Workshop on Nursing/Midwifery Service Administration, Manila, Philippines, 8-15 September 1975 : final report

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ORIGINAL:

ENGLISH

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WORKSHOP ON NURSING/MIDWIFERY SERVICE ADMINISTRATION Sponsored by the

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 8-15 September 19'75

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FINAL REPORT

1

Not for Sale Printed and Distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines December 1975

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NOTE 'i.'Ile views expressed in thisr'eport are those of the advisers and participants ~f the workshop and do not necessarily reflect the official policy of the World Health Organization

This report has been prepared by the Western Pacific Regional Office of the World Health Organization for Governments of Member states in the Region and for those who participated in the Workshop on Nursing/ Midwifery Service Administration which was held in Manila, Philippines from 8 to 15 September 1975.

CONTENTS

1.

INI'R.OOOCI'ION ........ '" .. '" '" '" .. '" '" '" .. '" '" .... '" .. '" '" '" '" '" • '" .. '" '" '" '" .. '" '" '" '" '" '" '" '" .. '" .. PREPARATION '" '" '" .. '" '" '" '" • '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" .. '" '" '" .. '" .. '" '" '" '" '" '" '" .. '"

1

2.

2

2.1 2.2 2.3

Participants "' .... '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" .. '" '" '" '" '" '" '" Secretariat", .. '" '" '" '" "' .. '" '" '" '" '" '" '" '" '" '" "' .... "' . "' .. "' .. "' .. "'. '" '" '" '" '" '" '" '" '" '" Working documents/background material................

2 2 2

3.

ORGANIZATION '" '" '" .. '" '" .... '" '" '" '" '" '" '" '" .. '" '" '" '" '" '" .. '" '" '" '" '" '" '" '" '" '" '" '" .. '" '" '" .. '" '" '" '" '" 3.1 3", 2

3

Agenda and Programme of Work •.••••••.•••.•••••••••..• Proced.ure .... '" '" .. '" '" '" '" '" '" '" '" ... '" '" .. '" '" .. '" '" . '" '" .. '" .. '" '" .. '" '" '" '" '" .... '" .. '" '" '"

3 4 4

3.3 Opening session ••••••.•..•...•..•••.•.••••.•.•....•..

3

4.

co N:rE:tII' 4.1

'" '" '" '" '" '" '" '" '" '" '" .. '" '" '" '" '" .. '" .. '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" .. '" • '" '" '" '" '" '" '" '" '" '" '" '" '"

Topic 1 - The scope of nursing and midwifery administration ...... '" '" .. '" .. '" '" '" '" '" '" '" '" '" '" '" '" '" '" '" .. '" ...... '" '" .. '" '" '" '" .. '" .. '" 4.2 Topic 2 - Administration in primary health care •••••• 4.3 Topic 3 - Technology of planning and administration for improving the performance of the health care system '" '" .. '" '" . • • . . • • . . • . . • . • . . . • • . • • . . • • • . . • • . • • . • . . • • •

4 7 10

4.4

4.5

Topio 4 - Technology of planning and administration ( continued) ........................................... Topic 5 - Major issues in administration of the nursing and midwifery component of health care progranune ................................................

16

19

5.

EV'AWATION................................................. CONCWSIONS. . . . . . • . . . • . . • . • . . . . . . • . . • . . • • • • . • . • • . • • • . . . . • •

20 21

6.

ANNEX ANNEX ANNEX ANNEX ANNEX

1 - LIST OF PARTICIPANl'S, OBSERVERS AND SECRETARIAT. 2 - LIST OF WORKING DOCUMENTS/BACKGROUND MATERIAL ••• 3 - DISCUSSION TOPICS •••••••••••••••.••••••••••••••• 4 - AGENDA AND PROGRAMME OF WORK •••••••••••••••••••• 5 - POSITION AND FUNCTION IN THE ADMINISTRATIVE STRl1(;'!'lJRE ••••••••.•.••••••••••••••••••••••.•••••

25 31 35 39 45

1.

INTROOOCTION

The Workshop was held at the Regional Office of the World Health Organization, Manila, Philippines, from 8 to 15 September 1975. Twantythree participants from 19 countries and areas of the Region attended. The objectives of the Workshop were: 1.1 To review the functions being performed and the positions currently held by nurses and midwives at the central and intermediate levels of health administrations, and study their working relations with each other and with staff of other divisions/units; 1.2 To identify problems and needs of nursing/midwifery service organization at central and intermediate levels of the health administration; •

1.3 To consider approaches by which nurse/midwife administrators can maximize their involvement in the planning and management of health programmes which utilize nursing/midwifery services; 1.4 To discuss the role of external agencies interested in health, in contributing to the strengthening of nursing services administration. The technology of planning and management is a recent additional dimension in the administration of health services, and has special significance where the best utilization of scaree resources and the efficiency and effectiveness of health programmes are under review. Nurses and midwives have traditionally administered the personnel aspects of programmes in which members of their professional disciplines are engaged, but have had only limited degrees of involvement, as administrators, in the technical aspects of the programme operation. This tends to isolate nursing administration from the overall planning, management and evaluation of health services. This situation is, to some extent, depicted by those national organizational charts which place a "nursing office" in either the same position horizontally as for instance medical service, maternal and child health or cOlllDUnity health services, or under a division of medical affairs without direct connection with a bureau of public health, etc. There are many examples where "nursing" (like "supplies") provides staff for all the other divisions but has no part in the planning and administration of the service programme of those divisions. While organizational charts cannot always fully depict the actual professional relationships that exist, the implication remains that nursing, as an office, is officially outside the administration of many programmes particularly at the central level. The Workshop followed closely on the twenty-sixth session of the WHO Regional Committee for the Western Pacific, held in Manila in September 1975. In his address to the Representatives entitled "Health for all by the year 2000", the WHO Director-General, Dr H.T. Mahler, referred to the new functions of the medical and nursing professions in ensuring better distribution of health care to unserved areas.

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Since nurses and midwives are deeply involved in many aspects of primary health care at the local level,the administration of this component of the service should be carried out with well-prepared and experienced nurse/midwife administrators at the central and intermediate levels. It was fitting, therefore, to use primary health care for the illustration and discussion of administration techniques, recognizing however that the same principles apply to nursing service administration in general, although the strategies for their implementation will be adapted to different situations. The technology of administration was presented by personnel drawn from the management disciplines, with reference to service needs described by personnel from the health professions. This coordinated approach stimulated discussion of management skills and technical proficiency as the two essential elements in the administration of the nursing/midwifery component of health services. 2. 2.1 Participants PREPARATION

Countries and areas in the Western Pacific Region were invited to nominate nurses and midwives in administrative positions to attend the Workshop. Participants were to be drawn from various fields including public health, hospital nursing and special programmes and to hold positions at the central and intermediate levels of administration. The larger countries were invited to send two participants. Observers were invited from UNICEF .• the International Council of Nurses (ICN) , International Committee of Catholic Nurses (CICIAMS) and the Philippine Nurses' Association (PNA). 2.2 Secretariat

To assist the WHO Secretariat, a public health nurse with experience in the administration of primary health care programme, Ms Helen Cohn, Was appointed as Workshop Director, and Dr J. Cortes, specialized in planning technology, as Temporary Adviser. In addition, Dr Aleya Hammad, Nursing and Public Health Officer, Division of Strengthening of Health Services, WHO Headquarters, attended the Workshop. See Annex 1, LJst of Participants, Observers and Secretariat. 2.3 Working documents/background material (Annex 2) 2.3.1 A working paper entitled "Role of nurse and midwife administrators in the national health services of the Western Pacific Region: problems and needs" was prepared by the Regional Adviser on Nursing Administration and Services at the WHO Regional Office.

- 3 2.3.2 Five WHO publications dealing with health planning and planning for nursing services, management and organization of health services, community health nursing, and primary health care wore distributed to the participants. 2.3.3 A list of reference books and documents on similar topics was prepared and.sent in advance to the participants. 2.3.4 A provisional annotated agenda, suggesting that participants prepare relevant information for discussion of the tOPics listed was issued in advance. 2.3.5 A list of problems to be discussed during the group work was prepared by the Workshop Director. During the Workshop itself, outlines of some presentations were distributed to the partiCipants. 2.3.6 A questionnaire on position and function of participants was prepared for completion at the beginning of the meeting. An evaluation questionnaire was prepared for distribution before the close of the Workshop.

