Unit 3-Organizing Nursing Care

Unit-threeOrganizing Nursing

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Learning objectives

At the end of this unit, the learner will be able to;Define system Differentiate among various types of nursing care delivery systemsList the advantages and disadvantages of various types of nursing care delivery systemsDiscuss about the different types of organizational structure

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Organization

Organization- is a group of people under formal or informal rules working together for common goal.

Organization is has two concepts, both structure and process.

A.Organization process-refers to the method used to achieve og’nal goal.

B.Organization structure-refers to the lines of authority, communication and delegation.

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Organizational concept

• Responsibility :-is the obligation to do.• Authority :-the right of decision and

commands.• Delegation :-assigning duties.• Accountability :-answering for what has

been done.

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Organizational characteristics

Span of control-The number of employees a manager can effectively oversee.

Mostly top manager can not manage as many employees as managers at lower level.

For example, the ratio for manager to employee’s is 1:3 in top level, 1:6 in middle level, and 1:20 in low level.

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Organizational characteristics…

The effective span of ctrl for each manager depends on;

Work pacePattern of worker skill and knowledgeThe amount of work interdependence

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Organizational characteristics…

When span of ctrl is broad; The manager has insufficient time to

observe Can not evaluate performance Can not give feedback

When span of ctrl is too narrow; Manager supervises employees closely. To

close supervision discourage subordinates problem solving, independent decision making, creative thinking.

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Organizational principle

• Unity of command :-the employee should be responsible to only one supervisor.

• Requisite authority :-an authority over both on the position and resource during delegation.

• Continuing responsibility :-managers function not diminished during delegation for subordinate.

• Organizational centrality (communication) :-greater interaction in work place and have high information in the org’n.

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Organization structure

The principal purpose for defining org’n diagram is to clarify chain of command, span of ctrl, official communication, and linkage for on dpt personnel.

It is customary to show formal org’n structure in a diagrammatic form with a three dimensional model having depth, height, and width.

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Organization structure…

Boxes containing various position titles are positioned vertically to highlight difference in status and responsibility.

Position boxes are connected with lines to demonstrate the flow of communication and authority through out the entire network.

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• D/t types of interconnecting lines signify d/t types of r/ships. – For example;

•A solid line b/n two positions indicates direct authority or command giving r/ship.

•A dashed line or a broken or a dotted line indicate a consulting r/ship with no prescribed frequency of the structure to collaborate for planning or ctrl purpose and commands don’t flow.

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The org’n chart does not show the degree of authority, i.e. a manager has over subordinates.

For example, a manager with authority of head nurse may lack authority hire or fire the worker.

Organizational structure can be informal or formal.

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1. Informal og’nal structure

Characterized by unspoken, often covert Lines of communication and authority

r/ships not depicted in the org’nal chart The informal structure develops to meet

individual’s needs for friendship, a sense of belongingness, and power

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1. Informal og’nal structure…

The lines of communication in the informal structure commonly called the “grapevine” and concerned mainly with social issue.

Persons with access to vital information can become powerful in the informal structure.

Some administrator try to hinder the effect of informal org’n, b/c they facilitate the passing of information.

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1. Informal og’nal structure…

The information may be a rumor, but the best way to combat rumor is by free flow of trustful information.

The informal org’n can help to serve the goal of formal org’n if it is made by the servant of administration. It should not be controlled.

A major shortcoming in its use is that not all employees are part of the informal org’n.

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2. Formal og’nal structure

• An og’ns formal structure is depicted in its og’nal chart i.e. provides a “blue print”, representing formal relations, functions and activities.

• The primary significance of formal org’nal structure is the frequency of communication b/n particular staff members.

• Particular workers are expected to relate directly with certain individuals and not others.

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Types of formal org’nal structures

1. Line pattern/relationship2. Line and staff pattern/relationship3. Matrix org’nal structure4. Functional line and staff pattern

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1. Line pattern/relationship

• The oldest and the simplest.• It is a straight forward, direct chain of

command with superior-subordinates r/ship.

• More efficient than other formal org’nal structure.

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1. Line pattern/relationship…

The typical line pattern is divided laterally into segments representing d/t nsg specialties.

The perspective of workers differs from the bottom to the top of structure.

Workers at the base of pyramid nsg assistant, at the middle head nurse and at the top vice president or director or assistant director.

