Leadership and Management M.Sc Nursing RGUHS

1. MANAGEMENT
SEMINAR ON LOBBYING, DECISION MAKING,
CRITICAL THINKING, STRESS MANAGEMENT
Submitted To: Submitted By:
Mr. B Venkatesan Geeta Rai
Asso. Prof cum HOD 2nd Year M.Sc. Nursing
Medical Surgical Nursing PION
PION

2. TERMINOLOGY
 Legislation
 Bill

3. LOBBYING
Introduction
Nurses can take an active role in the legislative
and political process to affect change. They may
become involved in influencing one specific
piece of legislation or regulation, or they can
become involved more universally and
systematically to influence health care legislation
on the whole.

4. DEFINITIONS
A lobbying is the deliberate attempt to influence
political decisions through various forms of
advocacy directed at policy makers. On behalf of
another person, organization or group.

5. A lobbying is the practice of private advocacy
with the goal of influencing a governing body by
promoting a point of view that in conducive to
an individual’s or organization’s goals.

6. LOBBYIST
 Lobbyist is an individual who attempts to
influence legislation on behalf of others, such as
professional organizations or industries.
 Lobbyists are advocates. That means they
represent a particular side of an issue.
 A person who receives compensation or
reimbursement from another person; group, or
entity to lobby.

7. TYPES OF LOBBYING
Direct lobbying Grassroots

8. TYPES OF LOBBYIST
The lobbyist’s Registration Act identifies three types of
lobbyists:
 The Consultant lobbyist – Is a person who is gainfully
employed or not and not and whose occupation is to lobby
on behalf of a client in exchange for money, benefits or
other forms of compensation.
 The Enterprise lobbyist – Is a person who holds a job or
has duties in a profit-making organization, where duties
include, for a significant- part, lobbying on behalf of the
firm.
 The Organization lobbyist – Is a person who holds a job
or has duties in a non-profit organization like the
enterprise lobbyist.

9. PREPARING FOR LOBBYING CAMPAIGN
An effective lobbying initiative takes background
work.
1. Develop plan of action. Consider; rework,
revamp, and define the plan in advance of the
trip to the legislator’s office.
2. Be sure one is fully aware of a similar initiative
on the same topic and the position of those
opposing one’s idea.

10. 3. Check with other nursing organizations to determine
their positions and if they have information to help
support one’s position.
4. Fine- tunes one’s presentation to several key points
because time will be limited.
5. Follow up after the meeting with a call or
correspondence outlining the points.

11. PREPARING FOR AN EFFECTIVE
LETTER-WRITING CAMPAIGN
1) Define the goals of this grass-roots campaign.
2) Develop a plan.
3) Assess the knowledge level of participants
concerning the legislative process and the
issues that impact the organization.

12. 4) Give interested participants information about the
bill in question and how this bill would directly
affect their practice. Clearly state what action the
legislative body needs to take to meet the goal, and
include the specific bill number and name.
5) Set up effective telephone or email networks that
can contact key members quickly, often legislative
issues are schedule, requiring an immediate change
of plan.

13. 6) Identify and set up contacts with the key legislators
involved in your issue.
7) Set numerical goals for how many letters or
mailings will be generated.
8) On large issues, focus groups or polls may be used
to acquire information that can be used to acquire
information that can be analyzed and used to the
legislators.

14. 9) Get the timing right. The time to begin your
campaign is just before the committee hearings
begin or just prior to the rate on the floor. Too early
is ineffective; too late is wasted effort.
You must follow the program of your issue closely
so as to mobilize your members at the right time.

16. DO ‘S’
1) Do write legibly or types, handwritten are
perfectly acceptable so long as they can be
read.
2) Do use personal stationary. Indicate that you
are registered nurse. Sign your full name and
address.
If you are writing for an organization, use that
organization’s stationary and include
information about, the services you perform,
and the employment setting you are found in.

17. 3) Do state if you are a constituent. If you campaign for
or voted for the official; say so.
4) Do identify the issue by number and name if
possible or refer to it by the common name.
5) Do state your position clearly and state what you
would like your legislator to do.
6) Do draft the letter in your own words and convey
your own thoughts.

18. 7) Do refer to your own experience of how a bill will
directly affect you, your family, your patients, and
members of your organization or your profession.
Thoughtful, sincere letters on issues that directly
affect the writer receive the most attention and are
those that are often quoted in hearings or debates.
8) Do contact the legislator in time for your legislator
to act on an issue.
If your representative is a member of the committee
that is hearing the issue, contact him/her before the
committee hearings begin.
If the bill is due to come to the floor for debate and
votes.

19. 9) Do write the governor promptly for a state issue,
after the bill passes both houses, if you want to
influence his/her decision to sign the bill into law or
veto it.
10) Do use e-mails to state your points.
11) Do be appreciative, especially of past favorable
votes. Many letters legislators receive feedback from
constituents who are unhappy or displeased about
actions taken on an issue. Letters of thanks are
greatly appreciated.