3. 3.1

ORGANIZATION

Agenda and Programme of Work

The agenda was designed to meet the four objectives by focussing on two major themes: (a) nursing and midwifery administration as it relates to service.

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(b) technology of planning, management and evaluation in nursing and midwifery administration. These themes were reflected in the discussion of topics related to service on the first two days, to technology of administration on the following two days and to major issues in nursing and midwifery administration on the fifth day. Each day's topic was introduced by presentations in the first plenary session. This was followed by group work for which appropriate problems were assigned for discussion to three groups. and were reported on and further discussed in the second plenary session (see Annex 3. Discussion Topics). Major issues as perceived by four participants nominated as "discussants" were presented for discussion on the fifth day. These were included in the draft report presented for adoption at the closing session of the Workshop. 3.2 3.2.1 Procedures Officers

One Chairman and one Rapporteur were nominated to conduct and record the proceedings each day and their names were written into the Agenda.

- 4 A group leader was elected on a totating basis to report the group's discussion to the plenary session. FOur participants were nominated as discussants to identify and report on major issues raised during the Workshop. Three group members (one from each group) were elected Committee. tQ

the Steering

3.2.2 Working Committee The Secretariat met each day to review the Rapporteur's record of the day's proceedings and to hear and, when neceaaary, act on the report of the Steering Committee.

3.2.3 Steering Committee A member of the Secretariat met daily with three participant representatives to discuss plans, problems and ether aspects ot the proceedings which required adjustment.

3.3 Opening session The Workshop was formally opened by the Regional Director, Dr F.J. Dy, who assured the participants of the support of WHO in their deliberations and concerns. The Workshop Director, Ms Helen Cohn, thanked Dr Dy for his support and, on behalf of the participants, thanked WHO for providing the opportunity to work together on important issues affecting the delivery of nursing and midwifery service. Dr Aleya Hammad, Nursing and Public Health Officer, Division of Strengthening of Health Services, WHO, Geneva, brought greetings from WHO Headquarters and expressed pleasure in having the opportunity to meet nurses and midwives from the countries and areas of the Region. After individual introductions, the Agenda was discussed and adopted (Annex 4).

4.

CONTENT

This section of the report is an account of the presentations and discussions held on consecutive days. The presentations and questions from the floor are summarized; and they are followed by a summarized report of (he group discussions. 4.1 Topic 1 - The scope of nursing and midwifery administration osition and function in the

4.1.1 uestionnaire on participants' administrative structure see Annex 5

Each participant gave replies to the listed questions while the other partiCipants entered the information on their individual copies of the questionnaire. This had the effect not only of ensuring that the participants

- 5 listened to each other describing their positions and functions. but of assembling information on the total group which could be analysed in terms of similarities and differences in the fUnction of nursing/midwifery administration. The following are some of the characteristics of the positions or functions of the 23 participants attending the Workshop. Type of position Central health administration 15 Intermediate health administration •••••••••••••••••••••••• 4 Local health administration .....•••••.•.•.•.••••.••••••••• 2 Insti tution """"""""""""""""""""""""""""""",,"""""""""""""""

4

Immediate supervisor NursiTlg offi cer """""""""""""""""""""""""""""""""""""",,",,"" 7 Medical officer """"""""""""""""""""""",,""""""""""""""""""" 13 13c>th """"""""""""""""""""""" .. """""""""""""""" .. ,,"",,""",, .. ,,""" 2 Other """""""""""""""""""""""""""""""""""""",,"""""""""""""" 1

Technical field COrnnTllni ty health .""""""""""""""""""""""""""""""""""""""""" 4 Hasp! tal service """"""""""""""""""""""""""""""""""""",,"""" Community and hospital •.•.•••••••••••.•••••.••••.•••.••••. 12 Hospital and teaching •.••••.•.••••••••••.••••••••••••••••• 3 Teachillg, only ................................................ 4

The following are some of the fUnctions and responsibilities held by the majority of participants: Assignment of staff ................................................. Personnel pol! cies ......................................... Employment of staff ........................................ Budget responsibilities ••••••••••••••••••••••••••••••••••• Nursing service - directly .....•••••••••••••••.••••••••••. Nursing service - indirectly ••••.•••••••••••••••.••..••.•• Policy making on patient care .............................. Implementation of progaamrnes l at operational level ..••••.•••••••••••••.•••••••••••• at supervisory level •.•.•.•.••••.••••••••.••••••••.•• at administrative level •••.••.•••••.••••••.•.•••••••• 17 16 12 11 13 10

15 12 17 19

While there were mainly similarities in the positions and functions of the participants, there were enough differences to a,ccount for the diversity in responses and reactions to subsequent presentations.

This terminology was not clear to all participants and their replies may have required clarification.

1

- 6 4.1.2 Presentation 1 - Implications for administrative responsibility and functions as depicted by organization charts The positions occupied by nursing personnel at central and intermediate level of the health administration were presented and commented on with reference to four organizational charts of large countries and four of small countries. The objectives were to locate the programme areas in which nursing and midwifery care is involved; to note how communications are established when all nursing/midwifery personnel is concentrated in one nursing office, as compared with the distribution of nurses in the various programme areas; to see how they relate to each other and to the staff of other divisions. On this basis, problems of vertical. horizontal and functional relationships were discussed. FUnctions exercised by nursing personnel at the central and intermediate levels of the administrative structure were summarized and found to relate more to questions of nursing manpower utilization and education than programme design. The fields of competence in nursing/midwifery care which need to be represented in the health structure were commented upon, taking into consideration the needs for nursing and midwifery services at the delivery level and up to the highest administrative structure. and the need to be involved in programme planning, organization management and evaluation of health areas utilizing nursing/midwifery personnel. Related to the needs is the preparation and experience required for nurses/midwives to function adequately in multidicipline, multipurpose and action-oriented aettings. Abilities in management as well as technical competence were emphasized. Discussion followed on the role of a nurse coordinator posted in a "multidisciplinary coordinating unit" with responsibilities both for professional-personnel and technical-operational aspects of the nursing/ midWifery programme at all levels. Some thought that nurses and midwives themselves might resist a change which involves them in multidiscipline administration and removes them from the nursing/midwifery hierarchy. However, the desirable relationship between structure and function in organization must be achieved. 4.1.3 Presentation 2: Staff development: a function of administration

Staff development is a management strategy for health manpower development through training and continuing education. The objectives are: (i) to ensure attainment of programme goals and (ii) to assist in development of the fullest potential possible of individual health team members and of health teams as a whole, thus providing for employee job satisfaction. A separate health manpower development unit at central level has several distinct advantages, namely in terms of availability of teaching staff, a separate, adequate budget and the use of a multidisciplinary approach to educational planning.