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Advantage Easy to orient new employee Easy to manage workers Well established division of labor There is a clear cut work specialization

and role separation

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Disadvantage• Makes employee task narrow, repetitive

performance and communication difficulties among specialists due to specialization.

• Workers tend to resist innovative change and resist recommendation from outsider’s b/c of rigidity.

• Causes passivity and dependency in staff members and autocratic b/r in manager.

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Disadvantage…•The strong chain of command and concentration of authority at the top of hierarchy causes lower level employees to refer difficult problems to their immediate superior.•Manager talks more than to listen.•Weak integration of d/t divisions or dpts.

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2. Line and staff pattern/relationship…

Line functions are those i.e. direct responsibility for accomplishing the objective of nsg dpt. For the most part they are filled with RN, licensed assistant nurse or other type of nurse.

Staff functions are those that assist the line in accomplishing the primary objective of nsg. They include clerical, personnel, budgeting and financing, staff development and research.

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The r/ship b/n line and staff are a matter of authority. Line has authority for direct supervision of employees while staff provides advice and counsel.

To make staff effective, top mgt ensures that line and staff authority r/ships are clearly defined. Personnel of both should work to make their r/ship effective.

They attempt to minimize friction by increasing trust and respect.

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Advantage Key mgt function that the chief executive

has neither skill nor time to execute well are delegated to functional experts who can devote full time to the assigned function with out being distracted by responsibilities of day today mgt of material and personnel.

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Disadvantage• Staff officer have less power than line

officer b/c the later directs the basic operations

• Staff officer must stand quietly in the background while, line managers receive recognition for improvements.

• Staff positions are located at the periphery of the org’nal structure, which casts incumbents in the role of social isolates.

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3. Matrix org’nal structure Is a complex constructed in which and

employee may be responsible to two or more bosses for d/t aspect of work.

Potential problem with a matrix type of org’nal structure can easily be observed or perceived.

If for example, the head nurse and the case manager give conflicting orders to the staff nurse the job may be indefensible, or a manipulative nurse may play his or her two bosses off against each other.

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3. Matrix org’nal structure…

When a matrix org’n is used, there must be a clear decision rules and it is hoped, good interpersonal r/ships.

The employees must know which bosses have the final word when they receive conflicting orders or demands concerning work priorities.

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4. Functional line and staff pattern

• Staff officers are no longer purely advisory but have some command authority over line employees.

• The director of in-service may have the authority to decide how much indoctrination training and what type of orientation each new nurses must receive and when orientation class will be held.

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4. Functional line and staff pattern…

Advantage• The expert responsible for a specified mgt

function, such as staffing, policies, quality improvement, or staff development has authority to command line managers to implement needed action that relate to the expert specified function.

As a nsg org’n increases in size, it may evolve from a pure line to a line and staff, and finally to functional line and staff structure.

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System

System is a set of elements standing in inter-relation and work together for common goal.

There are two type of system. These are;A. Open system:-interact with the out side

env’t. Relevant for the given org’ns.B. Closed system:-self contained, no

interaction with the external env’t. Not relevant for a given org’ns.

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System theory

“The whole is more than the sum of elements.”

The system itself is can be explained only as a totality.

Holism is the opposite of elementarism, which views the total as the sum of its individual parts.

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System theory…

Characteristics of system1. Input or importation of energy.2. Through put or process3. Out put4. System of cyclic events5. Negative entropy

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System theory…

Characteristics of system…6. Information input/feedback7. Homeostasis or steady state8. Differentiation9. Equi-finality

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System theory…

The total nursing management process and each management functions can be preserved as a system consisting of; Several inputs One or more throughput Numerous outputs Multiple feedback

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Nursing service delivery system

With in these different nsg service delivery system there are advantage and disadvantage for:-

® Quality care® Uses of resources® Staff growth

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Choosing a Nursing Care Delivery Model In order to determine the most proper

model - for a current situation, the following questions are to be answered: What staff mix is required? Who should make work assignments? Work assigned by task? By patient? How will communication be handled? Who will make decisions? Who will be responsible and accountable? Fit with unit/facility/organization

management?