20. 12) Do make your point quickly and discuss only one
issue per letter. Most letters should be one page
long.
13) Do remember that you are the expert in your
professional area. Most legislators know little about
the practice of nursing and respect your knowledge.
Offer your expertise to your elected representative
as an advisor or resource person to his or her staff
when issues arise.
14. 14) Do ask for what you want your legislator to do
on an issue. Ask him/her to state his/her position in
the reply to you.

21. DON’T S
1. Do not begin a letter with “as a citizen tax
payer.” Legislators assume that you are a
citizen, and all of us pay taxes.
2. Do not threaten or use hostility. Most
legislators ignore “hate” mail.
3. Do not send carbon copies of your letter to
other legislators. Write each legislator
individually. Do not send letters to other
legislators from other states- they will refer
your letter to your congressional
representative.

22. 4. Do not write House members while a bill is in the
Senate and vice versa. A bill may be amended many
times before it gets from one house to the other.
5. Do not write postcards; they are tossed.
6. Do not use form letters. In large numbers these
letters get attention only in the form that they are
tallied. These letters tend to elicit a “form letter
response” from the legislator.
7. Do not apologize for writing and taking their time. If
your letter is short and presents your opinion on an
issue, they are glad to have it.

23. CRITICAL THINKING AND
DECISION MAKING

24. MEANING
“Critical” as used in the expression “critical
thinking” connotes the importance or
centrality of the thinking to an issue,
question or problem of concern. “Critical” in
this context does not mean “disapproval” or
“negative”. There are many positive and
useful uses of critical thinking, for example
formulating a workable solution to a
complex personal problem.

25. DEFINITION
“Critical thinking is the intellectually
disciplined process of actively and skillfully
conceptualizing, applying, analyzing,
synthesizing and / or evaluating information
gathered from, or generalized by,
observation, experience, reflection,
reasoning, or communication, as a guide to
belief and action.”
-National Council for Excellence in Critical
Thinking, 1987

26. “Critical thinking is the skillful application of
a repertoire of validated general techniques
for deciding the level of confidence you
should have in a proposition in the light of
the available evidence.”
-Tim Van Gelder

27. LEVELS OF CRITICAL THINKING ACCORDING
TO BLOOM
Bloom identified six thinking levels:
1. Knowledge (knowing things)
2. Comprehension (understanding things)
3. Application (being able to apply knowledge in
the real world)
4. Analysis (ability to pull things apart
intellectually)
5. Synthesis (ability to see through the clutter to
the core issues)
6. Evaluation (the ability to important one for mid
and higher levels of management)

28. STAGES OF CRITICAL THINKING
Stage One: “We begin as unreflective
thinkers.”
We all begin as largely unreflective thinkers,
fundamentally unaware of the determining
role that thinking is playing in our lives. We
don’t realize, at this stage, the many ways
that problems in thinking are causing
problems in our lives. We unconsciously
think of ourselves as the source of truth.

29. Stage Two: “We reach the second stage when we
are faced with the challenge of recognizing the
low level at which we and most humans
functions as thinkers.”
For example; we are capable of making false
assumptions, using erroneous information, or
jumping to unjustifiable conclusions. This
knowledge of our fallibility as thinkers is
connected to the emerging awareness that
somehow we must learn to routine identify,
analyze, and assess our thinking.

30. Stage Three: “We reach the third stage when we
accept the challenge and begin to explicitly develop
our thinking. Having actively decided to take up the
challenge to grow and develop as thinkers, we
become “beginning” thinkers, i.e. thinkers beginning
to take thinking seriously.
Stage Four: “We reach the fourth stage when we
begin to develop a systematic approach to improving
our ability to think. At this stage, we now know that
simply wanting to change is not enough nor is
episodic and irregular “practice”.

31. Stage Five: “We reach the sixth stage when we
intuitively think critically at a habitually high level
across all the significant domains of our lives.
The sixth stage of development, the Master
Thinker Stage, is best described in the third
person, since it is not clear that any humans
living in this age of irrationality qualify as
“master” thinkers.

32. COMPONENTS OF THE CRITICAL THINKING
The eight components that have been
identified as part of the critical thinking
process include:
1. Perception
2. Assumption
3. Emotion
4. Language
5. Argument
6. Fallacy
7. Logic
8. Problem solving

33. METHODS OF CRITICAL THINKING
a. Debate: It involves inquiry, advocacy, and
reasoned judgment on a proposition. A
person or group may debate or agree the
pros and cons of a proposition in coming
to a reasoned judgment.
b. Individual decision: An individual may
debate a proposition in his or her mind
using problem solving or decision making
process.

34. c. Group discussion: Five conditions for
reaching decision through group discussion are
group members agree that a problem exist,
have comparable standard of value, have
comparable purposes are willing to accept
consensus of the group, and relatively few in
number.
d. Persuasion: It is communication to influence
the , beliefs, attitude, and value of others by
reasoning, urging or inducement. Debate and
advertising are two forms of communication
which intent is to persuade.

35. e. Propend: It can be good or bad; it is multiple
media communication designed to persuade or
influence a mass audience.
f. Coercion: Threat or use of force is coercion.
An example of coercion is brainwashing in
which subjects are completely controlled for a
indefinite period of time.
g. Combination of method: Some situation
requires a combination of foregoing
communication techniques to reach a decision.