- 7Nursing and midwifery administration must determine the needs for staff development in terms of both needs of staff in existing ongoing programmes and of nursing/midwifery needs in new programmes. These needs must not be looked at in isolation but in relation to the needs of other components of the programme and functions and responsibilities of other members of the health team. Discussion followed on: the cost of in-service. education and the claim of some staff members to higher positions and higher salaries after training programme&: and the advantage of central policies as a means of achieving some degree of uniformity in standards aa well~as relieving local services of the costs. The point was made that the building of new or expanded services should include as part of the plan the training of staff to serve in them. 4.1.4 Presentation 3: Standards of care:· a function of administration

Administration at all levels should be service-oriented. Nurse/ midwife administrators at central level tend to be less involved in service needs than at intermediate and local levels. There are two elements needed for achieving standards of care: (i) the appropriate assignment of nursing/ midwifery personnel to the programme areas and (ii) an involvement with the personnel in their service functions. The administration ahould work with staff in the development of manuals and for this should retain their own competence in technical aspects of service. Points raised in discussion included: the problem in time and cost of the administrator moving around her district; the question of how much technical competence she could maintain once she is promoted to an administrative position; the need for her to keep up with new concepts of practice and newly-identified community needs. There was no group work directly related to these three formulations. However, the topics assigned following the next session reflected some of the issues raised. 4.2 Topic 2 - Administration in primary health care

Three presentations were related to each other by the common theme of nurse/midwifery administration considered from different points of view: (i) participation in community development;

(ii) coordination between health services; and (iii) approaches to nursing/midwifery care delivery. 4.2.1

Presentation 1:

Primary health care

(i) "Primary health care 1s taken to mean a health approach which integrates at the community level all the elements necessary to make an impact upon the health status of the people. Such an approach

- 8 should be an integral part of the national health care system. It is an expression or response to the fundmental human needs of how can a person know of, and be assisted in the actions required to live a healthy life and where can a person go if he/ she needs relief from pain or suffering. A response to such needs must be a series of simple arid effective measures in terms of cost, technique and organization, which are easily accessible to the people in need and which assist in improving the living conditions of individuals, families and communities. These include preventive, promotive, curative and rehabilitative health measures and community development activities."l (ii) Rural population in developing countries are particularly underprivileged with respect to health care although they are usually interested in improving their health. This interest should be fully mobilized and communities be encouraged to take the initiative in developing simple health measures of their own. It should be possible to train locally-recruited health agents to participate with suitable guidance and support in providing simple health care: ante-partum, intra-partum and post-partum; in family planning; in infant and early childhood care; in nutritional guidance; in immunization against major infectious diseases; in elementary curative care of all age groups for disease and injury; in basic sanitation; and in health education with respect to prevailing health problems and method of preventing and controlling them. In this system, profeSSional health workers have the duty to consider the benefits of health action in terms of their social value rather than their technical excellence. They can assist in motivating community members to develop, or build on, their own structure for social development. They have also to give training and technical guidance to the local health agents who are responsible for a community committee. Collaboration between all agencies, including health serving the community, and working together with community committees, provide support for locally sponsored community action programmes for development. The implementation of a primary health care system based on community participation and action requires careful planning, moral support and technological guidance of the national health services in which nursing and midwifery groups have very important functions to fulfil as providers of health services. supervisors and administrato~s. Slides were shown of a village development programme demonstrating participation of local committees in planning health and environmental services. 2

lTwenty-eighth World Health Assembly Provisional Agenda (A28/9) dated 18 April 1975. Promoti"on of National Health Services summary. Yanasan Indonesia Sejalitera, Solo, Indonesia. World Neighbours International Headquarters. Oklahoma, United States of America.

~ealthier Living Through community Effort.

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- 9 Regarding the community's own involvement in their services, attention was drawn to the inaccessibility of hospitals; the need for support services and the possible contribution in donations, including labour, of community members. The slides which showed cooperative marketing of milk and milk products led to a discussion on nu.tri tion among rural people. Questions were raised regarding difficulties in collaboration with community groups where'the nurse/midwife concerned with professionalism may be seen as a stranger in village life. Methods to deal with this situation through practical training and retraining of nurses/midwives in the community itself were mentioned. 4.2.2 Panel presentation: Continuity of care

One person (nurse-midwife, sanitarian, village level worker, etc.) should be responsible for coordinating the care of a patient or family when services required come from different sources. Measures must be taken to ensure initial entry into the system; thereafter a referral system should provide a chain of services where one unit alone cannot meet the needs. Coordination between institutions must be formalized and steps taken to ensure not only that a patient reaches the required facility but returns to his primary source of care for follow-up. In visiting a patient at home there are opportunities for identifying health needs of other family members and using the referral system on their behalf. It was pointed out that many of the participants according to the way they had listed their positions in the questionnaire were involved in hospital as well as community services. This seems to indicate a move towards coordination of care. The problem of communication between health agencies was discussed and instances cited of hospitals' disinterest in referring patients back to the community service after discharge. The problem also remains of integrating preventive and curative services. 4.2.3 Presentation 3: Three approaches to primary health care

In services which are multidiscipline and/or multipurpose, the nurse/midwife is concerned with one or all three "units" of practice: the individual, the family and the community. In all three, her basic service includes appraisal of condition, treatment of the sick, health promotion, prevention and rehabilitation. All three units may be seen as having to withstand, by their own strengths and resources, the pressures and hazards of environmental and societal forces. Because of this concept, there is a necessity for Judgements as to how best to intervene: on the side of the patient to promote his health, or by working to improve environmental and social conditions. In primary health care the individual is seen in the context of the family and it is often in the family environment that intervention is most effective; similarly, the family reflects the "health" of the community and examples were given of how community action was enlisted to improve the condition of families and indiViduals. The planning and administration of services based on these concepts requires specific procedures and collaboration with other groups serving the needs of the people.

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Discussion focussed on: (i) the need for long-term relationships between the nurse/midwife and the families; (ii) eligibility and registration of all families in the neighbourhood; (iii) the fact that families in primary care are not "discharged" but retained as members of the neighbourhood: (iv) community participation in services for special categories; and (v) priority selection of high risk families for more intensive care. 4.2.4 Group work See Annex 3, Discussion topics, Day 2. The following were the major points discussed by the three groups:

(i) The need for change from traditional (individual) to new approaches (family and community) necessitating the education of health workers on broader lines and a more appropriate staffing structure for better utilization of personnel; (ii) characteristics of the area served as the determinants of the type of service likely to be the most effective; (iii) collaboration between health agencies and with non-medical agencies at official and informal levels of the community structure; (iv) providing the people with information on the health needs of their community in addition to providing on-going health education; (v) training, guidance and supervision of auxiliary nurses and midwives and working with local multipurpose health workers; (vi) the best use of community resources and available budgetary assistance from government and outside sources. 4.3 Topic 3 - Technology of planning and administration for improving the performance of the health care system Two days were devoted to discussion of three techniques of administration: planning, management by objective and evaluation. Next, the impact of organizational change was presented first conceptually and then by a case illustration. 4.3.1 Presentation 1: The planning process

Planning, management (implementation) and evaluation are interlocking processes with planning taking into account the latter two, indicating in the plan what as well as how to implement and evaluate. FUrthermore, planning is an element of planning itself (e.g., organizing it; determining the approach as well as method of planning) as well as being an element of organization, implementation and evaluation.

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Health administrators, supervisors and specialists in various disciplines at different administrative levels are involved in planning, or carry out the planning function to formulate directional, administrative (including programme) and operational plans. Thus, planning capability of various health professionals is needed at all levels. However, a professional (physician, nurse, etc.) serving in a planning unit becomes a participant in planning the overall health programme rather than only that part of the programme which relates to his/her area of operation. The planner in the unit will then have to look at the system as a whole and in relation to the larger socio-economic system. It was also pointed out that community participation be obtained as much as is possible. The opportunity for this involvement would be particularly in a "bottom-to-top" approach to formulation of a (national) health plan. Such an approach would also identify local needs, lead to their inclusion and be more realistic and acceptable. Thus, this is the approach that is being aimed for, rather than the traditional "top-to-bottom" planning which generally takes into account average needs which apply equally to the majority but may not apply equally to all. However, the type of approach followed will depend on the country situation, its administrative organization and the availability of planning capability; and a balanced scientificallybased mix between the two may be more appropriate. Planning is change-oriented, aiming to improve a given situation. The challenge is to be able to plan using available data rather than to go into preliminary, expensive surveys. The plan should automatically provide for the development/strengthening of a health information system that would furnish more, better and/or relevant data. Administration involves a series of decisions: planning seeks to help in decision-making as well as to provide directives. The health planning process was also presented, considering two major aspects, viz., "pre-planning considerations" and the "planning exercise" itself. The former includes the political decision to plan, intrasectoral commitments to planning. organization of planning mechanism, the decision on a methods to follow in evolving a health plan, consideration of available data, etc. With regard to the latter, the various components/steps related to situational analysis, formulation of policy and programme plans, preparation for implementation and evaluation were discussed. As planning is needed at every level of an organization - operational, supervisory and administration - it was suggested in discussion that planning techniques should be included in the basic training of nurses and midwives. Also since techniques are constantly changing, adjusting planning should be a subject for in-service and continuing education. Intersectoral planning at central level would ensure that budget distribution is adequate to meet the requirements of health services.

