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A Case Study On The Stress Of Caring

Parkway has taken some initial steps toward a new direction, but clearly it has a lot of work left to do. You’ve been brought in as a change management consultant to help the company change its culture and respond to the stress that employee experience.

You are required to produce a report for the Board of Directors of Parkway. In your report, you are expected to cover the following points: 

What do the data on employee injuries, incidents, absences, and turnover suggest to you? Is there reason for concern about the company’s direction?  [5 marks]

The company is going to be making some significant changes based on the AI process, and most change efforts are associated with resistance. What are the most common forms of resistance, and which would you expect to see at Parkway?  [10 marks]

Given the board of directors’ desire to re-energize the workforce, what advice would you provide for creating a leadership strategy? What leader behaviors should nursing home directors and nurse supervisors demonstrate?  [20 marks]

What are the major sources of job stress at Parkway? What does the research on employee stress suggest you should do to help minimize the experience of psychological strain for employees? Create a plan for how to reduce stress among employees.  [35 marks]

Based on the information collected in the focus groups, design a survey to hand out to employees. What sort of data should the survey gather? What types of data analysis methods would you like to employ for these data?  [30 marks]

Nursing is a nothing but taking the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death.

When ever we start thinking or talking about nursing homes one name is obviously came in our mind which is not other than Parkway health. Parkway nursing care is an organization which is all ways known for its very high quality of services, because of that it was very famous among the people from past 30 years but now a day’s parkway is facing lot of problem. To overcome from that problems management of Parkway nursing organization are going to make some massive changes in it.

2. SURVEY RESULTS:

According to data provided to us the researcher found that employee injuries, incidents, absents, and turnover rate are increased rapidly which is not at all good for the organisation.

Yes there are reasons for concern about company’s direction. And the reasons like injuries, absentees and turnover.

Employee Absentees:

There are numerous reasons for employee absentees which impacts their organization. Like they would not be able to provide quality services to their customers or clients on time or they can not meet the production deadline. The causes of absentees are physical health, stress and motivation.

Physical Health: It is a reason when the employees were not keeping well or they have some physical injuries.

Stress: When the employees personal and work life are not balanced and it makes the employees very stress full life.

Motivation: when the employees compare themselves with other organization employees they would be de-motivated.(Fisher; Scheoenfeldt; &show, 1999)

Injuries:

Health care it is kind of job which demands lot of physical strength of employees in their daily work. They suppose to lift their clients or patients for transferring from one place to another .The health care worker's loads are far more precious, come in all sizes and shapes, and may not always be cooperative. (David and Patterson)

In the nursing home environment, there are many causes for back injuries, including injuries such as the shoulder or arm, as well as neck strains. Most common reasons are low fitness level, overall physical strength, and proper posture of the worker. An employer who encourages, supports and promotes healthy lifestyles, such as weight management and exercise programs, may positively impact the staff's back injury exposure. Instructing staff in proper lifting techniques is basic to maintaining a safe environment in the nursing home

Turnover:

Employee turnover is nothing but a employees are changing there job they quit and go to another company .employees turnover is always found that headache for any organization because it is a costly part of doing business. When a company must replace a worker, the company incurs direct and indirect expenses. These expenses include the cost of headhunting fees, new hire training ,human resource costs, advertising, loss of productivity, and customer retention all of which can add up to anywhere from 30 to 200 percent of a single employee's annual salary, one again it is all depending on that company and the job role.

There are several reasons for employee turnover. While lower paying job roles experience an overall higher average of employee turnover, they tend to cost companies less per replacement employee than do higher paying job roles. However, they incur the cost more often. For these reasons, most companies focus on employee retention strategies regardless of pay levels. (Turnover, 2011). The most common reason for turnover is management and that kind of reasons are preventable

3. PROBLEM IDENTIFICATION

According to survey result we come to know that there are number of problems are going on in side the parkway nursing care organization but the main problem which we found that’s are

1. Staffing

2. Physical demands of employees

3. Documentation

4. Focus is on feeling the bed

(1) Staffing:

Staffing has been a very important part of all types of organizations’ development. There are lot of organization found that good staffing plan could increase productivity and reduce operation costs in terms of lower turnover rate and transition costs. As cost is decreases profit in creases. Very good staffing always helps to minimize cost in order to profit get increases. There can be three types of staffing problem in nursing homes.