36. PROCESS OF CRITICAL THINKING
As described by Wolcott and Lynch, critical
thinking process includes four steps.
Step 1: Identify the problem, the relevant
information, and all uncertainties about the
problem. This includes awareness that there is
more than one correct solution.
Step 2: Explore interpretations and connections.
This includes recognize one’s own bias,
articulating the reasoning associated with
alternative points of view; and organizing
information in meaningful ways.

37. Step 3: Prioritize alternatives and communicate
conclusions. This includes and communicates
conclusions. This includes thorough analysis,
developing the guidelines used for prioritizing
factors, and defending the solution option
chosen.
Step 4: Integrate, monitor, and refine strategies for
re-addressing the problem. This includes
acknowledging limitations of chosen solution and
developing an ongoing process for generating
and using new information.

38. MODELS OF CRITICAL THINKING
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Fig: Benjamin Blooms Model of Critical Thinking

39. TECHNIQUES OF CRITICAL THINKING
Here are 16 basic techniques of critical thinking:
1. Clarity
State one point at a time. Elaborate. Give examples.
Ask others to clarify or give examples.
2. Be accurate
Check for facts.

40. 3. Be precise
Be precise, so you are able to check accuracy. Avoid
generalizations, euphemisms, and other ambiguity.
4. Be relevant
Stick to the main point. Pay attention to how each
idea is connected to the main idea.
5. Know your purpose
What are you trying to accomplish? What’s the most
important thing here? Distinguish your purpose from
related purposes.

41. 6. Identify assumptions
All thinking is based on assumptions, however basic
7. Check your emotions
Emotions only continue your critical thinking. Notice
how your emotions may be pushing your thinking in
a certain direction.
8. Empathize
Try to see things from your opponent’s perspective.
Imagine how they feel. Imagine how you sound to
them. Sympathize with the logic, emotion, and
experience of their perspective.

42. 9. Know your own ignorance
Each person knows less than 0.0001% of the
available knowledge in the world. Even if you know
more about relevant issues than your opponent, you
still might be wrong. Educate yourself as much as
possible, but still be humble.
10. Be independent
Think critically about important issues for yourself.
Don’t believe everything you read. Don’t conform to
the priorities, values,: and perspectives of others.

43. 11. Think through implications
Consider the consequences of your viewpoint.
12. Know your own biases
Your biases muddle your thinking. Notice how they
might be pushing your thoughts towards a particular
end, regardless of the logical steps it took to get
there.

44. 13.Suspend judgment
Critical thinking should produce judgments, not the
other way around. Don’t make a decision and then
use critical thinking to back it up. If anything, use the
method of science: take a guess about how things
are then try to disprove it.
14.Consider the opposition
Listen to other viewpoints in their own words.
Seriously consider their must persuasive arguments.
Don’t dismiss them.

45. 15.Recognize cultural assumptions
People from different times and cultures thought
much differently than you do. In fact, your ideas
might have arrived only in the last 50 years of human
history.
16. Be fair, not selfish
Each person’s must basic bias is for themselves.

46. BENEFITS OF CRITICAL THINKING
1. We have too much information. Critical
thinking helps you focus on what
matters.
2. We have too many options. Critical
thinking helps you do what matters.
3. Millions of scam artists want to steal
your time and money. You can use
critical thinking to detect them.
4. Avoid false beliefs.
5. Helps you from some true beliefs.

47. USE OF CRITICAL THINKING SKILLS IN
NURSING
 Nurses use knowledge from other subjects and
fields.
 Nurses deal with change in stressful
environments.
 Nurses make important decisions.
 Nurses provide care according to nursing
process.

48. DECISION
MAKING

49. INTRODUCTION
Effective decision making is an art. The
ability to foster organized decision making
and problem solving is an essential skill for
nurses.

50. DEFINITION
“Decision making is a necessary component
of leadership, power, influence, authority
and delegations.
-John 1993
“Decision making is a systematic process of
choosing among alternatives and putting the
choice into action.”
-Lancaster and Lancaster

51. TYPES
There are 4 managerial decisions
1. Mechanistic
2. Analytical decision
3. Judgmental decision
4. Adaptive decision

52. Nursing Administration Decision Making
According to Ann Bill Taylor
1. Non-routine decision: made by directors of
nursing.
The out of the problem will be unpredictable.
E.g. changing ways of organizing for the delivery of
nursing care.
2. Routine decision: made by mid level and low level
managers, the outcome will be predictable.
E.g. assigning the duty roster, assigning the security
laws.

53. DECISION STRATEGIES
A strategy is an artful or clever plan for
applying technique in pursuit of a goal.
Some strategy suited for some type of
problems than others, they are:
1. Optimizing : It is an approach in which an
individual analyze a problem, determines
desired outcomes, identifies possible
solutions, predict the consequences of each
actions, and select the courses that yields
the greatest amount of preferred outcomes.

54. 2. Satisfying : It is an approach, where by an
individual chooses a problem solution that is
non-ideal but that is good enough to meet a set
at minimum requirements and minimum
standards of acceptance.
3. Mixed scanning : Making a decision that
satisfies to remove least promising solutions, and
then select best of remaining options.
4. Opportunities : Making a decision for the
solution chosen by problem identifier.