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)1. 3. 2

Presentation 2:

Management by objectives

Management by objectives is a method for systematically planning activities and resources to achieve goals in the most effective and efficient manner. It is also a method by which progress in the achievement of these goals can be measured. There are six steps which should be taken to manage by objectives. They are: (i) defining or formulating the objectives or goals of the project or programme; (ii) preparing operating budgets and active plans (who, what, when, where and how) related to these objectives or goals (iii) ascertaining the completeness of the action required; (iv) involving each worker in the plan; (v) eliciting opinions from various groups; and (vi) determining priorities. This process enables the manage ..' to: (i) organize and explain the programme; (ii) text the explanato~y statements in relation to actual experience; (iii) predict behaviour; (iv) appraise the soundness of decisions; and (v) analyse and improve performance. Within the context of management by objectives, the group discussed the differences between a programme and a project. A programme was defined as a set of strategies for accomplishing certain objectives using money, manpower and material. Once institutionalized, a progra:nme continues indefinitely, periodically changing its strategies and objectives according to the needs of the people it Is designed to serve. It is precisely during a period of change in a programme that a project is required. A project was defined as a managerial tool with the primary objective(s) of impleme~ting organized and rational changes in an ongoing programme or service. A project is limited by both time and resources. That is to say that it ceases to exist once it has brought about all the planned changes in the programme or service. A project is composed of inputs, processes and outputs (see figure), which are geared to implementing changes and measuring the effects on and benefits of these changes to the people served by the programme.

FICOE 4.1 PROJEC'r SYSt!M

INPUTS Technology Manpower Materials Information Funds

PIlOCESSES Or,aniznLon Management Trainlng Education Construction Distribution

OUTPUTS Trained Manpower Procedures Developed Facilities Constructed Pelicies A~inistrative Changes ---~-

EFFECTS Diaano.es/Tre.tsents Clients Seen Tests Administered

BENEFI:S

~

i--'

~

r-.

AwarenelS/ Attitude "':anaes Population Loverage Increased Problem/DiselSe Reduced

I

CLASSES OF IISPUT (the quantity of resources) PROC:::SS (S"Jant i ty, quali ty. I ti~eliness of activities) lorTP~T

HONITOP.I~C/EVALUATI~

~

\)j

(quantity, quality of products)

IEFFECTl':E:>ESS (quantitati-:e/qual itative res\.:: ts of producing ':lUtputs)

IBE~EFITS

(suantitative/qualitative changes in the health

syste~)

,EFFlCIE:;CY (costs of carr

activities. individually .rod in total, to

roducI! bo!n.:fits)

~ .... • N

• - 14 -

initial t-' Decision subsequent

EvaIuMion

~

/ Totll System

forecast

Results

"-

I V , Action

I

~

Policy

Pailn

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- 15 4.3.3 Presentation 3: Operations research: a tool for evaluation

Evaluation is the final step in the planning cycle and becomes the beginning of a new planning cycle (see figure). Evaluation is a continuous activity which must be periodically summarized to allow for measurement of accomplishments. Concern with the development of the programme at periodic intervals is as important as concern with accomplishments. The diagram depicts the developmental steps when a new element is added to three existing elements in an ongoing programme. Existing programme Family planning (FP) is to be added to child health (CH), communicable disease control (CDC) and prenatal care (P-N).

P-N

CH

CDC

(1) A series of steps are taken over a period in which FP may take too low or too high a priority in the programme. FP ~N

CH

P-N ~C

CH

~

(2)

Too low

'(3) Too high

The objective is reached when all four elements of the programme are adjusted to each other. FP The objective P-N CH

COC

(4)

Measurement at any of the interim stages may indicate failure because Figure No. 4 has not been reached. However, these are necessary stages in progressing towards the objective and are apparent at periodic evaluation. For evaluation to be effective, it is necessary to link evaluation with decision-options, providing a basis for deciding between alternative courses of action. Generally, this approach shows a need for technological innovation and it is this aspect that warrants the use of operations research.

- 16 Operations research is problem oriented; it is explanatory and descriptive and is concerned with improving effectiveness and efficiency of existing resources through innovative technology. Innovative approaches to problem solving involve a multidisciplinary approach. Thus broadly focussed teams are employed to examine problems. In addition to new techniques, a variety of models are used. Nurses and midwives are familiar with some of these models: work sampling, activity analysis, queuing theory, etc. However, nurses and midwives do not work in isolation and a number of health personnel working together are required to help solving problems of the community, family and individual. The studies undertaken by nurses should have a new orientation; rather than being service based, they should be concerned with the effectiveness of service rendered, for example, in terms of the impact on the well-being of the population. 4.?4 Group work See Annex 3, Discussion topics, Day 3. The groups discussed multilevel and multisectoral consultation in relation to planning and evaluation. It was agreed that the new concepts presented would stimulate rethinking of some of the planning and evaluation. carried out in the past. Two cases were discussed as examples of implementing techniques of planning and evaluation. The first concerned a plan for better nutrition of infants and preschoolers by surveillance of their growth and development and detection of nutritional defiCiencies; the other involved measurement of the need for expanded maternity services in a town where the present facility had become inadequate. The determination of the objectives to be achieved was base~ on priority needs, and the development of alternative services for normal deliveries was discussed. 4.4 Topic 4 - Technology, of planning and administration (continued) Organizational behaviours in leadership, authority

4.4.1 Presentation 1: and peer relations

The continued relevance or survival of any organization depends on ability of its staff to adapt to changes in the environment. The role which members in any given organization play with regard to change can be better illustrated by a conceptual model of the total organization as in the following figure. Environment

Institutional Managerial Technical

- 17 The square represents the environment in which the organization exists. For the health sector of most countries, this environment may include the population served including hospitalized and ambulatory patients, the policies and laws regarding health/medical practice, different health/ medical institutions, health/medical practitioners and medical technologies. The three concentric circles in the above figure represent three distinct levels of an organization; in this case, the ministry or department of health of a country. The institutional level represents the policy making executive body of the ministry of health, the director-general of health and the divisional directors in the ministry or department. The managerial level represents those persons who have day-to-day responsibility for the operation and the administration of the health service. The technical level represents those persons in the services which actually provide the health care to the population. The individuals or groups representing each of the different levels of the health service play important roles in promoting and instituting changes in the organization. The policy makers or executive man~ers have the responsibility to redirect the operations in the health services in response to changes in the environment. The managers or administrators of the health services are responsible for translating policies and directives received from executive managers into operational decisions and action. The technical staff or those individuals providing direct health care to the population are responsible for using new technology or adapting existing technology to the needs of the population. Conceptually, at least, there is a hierarchical process by which individuals contribute to change in an organization. In an actual situation however, the initiators of change are not always found at the institutional level of the organization. Both the managerial and technical levels of the organization can and often do instigate changes in~e system and therefore reverse the traditional hierarchical process. It is more and more recognized as sound practice to ask health workers at the~delivery level for their opinion regarding the strength, opportunities, faults and weaknesses of the programme. For instance, a midwife may find that a particular approach to patient care is not as effective as originally thought. She may propose alternative approaches which, based on her experience, may prove more effective. The public health administrator of a province or region or state may propose new staffing patterns or changes in procedures which can affect the tJPe of health care provided by the services. The initiation of changes at all levels of the service can, therefore, act within the scope of responsibilities. Change in an organization, whether administrative or technical, is a dynamic process which can be initiated by anyone in the health services and which requires the coordination of all levels for realization. The management of change thus becomes the responsibility of all levels of the organization.