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Nursing service delivery methods

I- The traditional methodsA.Case method.B.Functional method.C.Team method.D.Primary nursing method.II- The advanced methodA.Case management

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I- The traditional methodsA. Case/Total Patient Care/ method

Oldest patient care delivery method. Began in the early days of nsg profession

during F.Nightnigale. One professional nurse assumes total

responsibility of providing complete care for one or more patients (1-6) while she is on duty.

Used frequently in intensive care units and in teaching nursing students.

The nurse report to the head nurse (immediate superior).

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A. Case/Total Patient Care/ method…

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Advantage Patient receives holistic, unfragmented care Job satisfaction, Continuity of care Allow independent decision

making/autonomy/ Good therapeutic r/ship (nurse-client r/ship),

b/c increase personal contact Easy to identify the responsible nurse when

problem raises and success is occurred b/c…

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Disadvantage Not cost-effective, Lack of RN availability Much loss of energy in the staff or burdening

of the staff No specialty of care Each RN may have a different approach to

care Gap may be occur due to shortage of skill

and knowledge from the nurse Over extend span of control for the head

nurse

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B. Functional method

Emerged during 1950s, due to shortage of nurses.

Focuses on getting the greatest amount of tasks in the least time.

The nursing care is divided into tasks and each staff member is assigning to perform one or two tasks for all patients in the unit according to the level of skill required for performance.

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B. Functional method…

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AdvantageSpecialty of careExperienced or qualified staff careTimely care is given for the ptCare is provided economically and efficientlyMinimum number of professional nurses requiredTasks are completed quicklyUseful in emergency situations

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Disadvantage It may cause burden on the head nurse It is difficult to identify the responsible person No continuity of care, due to fragmentation of

care Decrease personal contact with pt Decreased job satisfaction Neglecting the humanity and the individual

needs of the patient

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C. Team nursing

This is accomplished by arranging the workers in team.

The head nurse doesn’t directly communicate with staff rather through team head nurse.

Introduced after 1945. There is delegation of authority and

activity or decentralization.

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C. Team nursing…

The team consists of; Senior professional nurse (team leader) Registered nurses (RNs) Licensed practical nurses (LPNs) or

vocational nurses Nurses’ aides.

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C. Team nursing…

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C. Team nursing…

Advantage Span of control decreased Comprehensive care is provided Increase cost-effectiveness Increase job satisfaction Team sprit is developed Decreased mgt burden for the head nurse Experience sharing b/n the team members Qualified care is given

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C. Team nursing…

Disadvantage It may endanger nsg service if there is conflict or

disagreement Reduce personnel responsibility Continuity of care is reduced Mgt is affected b/c there is a gap b/n manager

and the employee Insufficient time for planning and communication Continuity suffers if daily team assignments vary Team leader must have good leadership skills

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D. Primary nursing

Is a philosophy and structure that places responsibility and accountability for planning, giving, communicating and evaluation of care for a group of pt in the hands of the primary nurse.

Was intended to return the nurse to bedside.

The primary nurse is expected to establish therapeutic r/ship.

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D. Primary nursing…

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Advantageo Increase job satisfaction, Continuity of careo Improves the quality of care, if the

individual is well qualifiedo Allows independent decision makingo Support nurse-client communicationo Encourage discharge planningo High-quality, holistic patient careo Establish rapport with patiento RN feels challenged and rewarded.

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Disadvantage More RNs needed; not cost-effective Exhaustive Need high level qualified and experienced

profession or requires properly trained nurses to carryout system principles

RN must accept 24-hour responsibility Primary nurse must be able to practice with

a high degree of responsibility and autonomy

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II- The advanced methodA. Case management

Most recent. Evolved from other system. It is a process of monitoring an

individual patient’s health care by the case manger, for the purpose of maximizing positive outcomes and containing costs.

This is an all-inclusive, comprehensive model and is not restricted to hospital setting.

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A. Case management… The case manager may follow the patient

from the diagnostic phase through hospitalization, rehabilitation and back to home care.

Case manager has responsibility and authority for planning, implementing, coordinating and evaluating care for the patient throughout the period of illness, regardless of the patient’s movement among various units and services (such as emergency room, surgical unit, recovery unit, etc.).

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A. Case management…

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Advantage Totality of care Continuity of care Job satisfaction Improves nurse responsiveness to clients

changing needs Independent decision making

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Disadvantage Exhaustive Increase personnel cost It requires highly qualified and

experienced individual

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Unit 3-Organizing Nursing Care

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