55. 5. Do nothing : Taking decision after waiting for
the storm to pass.
6. Eliminate critical limiting factor : Making a
decision by removing most powerful obstacle to
success.
7. Maxima : An optimistic approach which , while
assessing the highest possible pay off from use
of any action the individual chooses that action
alternative will yield the largest payoff.

56. 8. Mini-regret : An approach designed to minimize
the surprise resulting from any action decision by
selecting the action alternative that will yield a
result midway between the most desired and the
least desired outcomes.
9. Precautionary : Making a decision by choosing
the action that will maximize gain or minimize
loss regardless of opponents’ actions.

57. 10. Evolutionary : Which taking a decision
individual has to make series of small changes
leading towards goal. It is based on the
assumption that subordinates can better adjust
to series of small changes than a quantum leap.
11. Chameleon : Taking a decision by making
vague plan, adjusted to changing circumstances.
It consists of farming management decision in
general terms, so that they can be interpreted,
differently at different times.

58. STEPS IN DECISION MAKING
The decision making task can be divided into
6 steps which are stated in order of their
sequence as:
1. Making the diagnosis
2. Analyzing the problem
3. Searching alternative solution
4. Selecting best possible solution
5. Putting the decision into effort
6. Follow up the decisions

59. DECISION MAKING AUTHORITIES
 Individual
 Group
 Committees

60. FACTORS AFFECTING DECISION
MAKING
Internal Factors
 Decision makers physical and emotional
status
 Personal characteristics and values
 Past experiences and interest
 Knowledge and attitude
 Self awareness and courage
 Energy and creativity
 Resistance to change
 Sensitivity and flexibility

61. External Factors
 Cultural environment
 Philosophical environment
 Social background
 Time
 Poor communication
 Cooperation
 Coordination

62. BEHAVIOURAL ASPECT OF DECISION
MAKING
Tannenbaun and Schmidt developed the
continuum of leadership behavior and
participation related to the degree of
authority used by the leader and the amount
of freedom granted to the subordinates in
taking decisions.

64. MODELS OF DECISION MAKING
Vroom and Yetton Normative/ Perspective Model
They define decision making as a social process
and emphasis how managers work there than
should behave in their normative way. It is used
when information is objective, the problem is
structured or routine, and options are known and
predictable.

65. THEY IDENTIFIED 5 ALTERNATIVE DECISION
MAKING PROCESS:
 A – Autocratic
 C – Consultative
 G– Group
 I – First Variant
 II – Second Variant

66.  A I – Making decision by yourself using
information available to you at that time.
 A II – Obtain necessary information from your
subordinates then decide on a solution to your
subordinates then decide on a solution to your
problem. But subordinates will be unaware of the
problems.

67.  C I – Share the problem with subordinates
individually, and gets their ideas and suggestions
than your subordinates influence.
 C II – You share the problem with subordinates
as a group, and their ideas and suggestions.
Then you make a decision that may or may not
reflect your subordinates influence.

68.  G II – You share the problem with subordinates
as a group; together you generate and evaluate
alternatives and attempt to reach agreement on
a solution. You do not try to influence the group
to adopt your solutions but are willing to accept
and implement any solution that has the support
of the entire topic.

69.  G I – Is applicable only in more comprehensive
models Vroom identified 7 rules that do most of
the work of the model. There rules protect the
decision and quantity and four protect the
acceptance.
1. The information rule: If the quantity of decision
is important and the leader doesn’t poses
adequate information to solve the problem then
AI is eliminated from the feasible set.

70. 2. The goal congruence rule: If the quality of
decision is important and the subordinates do not
share the organizational goals to be obtained in
solving the problem then G II obtained in solving
the problem then G II is eliminated.
3. The unstructured problem rule: If the quantity
of decision is important and the leader doesn’t
poses adequate information to solve the problem
and if the problem is unstructured then eliminate
AI, AII, and CI.

71. 4. The acceptance rule: If the acceptance of the
decision by the subordinates is critical for the
decision by the subordinates is critical for the
effective implementation, if it is uncertain that an
autocratic decision made by the leader would
receive the acceptance then AI, AII are
eliminated from the feasible set.

72. 5. The conflict rule: If the acceptance of the
decision is conflict and if it is uncertain that an
autocratic decision made by the leader would
receives the acceptance and subordinates are
likely to be in conflict over the subordinates are
likely to be in conflict over the appropriate
solution. Then AI, AII, CI is eliminated from the
feasible set.

73. 6. The fairness rule: If the quality of the decision
is unimportant, acceptance is critical, and an
uncertain to result from an autocratic decision,
AI,AII,CI and CII are eliminated.
7. The acceptance priority rule: If acceptance is
critical; not assured by an autocratic decision
and if subordinates can be trusted then AI, AII,CI
and CII are eliminated.

75. DESCRIPTIVE OR BEHAVIORAL MODEL
Used when information is subjective, non
routine or unstructured. Uncertainty exists
because outcomes are unpredictable.
Situations that fall in to this category can be
better handled by gathering more date,
using past experience, employing creative
approaches etc.