- 18 4.4.2 Panel presentation: Dynamics of change in health services

Some of the aspects of ensuring acceptance of the need for change, and in managing the implementation of change, were illustrated by reference to changes made in the structure of a health service, based on the findings of operational research and involving the redistribution of functions of the health personnel. In the example used, the midwife was given an expanded role after retraining. Some aspects of the change mentioned were: legal implications, training (category of worker directly involved but also of co-workers and supervisors): administrative support (in supplying the "tools" to do a better and bigger Job): and organizational constraines on implementation. The commitment of the government to the change was made at the same time as a decision on other major political and administrative changes in the country. The advantages of the trial period. with adequate evaluation not only of effectiveness and efficiency but also of personnel satisfaction, was stressed. The problem of resistance by professional groups to the change was explained in some depth: it can be alleviated to some degree by the contribution of professional associations in involving their members and keeping them informed. Health and health related needs, particularly in primary health care were discussed. Legal and administrative implications of expanding the role of a licensed professional were noted. 4.4.3 Group work

See Annex 3, Discussion topics, Day 4. Examples of non-involvement of the nurse/midWife in planning were presented and contrasted with situations in which such a contribution had been highly effective. In the first instance, a five-year delay in expanding a maternity service and the serious nurse shortage be'fore the initiation of a training programme for auxiliaries were both ascribed to lack of representation by the professions most involved. In contrast, situations were described where (i) representation at high policy making level had contributed to the efficient introduction of multiphase screening programmes; (ii) the field aSSignment of graduate nurses in rural areas had been accomplished with the help of a nurse coordinator involved in the planning and implementation of the project: and (iii) in the implementation of a leprosy and tuberculosis survey, a nurse had been involved at all levels of decision making, management and application of technical procedures. This had contributed to the efficiency of the plan and its acceptance by the personnel involved. The third group examined some of the characteristics of tile nursing/ midwifery professions which are and are not conducive to their participation in multidiscipline planning and policy making. In the view of the partiCipants, nurses may see themselves as being not educationally prepared and, therefore, not speaking the same language as other health professional groups: being

- 19 mostly women they are by culture and custom excluded from working on an equal footing with a mostly male professional group; being drawn mainly from the "middle class" they are conservative and do not make enough effort to broaden their approach to health care and promote change; and they are traditionally seen as providing a supportive service rather than being colleagues in health programme planning and implementation. aonversely, where the status of women is changing, where nurses themselves are becoming better educated and dynamic and where they have proven their capacity to contribute to the administration, their participation is sought. The group felt that training in the administration of their own operations and development of consensus management, by forming decision making committees in their own services, would go a long way to demonstrate their ability to participate at all levels. 4.5 Topic 5 - Major issues in administration of the nursing and midwifery component of health care programme This topic was designed to allow for an opportunity to discuss major issues in administration, first in group work and finally in plenary session. 4.5.1 Group work See Annex 3, Discussion topics, Day 5. All three groups discussed examples of organizational charts from their countries. No consensus was reached as to which, if any, would be appropriate for all. While the advantages of strong horizontal relationships were generally accepted, there was some feeling that the existence of a nursing office also had advantages. one group mentioned cultural and traditional elements in determining organizational structures suited to different countries, and considered that "guidelines" rather than a set method were the best answer to the question. Such guidelines were concerned with the relationship of the administrator to the service at all levels (vertical) and to other related services (horizontal); hence representation on policy making bodies and continuous exposure to current trends in service needs and management was proposed. Two groups, being reluctant to arrive at a decision on the "most suitable organizational structure", made a number of suggestions on the increasing responsibility and expanding range of relationships in moving from grass roots to central level in the structure. In each case the nurse/midwife administrator at central level should be expected to have direct anq/or collaborative responsibility-for programme design of services at all levels. 4.5.2 Plenary session

The following is a summary of major issues identified during the week by the four discussants selected for the purpose: (i) The importance of collaboration with other agencies as well as with community groups in the planning and administration of primary health carej and the contribution of the nursing/midwifery component in collaborative planning.

- 20 -

(ii) The problem of fragmentation of services by multiplicity of health workers; and the importance of retraining, at the operational level, for the purpose of coordinating services to families.

(iii) The need for in-service training and continuing education in planning and management techniques at the central and intermediate levels of nursing and midwifery services administration. (iv) Confusion arising from the use of professional Jargon which has different meanings for different people, and the need for more precise terminology in communication between people from different countries. Participants were then invi~ed to suggest ways in which external agencies could contribute to their programmes through collaboration and consultation. There was a consensus that consultation in nurse/midwifery education programmes and collaboration in in-service training and continuing education were needed. Mention was made of the advantage that would accrue to countries if WHO reports on current ideas and new technology were more widely available and distributed. Specifically, the WHO Public Health Papers on management and planning and programming were mentioned. Shared experience between countries with similar problems and conditions were suggested. It was considered that at a workshop such as the one being held, it would be beneficial to invite two participants from small countries (as well as large countries), so that on return to their country the participants would have the support of a colleague in interpreting new ideas gained. One participant whose country was soon to become independent expressed the need for WHO collaboration in preparing national nurses and midwives for senior positions which they had not hitherto occupied.

5.

EVAllJATION

5.1 The first objective was considered the "most important" before comine to the Workshop; objective 2 was considered the most satisfactorily covered in the discussion; and objective 3 was voted most often as the one for which two further days would be desirable. All presentations were considered very useful by 15 or more participants. Discussion of issues was thought to be very useful by only 13. Mos·~ "very useful" votes (21) were assigned to the planning process. The topics for discussion in group work were evaluated as follows: 80% very valuable, 17.4% fairly valuable and 2.6% of little value.

- 21 -

In "comments" following this question a number of participants expressed their intention to use for the first time, or to strengthen their use of, techniques in planning. One expected to be in better position to aim at more complete coverage in MCH services. Others talked of the multipurpo~e worker, of efforts of collaborating with other services. One proposaa to make "unofficial groups" her special target. Another intended to work at evaluating the present situation and discuss this with local people. Several resolved to apply planning techniques includlng evaluation, to primary health care, to the individual, family and community, at grass roots level. One emphasized the importance of coordination and collaboration and called on WHO to provide some consultation. There was also some constructive criticism in the comments; some felt that the mix of people representing developed and developing countries made some of the discussion appropriate to only some and not all of the partiCipants. One participant felt that technology of planning belongs to the developed world; another suggested that in this situation the discussion tends to concentrate on the larger richer countries. Most realized, however, that the principles of planning are the same in whichever situation they are applied. It was felt by some that too much material had been presented for a five-day meeting and one suggested two to three weeks as a period for really threshing out these concepts. It was suggested that material, including summaries of the presentations, should be sent to the participants ahead of time to enable them to prepare for the discussion. There were in the group some problems of language and communication and there was a reference to the use of jargon and terminology that means different things to different people. Finally, many participants used the "additional" comments space to express appreciation for the way the content was handled and there were many positive statements about the value of the Workshop.

6.

CONCWSIONS

In adopting the draft report, the participants agreed on the following conclusions. 6.1 The position of the nurse/midwife administrator in the organizational structure of national health programmes at the central and intermediate levels may affect the contribution of nurses and midwives to the delivery of health services at all levels. While no decision was taken as to the only appropriate position in the organizational structure of all countries, it was clear that when the opportunity arises in a country to examine the question, serious consideration

- 22 -

should be given to the advantages of the second of the following alternative options for administration at the central and intermediate level: (a) Nurse/midwife administrators functioning in a nursing unit with a chief nurse and administratively responsible for nurses and midwives in whichever programme they are engaged, but not directly involved in the overall administration of the programmes. (b) Nurse/midWife administrators functioning directly in serviceoriented programmes where they are responsible for the nursing/midwifery component. In this case, the administrators in the various programmes should constitute a coordinated group for the purpose of responding to the overall needs for nursing and midwifery services. 6.2 The second position requires that the nurse or midwife administrator should have all the necessary skills and qualities in administration and leadership and, in addition, should possess the high level training and experience required for the technical aspects of the programme. In this position she not only functions &8 an expert 1n her field but furthers the skills and promotes the standards ot care of the staff working at the operational level.

