontal – between colleagues or peers (same level of position);
o Puts back the nurses to the patient’s bedside by hiring ward
can be informal in nature
3. Diagonal – talking with someone who is not part of the organization clerks
(ex: nurse’s communication with patients or physicians) o Use: tertiary-level or large-scale hospitals (adequate staff)
 development development
 Primary Method  Informal: usually right after  Formal and planned
o Autonomous and authoritative method of patient care wherein the evaluation; incidental and  Responsibility of the staff
in the care; level of accountability of the nurse is increased in unplanned themselves
the care of a patient/s by formulating a 24-hr based NCP. Care  Responsibility of the  CPD: Continuing professional
is assumed by a reliever once the shift if done. agency/hospital development. Needed for
o Nurse decides and is responsible for how the patient will be renewal of license (45 units in
taken care of (decentralized decision-making) 3 years)
o Advantageous and satisfying because holistic approach
provides therapeutic relationship, continuity of care, and When should a manager perform controlling:
efficient nursing care.  Before the task – feed forward control; checked before the
o Use: hospice care px with terminal conditions (< 6 months to procedure to prevent mistakes (ex: vehicle check-up of
live) where consistent care is needed ambulance)
 During the task – concurrent control
 Case Management  After the task – feedback control
o Collaborative management of a patient with various HCPs and
the patient’s family or support system Ex: Operating room control measures:
o Most efficient (multi-disciplinary approach) and satisfying  Before the operation: pre-operative checklist which checks for
(presence of support system) allergies (latex and anesthesia), blood tests and types, consent, CP
o Utilizes scientific protocols that aid in managing particular clearance
conditions: CLINICAL PATHWAYS (evidence-based)  During the operation: checking the sterility of instruments, sponge
o Nurse is called the case manager – no direct care given, only count (simultaneous and concurrent; at least 3x)
health teaching and directions given. Patient becomes  After the operation: post-operative assessments (PACU or RR).
independent with the support system – promotes continuity of Patient usually positioned supine without head elevation with side
care to the home. rails up. Check ABCs first especially for those under GA.
o Ex: IMCI by WHO which covers common childhood illnesses

IMCI (Integrated Management of Childhood Illnesses)

o Identify the age of the child to identify which chart to use (0-
2 mos. old or 2 mos. – 5 y/o)
o Identify the chief complaint
o Assess general danger signs (convulsions, lethargy, unable to
breastfeed/drink/eat, vomiting)
o Triage
o Green – health teaching of mother
o Yellow – needs treatment with medications by
the mother
o Pink – needs referral to other HCPs

Controlling
 Mistakes are prevented by means of imposing norms and standards
 Manager monitors the quantity and quality of work and evaluates
whether both meet the expectations according to plan
 Priority activity: establish standards

Standard is defined as the:

 Minimum requirement
 Means of comparison to evaluate the performance of tasks
 Measured in numbers
 Applicable to all members concerned

3 types of standards:
 Structure standards – means of comparison for systems of
operations; usually personnel-related (ex: shifting, hours of work)
 Process standards – for procedures (ex: manual of procedures for
suctioning, blood transfusion)
 Outcome – for evaluation of a performance (ex: satisfaction survey
upon discharge usually in Likert scale format)

Steps for Controlling:

1. Establish standards
2. Measure the performance of tasks
3. Compare performance with the standard
4. Identify corresponding action:
a. If above average = praise, reward, recognize, and
promote
b. If below average = train the employee (staff
development efforts)
Methods of Staff Development: to improve performance (SKA)
In-Service Education Continuing Education
 Focused on skills  Focused on career