76. OPTIMIZING MODEL
Decision maker select the solution that
maximally meet the objective for a decision.
Usually this process involves assessing the
pros and cons of each known outcomes as
well as listing benefits and costs associated
with each option. The goal is to select the
most ideal solution. This process is move
likely to result in better decision, but takes
long time.

77. SATISFYING MODEL
Decision maker selects the solution that
minimally meets the objective for a decision.
It is more conservative method compared to
an optimizing approach. This process is
most expedient and may be the most
appropriate when time is an issue.

78. TOOLS OF DECISION MAKING
1. Judgmental technique
2. Operational research technique
3. Delphi technique
4. Decision tree

79. 1. JUDGMENTAL TECHNIQUE
 This is the oldest technique and subjective
in decision making.
 Based on past experiment and institution
about future.
 Useful in making routine decision.
 Cheap and not time consuming.
 Hazardous due to a chance for taking wrong
decision.
 Rarely used in large capital commitments.

80. 2. OPERATIONAL RESEARCH TECHNIQUE
 It can be defined as the analysis of decision
problem using scientific method to provide
manager the needed quantitative
information in making decision.
 Operational research makes the decision
analytic, objective and quantitative based.

81.  Construction of mathematical model that
pinpoints the important factor in the situation.
 Definition of criteria to be used for comparing the
relative merits of various possible courses of
action.
 Procuring empirical estimates of the numerical
parameters in the model that specify that
particular situation to which it is applied.
 Carrying out through the mathematical process
of finding and series of action which will give
optimal solution.
Steps of operational research
technique

82. TYPES OF OPERATIONAL RESEARCH
TECHNIQUE
I. Linear Programming
II. Queuing Theory
III. Games Theory
IV. Programme evaluation and review
technique (PERT)
V. Critical Path Method (CPM)
VI. Computers in decision making

83. I. LINEAR PROGRAMMING
 Determines the best way to use limited
resources to achieve maximum results.
 Based on the assumptions that a linear
relationship exists between the variables
and the limits of variation can be calculated.
 Sophisticated shortcut technique in which
computers can be used.

84.  Three conditions must be existing before it must
be utilized;
1. Either maximal or minimal value is sought to
optimize the objective. The value may be
expressed in terms of cost, time or quantity.
2. The variable affecting the goal must have a
linear relationship.
3. Constructions to the relationship of the
variables exist.

85. II. QUEUING THEORY
 Deals with waiting lines or intermittent
serving problems.
 Balances the cost of waiting versus the
prevention of waiting by increasing the
services.
 A group of items waiting to receive service is
known as a “queue”.

86. III. GAMES THEORY
 In normal games, each player or group of
player tries to choose a course of action
which will frustrate opponents action and
help in winning the game.
 The same will apply in the context of
business by maximize the profit and
minimize the loss and thus minimizing the
opponents profit and maximize his loss.

87. IV. PROGRAMME EVALUATION AND REVIEW
TECHNIQUE (PERT)
 PERT is a network system model for
planning and control under certain
conditions.
 It involves identifying the key activities in a
project, sequencing the activities in flow
diagram, and assessing the duration for
each phase of work.

88. V. CRITICAL PATH METHOD (CPM)
 Closely related to PERT, CPM calculates a
single time estimate for each activity, and
the longest possible time. CPM is useful
where the cost is a significant factor.

89. VI. COMPUTERS IN DECISION MAKING
 In management information system,
computers can be used for various activities
like patient classification system, supplies
and material management system, staff,
scheduling, policy and procedure changes
and announcements, patient changes,
budget information and management,
personal records, statistical reports,
administrative reports and memos etc.

90. 3. DELPHI TECHNIQUE
 It allows members who are dispersed over a
geographic area to participate in decision
making without meeting face to face.
 It is possible through the use of questionnaire.
 Members will returns the questionnaires
anonymously; the results of the first
questionnaire are centrally compiled and sent
to each member.
 Again the members are asked for suggestions.

91.  The process continues until the consensus is
reached.
 The Delphi technique is free from others influence
 Doesn’t require physical presence
 Appropriate for scattered group
 Time consuming

93. 4. DECISION TREE
 Is a graphic method that can help the supervisor in
visualizing the alternative available, outcomes, risk
and information needs for a specific problem over a
period of time.
 It helps to see the possible directions that actions
may take from each decision point and to evaluate
the consequences of a series of decisions.
 The process begins with a primary decision having
at least two alternatives.
 Then the predicted outcome of each decision
considered and the need for further decision is
contemplated.

95. THE NURSE LEADER ROLE IN DECISION
MAKING
1) Accumulate carefully the detailed facts,
their analysis, and interpretation and to
use the broad concepts of human and
physical behaviors to predict future
development.
2) Take the decision according to the
institution and success.
3) Apply her knowledge and skills whole
relating the type of decision.

96. 4) Obtain as well as consider the aspiratory
tradition and attitudes of the agency.
5) Use statistics, work study, operational research
and management survey to select the type of
decision.
6) Be tactful and diplomacy in taking the decision.
7) Create non threatening creative and conducive
environment where taking group decision.
8) Provide positive feedback to her subordinate.