1) The nursing home does not properly train its staff.

2) The nursing home simply doesn't have a full staff.

3) The nursing home does not perform sufficient background checks on staff members.

In the parkway nursing cares they are suffering with second type of staffing problem. because of more and more patients are coming in. The number of patients is going on increasing every individual year and there are no staffs to take care of these patients. The result is that nursing home staff jobs come with a very high turnover rate, and adult care facilities are often scrambling to fill openings.

(Staffing, 2011)

(2) Physical demands:

Nursing is a kind of job which demands lot of physical fitness from you because

Heavy lifting is required every time. Starting from the changing beds of the patients even for changing bandages, changing there diapers or carrying patients from one place to another Nurses need to be standing on there feet for hole day is the mostly happened every were, they do have lot of other responsibility on there shoulders like they need to caring, sympathetic, responsible, and detail oriented. As well as they need to take care of other work which is related to patients like giving proper medicine on proper time creating documentation etc. That kind of hard work gives lot of physical and mental stress to the nurses those who are working in parkway nursing homes. And there are lot of patients are coming every body is having his of nature some of them are not co operate with nurses that make there job very stressful. Because of that at the end of the day they become very tired. (Physical demand, 2011).

(3). Documentation:

Source: Google image

Documentation is nothing but to information about client is kept in form of paper or in the form of electronic documents for example information is store in the cd, emails, and tapes or in the form of image. In the documentation nurses mentioned there observation, decision and the response of the patient. Accurate documentation is very important task in occupation like nursing some of patient symptoms and observations is critical to proper treatment and recovery.  Entries written on a patient's medical record are a written, legal, permanent document.  If documentation is not properly written or inaccurately entered into a medical record, patient may receive improper or potentially harmful care.  What you document as fact in a medical record is directly used by physicians, nurses, and physician assistants to plan, implement, and evaluate their patient's course of treatment. (Doc, 2011).

The most of nurses in parkway nursing homes are prefer pen paper for documentation they are not very familiar with electronic documentation .so according to new rules of government they suppose to producing electronic document but they are not very comfortable with it. (Coleman, 1997).

4. Focus is on filling bed:

The main focus of any organization is gain profit. The top management is always looking for increase the profit. When sale increases and cost is decreases then automatically profit is an increase that is simple formula of increasing profit. In the parkway nursing homes management is looking for increasing sale by feeling beds and looking to reduce number of staff for decreasing cost. Which put extra pressers on experience staffs because of those lots of problems are going on in parkway nursing homes.

4. CHANGE MANAGEMENT STRATERGY:

“It is not the strongest species that survive, nor the more intelligent, but the most responsive to change”

- Charles Darwin

The change management strategy defines the approach needed to manage change given the unique situation of the project or initiative. There are always two types of changes one is revolutionary changes and other is evolutionary changes. Revolutionary changes are always coming from the top and they are going to affect each and every body in the organization (Change, 2007).

Some Adaptability Issues

Revolutionary change:

In such kind of changes we are very receptive to ideas from outside of the team. We are very proactive in seeing and managing external problems that could impact the team. We all respond to changes in our external environment in constructive ways. The change process itself becomes reliant on the individual.

Evolutionary change:

In such kind of changes we are very proactive in seeing and managing internal problems that could impact the team. We take the time to reflect on how well we are working as a team and make necessary adjustments. We all respond to changes on the team in constructive ways. Very often, this is related to efficiency. HR policies change, maybe you merge a couple of teams. (Eva-rev, 2010).

4.1 FORM OF RESISTANCE TO CHANGES:

We all know changes and resistance are always walking by keeping hand in hand. Every change comes with form of oppose by users. There are lots of reasons in people or in employees mind for resistance to changes. The forms of resistance are like habit, security, economic factor, selective information process, and fear of unknown etc.

4.2 RESISTANCE IN PARKWAY:

When we are talking about parkway we can clearly see that staffing is really very big problem in organization. To solve this problem we need to increase or improve number of nurses.

For that kind of changes parkways old staff or we can say senior staff definitely gives some resistance.

There are lots of reasons to resist changes and the reasons are like insecurity about there job they do have fear ness of losing there job. They have fear of failure, nurses are not comfortable because they feel that they might loss there Control, staff in parkway nursing care is not having Trust on there management, nurses feel that they may not Comfortable while working with new staff.