6.3 Primary health care is an approach which integrates at the community level all elements necessary to make a positive impact on the health status of the local population. As such, the activities involved are very much part and parcel of the regular responsibilities of nurses and midwives. To fulfil these responsibilities effectively, nursing/midWifery services must be directed to the individual within his family and to the family within the community. This involves specific approaches to the utilization, training and guidance of multipurpose health workers at village level whose function is within the framework of what is generally expected of nursing/ midwifery services. TO ensure standards ot care and coverage of community needs nurse/midwife administrators must be involved in programme planning and periodic evaluation, in close association with other services and groups. 6.4 Utilization of new techniques in management to increase service effectiveness and efficiency at all levels requires strong programmes of staff development for which international collaboration might be beneficial. 6.5 The compl.ex1ty of health and health related problems in individuals, families and communities necessitates a multidiscipline approach to their solution. However, the multiplicity of health professions at the professional and auxiliary levels has given rise to problems in administration ot services, which require serious consideration. It was suggested that these problems call for operations research, which is well suited to nurse/midwife administration. Some of these problems were touched on in the course of the Workshop: (a) The financial burden of training various categories of personnel and of staffing a service with duplication of records and a multiplicity of clinic attendances and home visits;

- 23/24 -

(b) The need for coordinators to tie all the various elements of a service together; (c) The impracticability of one worker covering the distances involved in handling cases of one category only, e.g., tuberculosis, as compared with the coverage of an entire neighbourhood or village in a more generalized manner with an understanding of the family's overall health condition. (d) The missed opportunity of interpreting to the family the relationship between health behaviour and status, as in sanitation and child health or nutrition and diseases. These problems highlight the need not only for the multipurpose worker to serve at village level, but also the need for nurses and midwives and other professional workers to envisage expansion and generalization of their roles at family level rather than limitation to narrow specialties which tend to create professional barriers and fragmented services. While health workers in general accept the concept of the inter-relation of health, social. economic and environmental factors in the lives of people, they do. not easilyrellnquishthe functions ascribed to their professions or adopt the functions ascribed to others. The group, for instance, expressed some dismay at the thought that a sanitarian could in some instances carry our "nursing procedures" when visiting a family. While some felt strongly that the multiplicity of health professions was a problem which requires study and change, others were less sure. All agreed, however. that this situation has major implications for nurse/ midwifery administration. Although no conclusion was reached, this report would be incomplete without mention of a matter which was widely discussed and will be of growing importance to nurse/midwife administrators in the future.

- 25 ANNEX 1

LIST OF PARTICIPANTS, OBSERVERS AND SECRETARIAT 1.

PARTICIPANTS

AMERICAN SAMOA

Me Diana Pilitati Director of Public Health Nursing Department of Medical Services Pago-pago Tutulla Ms Llorabel Rj!YDolds Acting Director of Nursing Department of Health P.O. Box 147 Darwin NT Habibah Binte Mohd. Hussin Principal Matron Bandar Seri Begawan Hospital Bandar Seri Begawan Dayang

AUSTRALIA

BRUNEI

COOK ISLANDS

Ms Emilia Goldie Acting Matron Health Department Rarotonga Ms Kuini Naqasima Controller of Nursing Services Medical Department Government Buildings ~

FIJI

FRENCH POLYNESIA

Mme Angeline Le Gayie Sabre Monitriee Ecole territoriale d'infirmiers et Infirmi~res de Papeete B.P. 1458 Papeete Ms Isabel T. Pangelinan Assistant Director for Public Heal th Nursing Department of Public Health and Social Affairs Agana

GUAM

- 26 -

Annex 1 (continued) JAPAN Ms Kayoko Shimizu Deputy Director, Nursing Division Medical Affairs Bureau Ministry of Health and Welfare 12-2 Kasumigaseki, Chiyoda-ku Tokyo 100 Ms

Shizuko Tamaki Chief, Nurse Sub-section MedIcal Affairs Section D1vision of Health and Envir"onmental Sanitation Okinawa Prefecture 1-2-32 Izumizaki Naba CIty, Okinawa Mme Khamsavanh Vilaythong Ecole des Infirmieres d'Etat l'H8pItal Mabosot Vientiane

LAOS

a

MALAYSIA

Puan Rosina bte HJ. Abdul Karim Principal Matron Nursing DivIsion Ministry of Health Kuala Lumpur Ms Kathleen Lo Acting Principal Matron Medical and Health Department Ku ching , Sarawak

NEW ZEALAND

Ms Barbara G. Shadbolt Nurse Adviser, Division of Nursing Department of Health P.O. Box 5013 Wellington Ethel M. Millar Matron-in-Chief Auckland Hospital Board Wellesley Street Auckland Ms

PAPUA NEW GUINEA

Ms J &net Doke Matron Port Moresby General Hospital Port Moresby

- 27 Annex 1 (continued) PHILIPPINES Ms Zenaida P. Nisce Nursing Programme Supervisor Bureau of Disease Control Department of Health Manila Ms Rosario S. Zaraspe Nursing Programme Supervisor Bureau of Health Services Department of Health Manila REPUBLIC OF KOREA Ms Kwang Hee Yang Public Health Nurse Administrator Medical Affairs Section 2 Ministry of Health and Social Affairs Seoul

SINGAPORE

Ms Tan Phaik In Nursing Officer MCH Headquarters National Family Planning Centre 26, Dunearn Road Singapore 11 Mr John A. Sisio10 Nurse Tutor School of Nursing Ministry of Health and Welfare Honiara Ms Kafo'atu Luani Matron, Vaio1a Hospital Ministry of Health Nuku 'a10fa Mr Asher Palik Chief District Nurse Ponape Hospital Kolonia, Ponape E.C. Islands 96941 Ms Sally Elizabeth McFall Nurse Teacher Health Department Apia

SOIDMON ISLANDS

TONGA

TRUST TERRITORY OF THE PACIFIC IS rANDS

WESTERN

SAMOA

- 28 -

Annex 1 (continued) 2.

OBSERVERS Ms Marcela R. Ordonez Division of Nursing Services Manila Health Department City Hall Manila Philippines Ms Felicula C. Castaneda Chief Nurse National Mental Hospital MandaluyOng, Rizal Philippines Me Fe M. Valdez President Philippine Nurses Association 1663 Kansas Manila Philippines

INTERNATIONAL COMo1ITl'EE OF CATHOLIC NURSES (CICIAf0f3)

INTERNATIONAL COUNCIL OF NURSES (ICN)

PHILIPPINE NURSES ASSOCIATION (PNA)

UNITED NATIONS CHILDREN'S FUND (UNICEF)

Mr Roger Tangara UNICEF Pro~ Supervisor P.O. Box 883 Manila Philippines 3. SECRETARIAT Me Helen Cohn Lecturer on Public Health Nursing Harvard University School of Public Health 6 !7 Huntington Avenue Boston, Massachusetts 02115 United States of America C

Workshop Director

Secretary

Me Madeleine Lenoir Regional Adviser on Nursing Administration and Services WHO Regional Office for the Western Pacific Manila Philippines

- 29 Annex 1 (continued) Consultant

Dr Aleya Hammad Nursing and Public Health Officer Division of Strengthening of Health Services WHO Headquarters Geneva Switzerland Dr Jose Cortes Professor, National Health Planning University of the Philippines Institute of Public Health Pedro Gil street Manila Philippines

Temporary Adviser

WHO staff resource persons

Mr George Dorros

Technical Officer (Project Systems Analysis) Health Planning Unit WHO Regional Office for the Western Pacific Manila Philippines Ms Helen Fillmore Regional Nursing AdViser/ Family Health WHO ~gional Office for the Western Pacific Manila Philippines Ms Naomi Gelina WHO Public Health Nurse Administrator General HeaLth Services Development Project Manila Philippines Ms Olive Manning WHO Public Health Nurse Public Health Advisory Services Project Suva F iji Mr M. Subramanian

-

Technical Officer (Operations Research) Health Planning Unit, WHO Regional Office for the Western Pacific Manila Philippines

- 30 Annex 1 (continued) WHO staff resource persons Mr Edgar TUrner WHO Public HQalth Nurse Administrator Development of Health Services Project Vientiane Laos