97. ADVANTAGES OF DECISION MAKING
 It is characterized by order and direction
that enables managers to determine where
they are.
 Provide a framework date gathering which
is relevant to the decision.
 Allows application of previous knowledge
and experience that minimize errors and
improve quality of patient care and work of
an organization.
 Increase manager’s confidence and ability
in making decision.

98.  Obtain as well as consider the aspiratory
tradition and attitudes of the agency.
 Use statistics, work study, operational research
and management survey to select the type of
decision.
 Be tactful and diplomacy in taking the decision.
 Create non threatening creative and conducive
environment where taking group decision.
 Provide positive feedback to her subordinate.

99. FACTORS AFFECTING DECISION MAKING
Internal Factors
 Decision makers physical and emotional
status
 Personal characteristics and values
 Past experience and interest
 Knowledge and attitude
 Self awareness and courage
 Energy and creativity
 Resistance to change
 Sensitivity and flexibility

100. External factors
 Cultural environment
 Philosophical environment
 Social background
 Time
 Poor communication
 Cooperation
 Coordination

104. INTRODUCTION
The word “stress” was originally used by Selye in
1956 to describe the pressure experienced by a
person in response to life demands.
These demands are referred to as “stressors”.

105. DEFINITION
Stress is a process of adjusting to or dealing
with circumstances that disrupt or threaten
to disrupt a person physical or psychological
functioning.
-Selye 1976
Stress is a state produced by a change in the
environment that is perceived as
challenging, threatening or damaging to the
person’s dynamic balance or equilibrium.
-Brunner and Suddarth

106. DEFINITION OF STRESS MANAGEMENT
Stress management is the amelioration of
stress for the purpose of improving
everyday functioning.

107. TYPES OF STRESS
According to Hans Selye ; It is of two types:
 Eustress : Stress that helps us function
better. In fact, a bit of stress can be
energizing and motivating, that is why many
of us work best under pressure.
 Distress : Stress that cause mental agony.
Stress can be mild, moderate or severe.

108. SOURCES OF STRESS
It is broadly classified as:
1. Internal stress
2. External stress
3. Developmental stress
4. Situational stress

109. I. Internal stress: They originate within a
person. E.g.; cancer, feeling of depression.
II. External stress: Originates outside the
individual. E.g.; moving to another city, a death
in family.
III. Developmental stress: Occurs at predictable
times throughout an individual’s life. E.g. child-
beginning of school.
IV. Situational stress: They are unpredictable
and occur at any time during life. It may be
positive or negative. E.g death of family
member; marriage / divorce.

110. SOURCES OF CLINICAL STRESS
For Patients
 Uncertainty
 Fear
 Pain
 Cost
 Lack of knowledge
 Risk for harm
 Unknown resources

111. For Nurses
 Poor patients
 Risk of making an error
 Unfamiliar situations
 Excessive workload
 Inadequate resources

112. COMMON SYMPTOMS OF STRESS
 Insomnia
 Fatigue
 Depression
 Irritability
 Anger
 Hopelessness
 Change in appetite

113. STRESS ASSOCIATED DISEASES
 Hypertension
 Coronary Heart Disease
 Migraine, Tension Headache
 Ulcers
 Asthmatic conditions
 Chronic backaches
 Arthritis
 Diminished immunity
 Fatigue
 Psoriasis , Eczema

114. INDICATORS OF STRESS
 Physiological Indicators
 Psychologic Indicators
 Cognitive Indicators

115. PHYSIOLOGIC INDICATORS :
Results from activation of sympathetic and
neuro-endocrine systems of body.
 Pupils dilate to increase visual perception
 Sweat production increases
 Heart rate and cardiac output increases
 Skin is pallor due to peripheral blood vessel
constriction
 Mouth may be dry
 Urine output decrease
 Blood sugar increases

116. PSYCHOLOGICAL INDICATORS:
 Anxiety: State of mental uneasiness,
apprehension, dread or feeling of helplessness. It
can be experienced at conscious, subconscious or
unconscious level.
 Fear: An emotion, feeling of apprehension aroused
by impending or seeming danger, pain or threat.
 Depression: It is an extreme feeling of sadness,
despair, lack of worth or emptiness.
 Unconscious ego defense mechanism: A
psychologic adaptive mechanism developing as the
personality attempts to defend itself and by inner
tensions.

117. COGNITIVE INDICATORS:
 Problem solving: The person assess the
situation or problem, analyzes, chooses
alternatives, carries out selected
alternatives and evaluates.
 Structuring: arrangement / manipulation of
a situation. So that threatening events does
not occur.

118.  Self control: Assuming a manner and facial
expression that conveys a sense of being in
control or in change.
 Suppression: Willfully putting a thought or
feeling out of mind.
 Day dreaming: Unfulfilled wishes and
desires are imagined as fulfilled or a
threatening experience is reworked or re
played so that it ends differently from reality.