(Resistance, 2011). Physical injuries can de minimized by using automatic carrying equipments or machines but the older staff which was appointed for do carrying patients will definitely appose this changes because they do have fear ness of losing there job.

Because of the new rule and regulation of government of Singapore documentation is has to be electronic, but most of nurses in parkway nursing homes are prefer pen and paper for documentation they are not very familiar with electronic documentation. They are more than happy in doing traditional documentation. They will definitely appose this idea because are not very comfortable with it.

In the parkway nursing homes the main focus of an organization is to filling a bed. The management need to think about it they need to choose limited patients as much they can handle properly. To implement this change management will resist because they are in under impression like that if they reduce filling bed there income will reduce.

4.3 OVERCOMING RESISTANCE IN PARKWAY

Source: Google image

To overcome resistance is going on in the parkway nursing homes we will use kotter’s 8 change plan

Increase urgency –

Provide job security to all nurses. Organize some new training program for them to remove fear in there mind.

Build the guiding team –

Choose perfect employee on perfect place. Create a team with a combination of senior and junior nurses.

Get the vision right –

Allow that team to create new vision and strategy to minimize resistance to changes The vision should be designed in such a way that it should completely focus on good quality and services.

4. Communicate for buy-in –

Communication is best way of taking response. Because instant response is very important after every changes in organization. Try to involve more number of nurses in the process. De-clutter communications - make technology work for you rather than against.

Empower action –

Inperticular this stage implement all kind of changes in organization. Like electronic documentation, automatic lifting equipments etc. and try to take feedbacks from them provide very good support to implement it. Try to remove obstacles in the way.

Create short-term wins –

Give some short term easy goal to achieve. Arrange training and counselling to those nurses those who are still apposing to changes. Give training announce to nurses.

Don't let up –

After completing training section take test of nurses and find out how they are responding to training.

Make change stick -.

Select a leader who is having quality to support changes and who take organization in right direction.

http://www.businessballs.com/changemanagement.htm

5. IMPLIMENTATION:

A leader is a person who has a vision, a drive and a commitment to achieve that vision, and the skills to make it happen.

“A Quality leader should be a person with vision and should be brave enough to support change. The traditional role of a leader as a commander has to change that of a coach. Instead of supervising, a leader should delegate; and instead of controlling, she/he should be a mentor.”

A.P.J.Abdul Kalam

Characteristic of good leaders are:

Bring out the best in people of differing personalities and skills

Get to know everyone in the team and know how to user them in the best advantage

Delegate and empower people while keeping an eye on what has to be achieved, and being able to stand back from the day to day action

Recognize and exploit the strengths of the team and are prepared to compensate for individual weaknesses

Inspire people to give their best

Accept team members as having expertise that they may not have

Create and environment in which team members share responsibility for achieving results

Are good communicators and know how to involve everyone

Combine qualities that at first may seem contradictory, such as the need to be

(Leader, 2010)

(1) CREATING LEADERSHIP STRATEGY:

From the past couple of years the basic responsibilities and role of nurse has changed today’s nurses are not only taking cares of patients but also they are helping doctors to take a decision as well as they have also taken a decisive role in the administration of hospitals because of that it is become very important to nurses to jump in to leadership role so they can involve in planning, leading, controlling and organizing the activities of others. As per Dr. Rose Sherman, "Facilitating the growth and development of staff is an important nursing leadership function."

(Leadership, 2011) Every individual person is having is own experience, attitude, approach and own style to look at situation. Leadership style varies with personality and situational need. There are lots of different approaches, or 'styles' to leadership and management. Leadership style is partly decision making style and partly a way of motivating employees. The styles are always depends on leaders culture, belief and preferences.(Hersey & Blanchard, 1981)

There are several leadership styles like:

Charismatic Leadership

Participative Leadership

Situational Leadership

Transactional Leadership

Transformational Leadership

The Quiet Leader

Servant Leadership

(Styles of leadership, 2011)

(2) RECOMMEND LEADERSHIP STYLE IN PARKWAY:

After doing all kind of study about parkway researcher thinks that instead of only leadership style combination of two leadership like situational leadership and Charismatic Leadership styles are more effective in this particular situation. (Situational leadership, 2009)

There are basically three types of leadership styles - autocratic, bureaucratic, participative, situational and transformational leadership. Autocratic leaders are those who set a goal and do not allow others to take any decisions. If a person strictly sticks to policies, rules and regulations, it's called a bureaucratic leadership style, while a participative leader allows others to participate in the decision making process. A participative leader style makes it a point to make others realize the importance of attaining a goal. If a leader combines all the three above mentioned leadership styles, it's called situational leadership style. In the world there is nothing like all leadership style in the one. Those can be a successful leader who are having quality of taking or changing decision according to demand of the situation. This is called ‘situational leadership’. (Hersey& Blanchard, 1982).