Other members of the Secretariat

Ms Mary O. Abbott Regional Adviser on Nursing Education WHO Regional Office for the Western Pacific Manila Phil1pp1nes A.A. Angara Assistant Director of Health Services WHO Regional Office for the Western Pacific Manila Philippines Dr Dr George Emery Regional Adviser on S\rengthening of Health Services WHO Regional Office for the Western Pacif1c Manila Philippines

-,1 ANNEX 2

LIST OF WORKIm DOCUMENTS/BACKGROUND MATERIAL 1. Working paper Role of Nurse and Midwife Administrators in the National Health Services of the Western Pacific: Problems and Heeds, by Ms Madeleine Lenoir, WHO Regional Adviser on Nursing Administration and Services. 2. WHO publications distributed to the participants Technical Report Series No. 499 - Organization of Local and Intermediate Health Administrations Technical Report Series No. 558 - Community Health Nursing Public Health Papers No. 44 - Planning and Programming for Nursing Services Public Health Papers No. 55 - Modern Management Methods and the Organization of Health Services Report of the Technical Advisory Committee on Nursing, Manila, Philippines. World Health Organization, Health by the People. Geneva. 1975. 3. Books and documents for reference Amundson, N.E. (1972) Labor relations and the nursing leader. Journal of NurSing Administration, 2: 6 Passim, September-October 1972. Baker, Frank and Gregory O'Brien (1971) Intersystems relations and coordination of human service organizations. American Journal of Public Health, 61: 130-7. January 1971. Becker, Marshall (1970) Factors affecting diffusion of innovations among health professionals. American Journal of Public Health. 60: 294- 304, February 1970 Campbell, John (1971) Working relationships between providers and consumers in a neighborhood health centre. American Journal of Public Health. 61: 97-103, January 1971. Devlin, H.B. (1974) Nurses in administration. 2: 505-6, 1 June 1974. British Medical Journal,

- 32 Annex 2 (continued) Evans. M. (1973) The future role of nurses in the delivery of health care in urban areas. Australian Nurses Journal, 6:38-40, December 1973. Fielder, R. (1971) District nursing has a frontline organization, some lessons to teach? NurSing Times, 67: 1132-3, 9 September 1971. Freeman, Ruth B. and E.M. (1960) Administration of public health services. Philadelphia, W.B. Saunders. Pt. 3, Management and development of personnel, "pp. 307-415. Freeman, Ruth B. Teamwork in public health. Canadian Journal of Public Health, 55: 380-5. September 1964. Hanlon, John J. (1969) Principles of }8bliC health administration. St Louis, C.V. Mosby Co. pp. 25Q-2{ • Kramer, M. (1972) The consumer's influence on health care. Outlook, 20:574-8, September 1972. LeVin, Lowell S. (1972) Time to hear a different drum. Journal of NurSing, 72:2007-10, November 1972. ~ndars,

Nursing

American

M.E. (1974) Reorganisation: Under new management - 1974. Nursing Times, 70:454-6, 28 March 1974

Lum, Jean L. (1970) Interaction patterns of nursing personnel. NurSing Research, 19: 324-30, July-August 1970 Maas, Meridean L. (1973) Nurse autonomy and accountability in organized nursing service. Nursing Forum, 12":237-59, 1973 Mahowald, J.F. and others. (1974) Decentralization of nursing authority. Superv Nurse, 5: 40-1 passim, March 1974. Mars, M.L. (1973) Nurse autonomy and accountability in organized nursing services. Nursing Forum, 12:237-59. 1973 NaJman, J .A. Asking the unanswerable. 6:35-7, December 1973 Austra1i8l1Nurses Journal, Geneva, World

Newell, Kenneth W. (1975) Health by the people. Health Organization.

Palmer, J. (1973) Management by objectives. Journal of Nursing Administration, 3:55-60, September-October 1973. Pan American Health Organization. (1972) Health systems. D.C. (Scientific Publication No. 234) Washington,

Petersen, H.M. and others. (1974) An approach to citizen involvement in education and health care delivery. Journal of Medical Education, 49:189-91, February 1974.

-"Annex 2 (continued) Pitts, A. (1974) Introducing management concepts. Journal, 68:12-3, July 1974. New Zealand Nursing Plu ckhan , Margaret L. (1972) Professional territoria11ty - a problem affecting the delivery of health care. NurSing Forum, 11:300-10, 1972. Primary health care. (1975) World Health, April 1975.

Prouty, M.P. (1974) Making an organizational chart. Journal of Nursing Administration, 4:32-5, January-February 1974. Skarupa, J.A. (1969) Management by objectives, a systematic way of managing change. Hospitals, 43:49-52, 16 September 1969. Skrovan, Clarence and others. (1974) Community nurse practitioner; an emerging role. American Journal of Public Health, 64:847-53, September 1974 Slater, Patricia V. (1973) The nurse practitioner, family practice nurse or physician's assistant. Australian Nurses Journal, 3:31-4, December 1973. Smith, D. (1972) Organizational theory and the hospital. Nursing Administration, 2:19-24, May-June 1972. Journal of

Snoke, A.W. (1970) States must bring public and private sectors together. Modern Hospitals 115:92-3. September 1970 Swaby, D. (1974) The use of philosophies and objectives in the administration of a nursing service department. Jamaican Nurse, 14:15 passim, April 1974. A theoretical basis for participatory planning. 4:275-95. 1973. Policy SCiences,

U.S. Department of Health, Education and Welfare. Planning for nurSing needs and resources. Maryland, 19(2, pp. 72-87. Varley, A. (1973) The nurse's role in health centre planning. Nursing Times, 69:904-7, 12 July 1973. Wagner, D.L. (1973) Issues in the provision of health care for all. American Journal of Public Health, 63:481-5, June 1973. Wieland, a.F. (1972) Manager-directed surveys for organizational improvement. Journal of NurSing Administration, 2:42-7, NovemberDecember 1972. World Health Organization. (1974) ~Mo~d~e~r~n~~~~~~~~~~ the organization of health services. Papers No. 55)

- 34 Annex 2 (continued)

4.

Outline of presentations (a) (b) (c) Three Approaches to Primary Health Care, by Ms Helen Cohn. The Planning Process, by Dr Jose Cortes. Operations Research - A Tool for Evaluation, by Mr M. Subramanian.

- 35 ANNEX 3

DISCUSSION TOPICS Day 2 Administration in Primary Health Care

Group 1 The health of the community is not served by health services alone. Nursing and midwifery, with other health services, and with workers from other sectors, reach into the family life, the sooial and economic conditions, the housing, education and many other faoets of the community. What measures need to be taken by administrators in nursing and midwifery to collaborate effectively with others in planning and implementing programmes for the community's health and welfare? Group 2 The most important resource in the delivery of health care is the availability of manpower. For this reason, nurses and midwives in administration are concerned with the education and training of various levels of health worker. However, the assignment of personnel and the best utilization of manpower are also important administrative functions. Discuss the major factors in determining the number and types of personnel required, and how best to struoture the staff for the purposes of the programme. Group 3 When planning programmes or participating in the plans of other sectors, nurses and midwives must take into account the needs and wishes of the people for whom the programme is planned, as well as the availability of nursing and midwifery personnel. Community participation in planning and implementing health programmes is a concept which has evolved from our understanding that the "professional" is not always the best judge of what is needed. In many instances "professionals" have found it difficult to work with, and accept, the wishes of the community. What is the basis of these problems and where do the solutions lie?

- ~Annex 3 (continued) Day 3 Technology of Planning and Administration for Improving the Performance of Health Care Systems

Group 1 In planning a programme, or one component of a programme, or even in making a plan of care for one patient or one family, it is clear that a network of interactions and interrelationships are created. Therefore each plan must be seen in the context of a broader plan, or a series of plans. How will this concept affect or strengthen your contrieution to programme planning in the fUture? Use illustrations from your past experience and say how you would now do it differently. Group 2 There may be a general feeling on the part of the administrator that i f the staff are working hard they are doing the best that can be expected of them. However, it may be that the service is not adequately meeting the ~ needs of the people in the best way possible. You could euild into your programme an evaluation tool which would help you to identify ways of improving the service. Select an example and give practical suggestions on how to develop and apply such an evaluation tool: include the participation you would expect of the staff in this process. Group 3 In the daily routine of nurses and midwives "getting the work done" may seem to be all that can be expected to reach the general goals of the programme.- But specific objectives, to be accomplished over a specified period of time, are required to motivate and encourage staff members to contribute to the best of their ability. Considering that the contributions differ according to the level of staff members, how could the administrator improve their performance quantitatively and qualitatively, what new or additional features would you now introduce in your programme? Select an example of a programme, formulate its objectives and say how you would proceed in order to reach your objectives. Include the participation expected of staff at all levels.