119. TYPES OF STRESSORS
 Physiological stressors
 Psychological stressors

120. PHYSIOLOGICAL STRESSORS
 Chemical agents
 Physical agents
 Infectious agents
 Nutrition imbalances
 Genetic or immune disorders

121. PSYCHOLOGICAL STRESSORS
 Accidents can cause stress.
 Stressful expression of family members and
friends.
 Fear of aggression or mutilation from others
such as murder, rape, terrorist and attacks.
 Events that we see on TV such as war,
earthquake, violence.
 Development and life events.
 Rapid changes in the world, including economic
and political structures and technology.

122. STRESS MODELS
1. Stimulus Based Model
In this model, stress is defined as a stimulus,
a life went or a set of circumstances that
arouses physiologic or psychologic
reactions may increase the individual
vulnerability to illness.

123. 2. Transaction Based Model
It is based on the work of Lazarus (1966) who
states that stimulus theory and response
theory do not consider individual
differences. It encompasses a set of
cognitive, affective and adoptive responses
that arouses out of person environment
transactions. As the person and
environment are inseparable each affects
and is affected by other.

124. RESPONSE BASED MODEL
It consists of mainly 2 responses:
Local adaptation syndrome: It is a localized
response of body to stress. The local adaptation
syndrome may be traumatic or pathologic e.g.,
inflammatory responses of a body part in response
to a trauma or injury.

125. General adaptation syndrome (Stage of the
Stress Response): It describes body’s general
response to stress. It consists of 3 stages.
 The alarm reaction: It is initiated when a person
perceives a specific stressor, various defense
mechanisms are activated.
 Resistance: The body attempts to adapt to
stressor, after perceiving the threat.
 Exhaustion: It results when the adaptive
mechanism are exhausted without defense
against the stressor, the body either rest or
mobilize its defense to return to normal or reach
total exhaustion and die.

126. STRESS ADAPTATION MODEL
The model was given by Gail Stuart so it
called Stuart Stress Adaptation Model. It
integrates biological, socio cultural,
psychological; environment and legal-ethical
aspects of patient care into a united
framework for practice.

127. First Assumption
It is ordered as a society hierarchy from the
simplest unit to the most complex. Each
level is a part next higher level, so nothing
exists in isolation. Thus individual is a part
of family, group, community, society and the
large biosphere, through which material and
information flows across various levels.

128. BIOSHPERE
SOCIETY
COMMUNITY
GROUP
FAMILY
INDIVIDUAL
BODY SYSTEM
ORGAN
TISSUE
CELL

129. Second Assumption of the model is that
nursing care is provided within a biological,
psychological, sociocultural, environmental
and legal ethical context. The nurse must
understand each of them to provide holistic
nursing care.

130. Third Assumption of the model is that
health/ illness and adaptation/ mal
adaptation are 2 distinct continuums.
The health/ illness continuum comes from a
medical world view. The adaptation/ mal
adaptation continuum come from a nursing
world view. This means that a person with a
medically diagnosed illness may be
adapting will to it. In contrast a person
without a medical illness may have adaptive
coping resources.

131. Fourth Assumption is that the model
includes the primary, secondary, and tertiary
levels of prevention by describing four
stages of psychiatric treatment: crisis, acute,
maintenance and health promotion. For
each stage of treatment the model suggests
a treatment goal, a focus of nursing
assessment, nature of interventions and
expected outcomes of nursing care.

132. Fifth Assumption is based on the use of
nursing process and standards of care
professional performance. Each stop of the
process is important and the nurse assumes
full responsibility for all nursing
implemented.

133. PSYCHOLOGICAL PRESPONSE TO
STRESS
 Various emotional responses occur due to
stress including depression and anger. The
most common response is anxiety.
 Anxiety- It is vague, uneasy feeling of
discomfort or dread accompanied by
autonomic response.

134.  The four levels are:
 Mild: present in day to day living. It is manifested
by restlessness and increased questioning.
 Moderate: narrows the person perceptual field
and focus on immediate concerns. Manifested by
a quivering voice, tremors, increased muscle
tension, slight increase in respiration and pulse.

135.  Severe: creates the person to lose control
and experience dread and terror.
Manifested by difficulty to communicate
verbally, agitation, trembling, poor motor
control, sweating tachycardia, dyspnea,
palpitations, chest pain or pressure in chest.
 Panic: state of apprehension. Here mild
anxiety has a positive effect. For e.g, mild
anxiety motivates a student to do the
required reading for a upcoming.

136. PHYSIOLOGICAL RESPONSES TO
STRESS
 It is response of body to stress and it
involves only specific body part (tissues,
organs) instead of the whole body.
 It is a short term adaptive response which
primarily is homeostatic. The two most
common stress response that influence
nursing care reflex pain response and the
inflammatory responses.

137. Reflex pain response
It is the response of central nervous system to
pain. It is rapid, automatic and serves as a
protective mechanism to prevent injury. E.g.; if
you are about to step into a bath tub filled with
dangerous hot water, skin senses the heat and
immediately sends a message to the spinal
cord. A message is then sent to motor nerve,
which consciously realize that the water in too
hot not safe.