In the parkway nursing homes we need that kind of leader who can choose different styles according to the competency of their followers.

Because there are different kinds of nurses. There are nurses who lack competence but are enthusiastic and committed. They need direction and supervision to get started.

A smart leader is always sensitive to the willingness of their followers and he/she may assign the task according to the will and skill set of the followers.(Jooste, 2004)

Below are the lines that explains briefly about Situational Leadership

5.3 LEADER BEHAVIOR OF NURSING HOME DIRECTORS

Motivation

Nurses are coming from various places with different background they are having there own experience, behavior and attitude. A caliber of leader to motivate each and individual nurses in the parkway with perfect way is included in very good nursing leadership strategy. The main problem in the parkway is that most of nurses are coming from different generation. To solve that problem leader has to be a very good motivator. Mostly senior nurses are from old generation and they are comfortable with traditional methods they may feel threatened by new young nurses because they are used to with new system so that is responsibility of young nurses to show there respect to senior nurses and try to motivate them to share there knowledge and experience to others. And young nurses those who are doing well they should motivate by leaders by giving constant feedback on there performance.

5.2.3 Communication

Communication is very important in leadership. Communication is best way of being touch with Nurses. Because instant response is very important after every changes in organization. And when you are communicating with nurses so they feel assurance when they hear from their nursing leadership. Communication is has to be in both direction so open your self to listening suggestion of your nursing staff. Leader also can express his thoughts in writing form.

.

5.2.4Encouragement

While leading a team or organization giving encouragement to subordinates is very important because encouragement give psychological effect. Those who are really working very hard tell them nursing leadership is looking at there affords so that they can have confidence to approach you with any problem. Try to give some special things those who are really dedicated and giving very good out puts (Vroom and Yetton, 1973)

5.4 LEADER BEHAVIOR OF NURSING SUPERVISORS:

As a nurses supervisor manager you need to manage working shifts of all nursing staff those are working in your team. That time lots of difficulties are coming to front of you that leader has to be calm and motivate your staff to perform better under the situation. Always help junior to understand how to handle conflict options in hard situation and following discipline in nursing homes. When any new nurse is coming in then it is responsibility of supervisor to ask seniors to give training to junior nurses in that fashion so they can relate theory to practical environment.

(Hersey & Blanchard, 1981).

Motivate new nurses to apply there knowledge and skills under the supervision of experience staff. Provide all kind of leadership training to senior nurses for providing support and teaching skills to juniors. If experience staff is co operative then it will reduced presser from the new nurses. Keep providing feedbacks to juniors or seniors about there job whether it should be positive or negative so they can keep updating there knowledge. (House and Mitchell, 1974).

Try to solve all kinds of misunderstanding between your staffs and try to minimize distance between seniors and juniors. Ask juniors to keep observing your seniors carefully, and analyze whatever decisions your seniors take, so that when you reach their position, you are ready to take over the responsibility. Use advocacy skills to motivate or reinforce the administrator and staff in favour to change.

6. JOB OF STRESS IN PARKWAY:

STRESS:

Stress is nothing but a feeling of emotional or physical tension. It is the way of response of our body in different situation. People feel stressed when something going on around them. Stress can affect both your body and your mind. People under large amounts of stress can become tired, sick, and unable to concentrate or think clearly. Sometimes, they even suffer mental breakdowns.(Stress, 2011)

6.1 Sources of stress in parkway

Environment Stress

Environmental stress is nothing but a response to things which are going around you that cause stress. From the beginning of the day to the end of the day, we experience lot of minor irritations and frustrations.  These can be very small, such as noise, crowding, and pressure from work or family and include things like getting stuck in a traffic jam, suffering a backache from an uncomfortable chair, being distracted by gossiping colleagues, disorganized environment. (Kahn, Wolfe, Quinn, Snoek and Rosenthal, 1964). Even though these frustrations are small, each one either triggers a small release of stress hormones into our bodies or reduces our overall sense of happiness. This creates a background level of stress in our lives, which is then exacerbated by the serious stressful incidents we deal with elsewhere within this site. By managing the small stresses in our life, we can reduce the impact of the major stresses when they occur. Understanding how the environment might affect you is the first and necessary step to overcome this kind of stress or it will help lower your stress level.