- 37 Annex 3 (continued) ~y4

Theme Continued

Groups 1, 2 & 3 In the administration of a health programme there is an individual or group 9f individuals who have the authority to make policy decision. Sometimes the nurse and midwife administrator is a member of this group, or is consulted by the individual, thus participating fully in the policy and decision making process. There are times. however. when decisions are made. even affecting nursing and midwifery, without their participation. Group 1 Discuss the effective 'implementation of change in programmes when Nursing and/or Midwifery Administration is not involved in the decision making process. Use examples from your experience to illustrate your discussions. Group 2 Discuss the sarne when Nursing and/or Midwifery Administration is involved in the decision making process. Use examples from your experience to illustrate your discussions. Group 3 In the situation cited above discuss what seem to be the reasons for inclUding or excluding nurses and midwives in the decision making process. Illustrate with examples from your experience and discuss the potential changes which could be made in your organizations. Day 5 Major Issues in Administration of the Nursing and Midwifery Component of Health Care Programmes

A.

Group Work (The Three Groups may discuss either one or both topics) 1. Administrators are often faced with the dilemna of centralization versus decentralization. Centralization means that, by and large. all decisions are made at central level.

-~Annex 3 (continued) Decentralization means that much of the decision making is delegated to the periphery. In both cases however the Nurse or Midwife Administrator at central level has maJor responsibility. Discuss these factors as they reflect the characteristics of a good administrator. 2. The Nurse or Midwife Administrator is called upon to represent the nursing and midwifery needs, (i.e., the people's needs for nursing and midwifery) as one component of the overall programme. To do this she must maintain the appropriate working relationship with the practising staff and must be aware of the needs of the community. What do you think is the most suitable organizational structure by which the nurse and midwifery administrators, at the central, intermediate and local levels, can best fulfil this function? B. General Discussion following Summary of Major Issues 1. During the Workshop a number of administrative strategies have been presented and discussed. Which of these seem most appropriate in your situation? Which seem appropriate but may be too difficult to implement? 2. Many of the concepts discussed in the sessions may require assistance from external agencies for their implementation. What role would you ask WHO to play?

- 39 ANNEX 4

AGENDA AND PROGRAMME OF WORK Monday, 8 September 8:00 - 8:30 8:30 - 9:00

Registration Opening Session - MB Madeleine Lenoir

Welcome by Dr F.J. ny, Regional Director, WPRO Opening Remarks - Ms Helen Cohn, Workshop Director Greetings from WHO Headquarters, Dr Aleya Hammad, Nursing and Public Health Officer Introduction by Participants 9:00 - 9:30 9:30 - 10:30

Coffee Workshop procedures - M. Lenoir Review and Adoption of Agenda - H. Cohn Nomination of Officers

Day 1.

The.e:

The Scope of Nursing and Midwifery Administration Chairman - -

- - Ms Z. Nisce

Rapporteur - - - - - Mr J. Sisiolo 10:30 - 12:30

Questionnaire on Participants' Positions and Functions Summary and Discussion

12:30 - 1:)0 1:)0 - 2:45

llmch

Panel Presentations 1.

Implications.of Administrative Responsibility and Functions as Depicted by Organization Charts - M. Lenoir Staff Development: - H. Fillmore A Punction of Administration

2.

- 40 -

Annex 4 (continued) Coffee

2:45 - 3:00 3:00 - 3:30

3.

Standards of Care - A Function of Administration H. Cohn

3:30 - 4:00

General Discussion

Tuesday, 9 September Day 2. Theme: Administration in Primary Health Care Chairman - - - - - -. Puan Rosina bte HJ. Abdul Karim Rapporteur 8:00 - 9:30 9:30 - 10:00 10:00 - 12: 30 - Ms Diana Pilitati

1.

Primary Health care Programmes - A. Hammad

Coffee 2.

Continuity of Care: and Challenges

Organizational Implications

Panel - M. Lenoir, N. Gelina, O. Manning, E. Turner

3.

Administration in Three Approaches to Primary Health Care. The Individual, the Family, the Community - H. Cohn

12:30 - 1:30 1:30 - 2:45 2:45 - 3:00 3:00 - 4:00

Umch Group Work. Cotfee Reports by Group Leaders Discussion See Discussion Topics Day 2

- 41 -

Annex 4 (continued) Wednesday, 10 September Day 3. Theme: Technology or Planning and Administration for Improving the Performance of the Health Care System Chairman Rapporteur 8:00 - 9:00 9:30 - 10:00 10:00 - 12:30 - - - Me Kwang Hee Yang

- - Ms L. Reynolds

1.

The Planning Process - J. Cortes

Coffee 2.

Management by Objectives - G. Dorros Operations Research: M.. Subramanian

3. 12:30 - 1:30 1:30 - 2:45 2:45 - 3:00 3:00 - 4:00

A Tool for Evaluation -

amch

Group Work.

See Discussion Topics Day 3

Cottee Reports by Group Leaders Discussion

Thursday, 11 September Day 4. Theme: Continued Day 3 Chairman Ms Kafo'atu Luani

Rapporteur - - - - - Ms Tan Phaik In 8:00 - 9:30

Organizational Behaviour in Leadership, Authority and Peer Relations - G. Dorros Coffee Dynamics ot Change: Servic.~Programmes.

9:30 - 10:00 10:00 - 12:30

Managing Change in Health .Issues and Problems

Panel:

J. Cortes, G. Dorros, M. Subramanian

';'

- 42 -

Annex 4 (continued) 12:30 - 1:30 1:30 - 2:45 2:45 - 3:00 3:00 - 4:00

wnch Group Work. Coffee Reports by Group Leaders Discussion See Discussion Topics Day 4

Friday, 12 September Day 5. Theme: Major Issues in Administration of the Nursing and Midwifery component of Health Care Programmes Chairman - Rapporteur 8:00 - 9:30 9:30 - 10:00 10:00 - 11:00 - Mr A. Palik

- - Ms E. Millar See Discussion Topics Day 5.

Group Work. Coffee

Reports by Group Leaders Discussion

11:00 - 12:30

Summary of Issues Presented Days 1 and 2. Discussants:· Ms K. NaqasilJ!& .. Ms K. Shimizu Problems of Implementation Panel: H. Cohn, A. Hammad, M. Lenoir

12:30 - 1:30 1:30 - 3:00

Utnch Summary of Issues Presented Days 3 and 4 Discussants: Ms K. Lo Ms B. Shadbol t

Problems of Implementation Panel:

J. Cortes, G. Dorros, M. Subramanian

- 43/44 -

Annex 4 (continued) 3:00 - 3:15 3:15 - 4:00

Coffee Open Session Evaluation Questionnaire

Monday, 15 September

Conclusions - Ms J. Doke

Chairman - -

Rapporteur - 8:00 - 9:30 9:30 - 10:00 10:00 - 12:00 12:00 - 12:30 ~y

Ms E. Goldie

or Evaluation Questionnaire

Coffee Presentation or Draft Report Closing Session

•

POSITION AND ruNCTION IN THE ADMINISTRATIVE STRUC'lURE

1. Level ot position Central InteI'lllediate Local Institution 2. Are you in: Community health Hospital Service Both Teachins Institution 3. What is the position of your immediate supervisor? Nursing Officer Medical Officer Lay Administrator Board of Directors Others

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8. Are your professional colleagues in your daily activities? Nurses only Nurses & doctors Nurses doctors and others Doctors only Others only

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•

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