138. Inflammatory response
It is a local response to injury or intuition. It helps to localize and
prevent the spread of infection and promote wound healing.
There are 3 phases:
 First phase: vasoconstriction occurs to control bleeding
initially. Histamines are released and capillary permeability
increases resulting in increased blood flow to WBCs to the
area. Then the blood flow returns to normal but WBCs remain
to help resist the infection.
 Second phase: exudates (made up of fluids cells and
inflammatory by products) are released from the wound. The
exudates amount depends up on the site, severity of wound.
 Third phase: damaged cells are repaired by regeneration
replacement with identical cells) or formation of scar tissue.

139. COPING MECHANISMS
 Are behaviors used to reduce stress and
anxiety like crying, laughing, sleeping and
cursing.
 Coping may be described as dealing with
problems or situations or contending with them
successfully.
 A coping mechanism is an innate or acquired of
responding to changing environment or specific
situation.

140. TYPES OF COPING
Problems focused coping: it refers to efforts
to improve a situation by making changes or
taking some action.
Emotion focused coping: it includes
thoughts and actions that relieve emotional
distress. It does not improve the situation
but person often feels better.

141. Coping can also be classified as:
 Short term coping: it reduces stress to a
tolerable limit temporarily, but ineffective
way to deal with reality. E.g.; day dreaming.
 Long term coping: it is constructive and
realistic e.g.; talking to others about
problems.

142.  Adaptive term coping: it helps a person to
deal with a stressful event and minimizes
distress associated with them.
 Maladaptive coping: it can result in
unnecessary distress for a person and
others associated with person or stressful
events.

143. Avoid maladaptive coping
 Blurring of boundaries
 Avoidance / Withdrawal
 Negative attitude
 Anger outbursts
 Alcohol / wings
 Hopelessness
 Negative self- talk
 Resentment
 Violence

144. STRESS MANAGEMENT
Stress management encompasses techniques
intended to equip a person with effective coping
mechanisms for dealing with psychological
stress, with stress defined as a person’s
physiological response to an internal or external
stimulus that triggers the fight-or-flight
response. Stress management is effective
when a person uses strategies to cope with or
alter stressful situation.

145. STRESS MANAGEMENT STRATEGIES
 Take a breath
 Practice specific relaxation techniques
 Manage time
 Connect with others
 Talk it out
 Take a minute vacation
 Monitor your physical comfort
 Get physical
 Take of your body

146.  Laugh
 Know your limits
 Think positively
 Clarify your values and develop a sense of life
meaning
 Have a good cry
 Avoid self medication
 Look for the pieces of gold around you
 Identify your strengths
 Social support
 Religion and spirituality
 Altruism

147. BENEFITS OF STRESS MANAGEMENT
 Improves physical health
 More energy and stamina
 Stabilizes emotions
 Positive attitude
 Hopeful / Happier
 Improves ability to focus
 Able to learn and achieve

148. ROLE OF A NURSE ON A STRESS
MANAGEMENT
ASSESSMENT
 Assessment of the person.
 Assess for the following characteristics in
the individual. Such individuals are at high
risk of developing stress related disorders.
 Rigid and self punishing and moral
standards.
 High and unrealistic expectations.

149.  Two much dependence on others for love
and affection and approval.
 Inability to master change or learn new
ways of dealing with frustration.
 Easily prone to extreme emotional
responses of fear, anxiety and depression.
 Stressful events like birth, deaths,
marriages, divorces, retirement etc can
predispose to stress related illness.

150.  Assessment of the family.
 Assess the family perception of the problem
and whether it is supportive of the clients
efforts at coping.
 Assessment of the environment.
 Occupation with a high degree of stress;
adverse environmental influences like too
much of lightening, temperature etc.

151. INTERVENTIONS
 They are directed towards the relict of acute
or chronic stress, a nurse can help person
to examine the situation, identify possible
solutions and accept his feelings without
guilt or fear.
 People suffering from acute stress related
illness often needs to change their life style
and ways of relating to others.
 Increasing client awareness as a actual or
potential health problem exists.

152.  Helping him realize that the health problem
can increase if personal changes do not
occur.
 Identifying all personal resources. To
support the client through the process of
change and cooperation with the treatment.
 When the client becomes aware of the
nature of the health problems and if told of
the change need, he often experiences a
feeling of anxiety, depression, and anger.

153.  The client is encouraged to talk about the
losses that have resulted from the behavior
change.
 Family members also need accurate
information about nature of the disorder;
and how they can help the client in coping
with stress.
 In all this, the nurse must always bear in
mind that they are only facilitators of the
change process and the clients have rights
and responding in relation to change.

154. LEARN STRESS MANAGEMENT
 L - Laugh
 E - Exercise
 A - Attitude
 R - Rest / Relax
 N- Nutrition
 S- Sleep

155. BIBLIOGRAPHY
 Basavanthappa BT. Nursing Administration. 1st edition.
New Delhi: Jaypee Brothers; 2000
 Chandra Ballabh. Encyclopadia of Hospital and Health
Science Management. New Delhi: Alfa Publishers; 2008.
 Russell C. Swanburg, Richard J. Swansburg.
Management and Leadership for Nurse Manager. 3rd
edition. San Antonio Texas: Jones and Barthett Publisher:
2002
WEB REFERENCE
https://www.amjmed.com/article/S00029343(03)00803-
9/abstract