(Environmental stress, 2010).

Personal stress:

There lots of reason of personal stress the main reason of all of them is not happy in the particular environment such as a difficult or demanding job. Or personal stress can occurs because of the economical problems like exceeding income capacity .personal relation with employee’s family or friends is also cause for personal stress Or Major life changes such as divorce, the death of a family member or an illness cause personal stress. Positive events such as the birth of a child or attending college also will cause personal stress, because the sudden change requires a quick adjustment to a new situation. (Personal stress, 2010)

Effects of Stress

Stress affects our body as well as our emotional system badly.

How stress affects the body

Common symptoms of stress are like fast heartbeat, headache, stiff neck and/or tight shoulders, Back pain, fast breathing, sweating, and sweaty palms. An upset stomach, nausea, or diarrhea.

Over time, stress can affect our:

Heart. Stress is cause to high blood pressure, abnormal heartbeat. Blood clots and hardening of the arteries. It's also linked to heart attack, and heart failure.

Muscles. Constant tension from stress can lead to neck, shoulder, and low back pain. Stress may make rheumatoid arthritis worse.

Stomach. If you have stomach problems, such as gastroesophageal reflux disease (GERD), peptic ulcer disease, stress can make your symptoms worse.

Reproductive organs. Stress is linked to low fertility, erection problems, and problems during pregnancy, and painful menstrual periods.

Lungs. Stress can make symptoms of asthma

How stress affects your thoughts and emotions

You might notice signs of stress in the way you think, act, and feel. You may:

Feel cranky and unable to deal with even small problems.

Feel frustrated, lose your temper more often, and yell at others for no reason.

Feel jumpy or tired all the time.

Find it hard to focus on tasks.

Worry too much about small things.

Feel that you are missing out on things because you can't act quickly.

Imagine that bad things are happening or about to happen.

The type of stress matters

Stress can affect you both instantly (acute stress) and over time (chronic stress).

Acute (short-term) stress is the body's instant response to any situation that seems demanding or dangerous. Your stress level depends on how intense the stress is, how long it lasts, and how you cope with the situation.

Most of the time, your body recovers quickly from acute stress. But stress can cause problems if it happens too often or if your body doesn't have a chance to recover. In people with heart problems, acute stress can trigger an abnormal heartbeat or even a heart attack.

Chronic (long-term) stress is caused by stressful situations or events that last over a long period of time. This could include having a difficult job or dealing with a chronic disease. If you already have a health problem, stress can make it worse (Affect of stress, 2011).

6.2 ACTION REQUIRED

Stress management involves controlling and reducing the tension that occurs in stressful situations by making emotional and physical changes. The degree of stress and the desire to make the changes will determine how much change takes place.

Workplace stress occurs when demand of work is increases and employees not having sufficient recourses to handle or to complete that demand .there recourses are can be physical, emotional, economic, social, or spiritual. Workplace stress can be described as the physical and emotional outcomes that occur when there is disparity between the demands of the job and the amount of control the individual has in meeting those demands. Anytime stress occurs, it. Thus, workplace stress occurs when the challenges and demands of work become excessive, the pressures of the workplace exceed the worker's ability to handle them, and job satisfaction turns to frustration and exhaustion. Due to these employees’ absentees, workplace accidents, injuries, turnovers are increases. (Jick and Payne, 1980).

Emotional stress is one of the parts of stress it usually occurs when employees found situation which is difficult or challenging. Different people consider different situations to be stressful.

Emotional stresses are always very difficult to understand and manage. because , it is self-created, in that kind of situation employees worried about there families or there job it can come out of nowhere and the stress caused by it only heightens the emotions felt. Thus, as the emotional stress increases, the emotions get worse, heightening the emotional stress. Thus with out solving problem, problem became worst. It is also called as internal stress this often happens when we worry about things we can't control or put ourselves in situations we know will cause us stress. (Quick and Quick, 1984)

The main cause of this kind of stress is employees feel that they are not having job security. To reduce its impact and to increase the chance of survival in the wilderness,

The main key point to overcome survival stress are keeping a clear head and thinking logically, prioritizing your needs, and improvising all will help alleviate some of this stress.

When a problem arises, remember the acronym STOP:

S: Stop - Clear your thoughts and focus on the problem.

T: Think - Identify practical solutions. Consider each in detail.

O: Organize - After looking at your options, pick one. Develop a step-by-step plan from beginning to end.

P: Precede With Your Plan - Be flexible and make adjustments as necessary.(Williams and Huber, 1986)

6.3 STRESS MANAGEMENT PLAN:

Stress can impact our body very badly the nurses in the parkway nursing homes are going under lots of stress so we suppose to be manage stress before every thing. We can take some positive steps to reduce or to control the stress. (Van Den Tooren and De Jonge, 2008)

There are several ways to reduce stress like:

Stress management training:

In this kind of training professionals will teach nurses how to control stress on there mind by doing some physical exercise training, time management, relaxing, proper break planning, improving social life.

Physical exercise training:

Health is always important factor of reducing stress. When the fitness level of nurses is high then they will feel more energetic for work. Because of that Physical exercise is require. As well as they require good and healthy food. Good health always appose impact of negative harmonise.

Relaxing:

Because of the heavy and busy schedule of nurses they never get time for relaxing if we give some time for relaxing they will defiantly get refreshed and feel good while working that kind of process is always works for reducing stress over the nurses.

Proper break planning:

Day by day they are doing same thing and nursing job give physical and mental stress to them if we give proper break to them so they can go out side and enjoy there personal life with there family and friends. It is also a very good way of reducing stress.

Improving social life:

Improving social life is the best way of reducing the stress. If nurses are start making friends and start attending social functions it will really help them to reduce there stress it will help them to change there mind from the work.

There are other lots of methods those nurses can use for reducing there stress and the methods are like laughing. Laughter is one of the most valuable resources to help you reduce and manage stress; breathing taking interest on other curricular activities like playing, singing, dancing this all kind of thing will gives strength to nurses for overcoming stress. (Stress management, 2011).

CONCLUTION:

After studying case study in various direction researcher comes to one point is that to stop high turnover rate, absentees, and injuries of staff member management has to be look forward for making some changes in organization. The world we live in is continuously changing. And to stay in competition we need to change our knowledge and technology. After implementing changes in to organization management might be need to be suffering for some initial time of period like experience staff will definitely oppose it and they need to invest more money and need to take a more risk. But that kind of investment will give more benefit in the future.

8. REFERANCESS:

Books and Journals:

Coleman, A. (1997). Where do I stand? Legal implications of telephone triage. Journal of Clinical Nursing, 6, pp. 227-231.

Fisher, C.D; Scheoenfeldt. L.F; &show. J.B (1999), Human Resource Management, Boston, Houghton Mifflin.

Hersey, P., & Blanchard, K. H. (1982). Leadership style: Attitudes and behaviours. Training and Development Journal, 36 (5), pp. 50-52.

Hersey, P., & Blanchard, K. H. (1981). So you want to know your leadership style?. Training and Development Journal, 35 (6), pp. 34-54.

House, R.J. and Mitchell, T.R. (1974). Path-goal theory of leadership. Contemporary Business, 3, Fall, pp.81-98.

Jooste, K. (2004). Leadership: A new perspective. Journal of Nursing Management, 12 (3), pp. 217-223.

Jick, T. D., and Payne, R. 1980. "Stress at work." Exchange: The Organizational Behavioural Teaching Journal 5: pp.50-55.

Kahn, R. L., Wolfe, D. M., Quinn, R. P., Snoek, J. D., and Rosenthal, R. A. 1964. Organizational Stress: Studies in Role Conflict and Ambiguity. New York: Wiley.

Quick, J. C., and Quick, J. D. 1984. Organizational Stress and Preventive Management. New York: McGraw-Hill.

Van Den Tooren, M. and De Jonge, J. (2008), Managing job stress in nursing: what kind of resources do we need?. Journal of Advanced Nursing, 63: 75–84.

Vroom, V.H. and Yetton, P.W. (1973). Leadership and decision-making. Pittsburg: University of Pittsburg Press

Williams, J. C., and Huber, G. P. 1986. Human Behaviour in Organizations. Cincinnati, OH: South-Western Publishing.

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