NURSING LEADERSHIP AND MANAGEMENT

ORGANIZING

Ö Determine what task are to be done, who is to do these, how the tasks are to be grouped, who reports to whom and what decisions are to be made.

Ö It is a form of identifying roles and relationships of each staff on order to delineate specific tasks or functions that will carry out organizational plan s and objectives.

Ö Process of identifying and grouping the work to be performed, defining and delegating responsibility and authority and establishing relationships for the purpose of enabling the people to work more effectively together in accomplishing objectives.

Ö As a process, it refers to the building of a structure that will provide for the separation of activities to be performed and for the arrangement of these activities in a framework which indicates their hierarchal importance and functional association.

The Process Involves:

1.      Identifying and defining basic tasks.

2.      Delegation of authority and assigning responsibility

3.      Establishing relationships

Three forms of authority:

1.      Line authority – is a direct supervisory authority from supervisor to subordinates.

a.       Chain of Command – unbroken line of reporting relationships that extends through the entire organization. The line defines the chain of command and the formal decision making structure.

b.      Unity of Command – within the chin states that, each person in the organization should take orders and reports only to one person.

c.       Span of Control – refers to the number of employees that should be placed under the direction of one leader-manager.

2.      Staff Authority – authority that is based on the expertise and which usually involves advising the line managers.

3.      Team Authority – is granted to committees or work teams involved in an organization’s daily operations. Work teams are group of operating employees who shared a common vision, goals and objectives.

Organizational Chart

Ö Drawing that shows how the parts of the organizations are link.

Ö It depicts the formal organizational relationship, areas of responsibility and accountability and channel of communication.

Ö Depicts an organization’s structure.

ORGANIZATIONAL STRUCTURE

Ö Depicts and identifies role and expectations, arrangement of positions and working relationships.

a.       Dotted or Unbroken line – represents staff positions/staff authority (advisor to the line managers).

b.      Centrality – refers to the location of a position on an organizational chart where frequent and various types of communication occur. Determined by organizational distance; those with small organizational distance receive more information than those who are more peripherally located.

c.       Solid Horizontal Line – represent same positions but different functions.

d.      Solid Vertical Line – chain of command form authority to subordinates (line authority)

MANAGERIAL LEVELS

Level	Scope of Responsibility	Examples
Top Level Managers	1.      Generally make decisions with the help of a few guidelines or structure. 2.      Coordinates internal and external influences.	CEO, President, V-President, Chief Nursing Officer
Middle Level Managers	1.      They conduct day-day operations with some involvement, long term planning and policy making.	Head Nurse, Department Head, Unit Supervisor/Manager
First Level Managers	1.      Concerned with specific unit workflows. 2.      Deals with immediate day-day problems.	Charge Nurse, Team Leader, Primary Nurse, Staff Nurse

PATTERNS OF ORGANIZATIONAL STRUCTURE

1.     Tall/Centralized Structure

ð  Responsible for only few subordinates so there is narrow span of control

ð  Because of the vertical in nature, there are many levels of communication

ð  Communication is difficult and messages do not get to the top.

ð  Workers are boss-oriented because of close contact with their supervisor.

 

Example of tall organizational structure.

2.     Flat/Decentralized Structure

ð  Characterized by few levels and a broad span of control

ð  Communication is easy and direct

Advantages:

1.      Shortens the administrative distance from the top to the lower

2.      Solutions to problems are easily carried out/fast response

3.      Workers developed their abilities and autonomy

Disadvantage:

1.      Impractical in large organization.

 

Example of a flat organizational structure.

TYPES OF ORGANIZATIONAL STRUCTURE

1.     Line Organization/Bureaucratic/Pyramidal

ð  There is clearly defined superior-subordinate relationship

ð  ARA and power are concentrated at the top

2.     Flat/Horizontal Organization

ð  Decentralized type

ð  Applicable in small organization

ð  Nurses become productive and directly involved in the decision making skills

ð  Workers become satisfied

3.     Functional Organization

ð  Permits a specialist to aid line position within a limited and clearly defined scope of authority

4.     Ad Hoc Organization

ð  Modification of bureaucratic structure

5.     Matrix structure

ð  Focus on both product and functions

ð  Most complex

ð  Has both vertical and horizontal chain of command and line of communication

STAFFING

Ö Process of assigning competent people to fulfill the roles designated for the organizational structure through recruitment, selection and development, induction and orientation of the new staff of the goals, vision, mission, philosophy etc.

Staffing Process

1.      Preparing to Recruit – types and number of personnel

2.      Attracting a Staff – formal advertisement

3.      Recruiting and Selecting a Staff – interview à induction à orientation à job order à pre-employment testing à signing of contract

Staffing Pattern – plan that articulates how many and what kind of staff are needed/shift or per day in a unit or in a department.

2 ways of developing a staffing pattern

1.      Determine the # of nursing care hours needed/patient

ð  Generating the full time equivalents of an employee

2.      Determine the nurse-patient ratio in providing nursing care

FTE – measure of work committed of full time employee

1.0 FTE = works 5 days/week, 8 hours/day

0.5 FTE = part time employee who works 5 days/2 weeks

CONSIDERATIONS IN STAFFING PATTERN

1.     Benchmarking

ð  Management tool for seeking out the best practice in one’s industry so as to improve one’s performance.

ð  Process of measuring products, practices and services against best performing organization as a tool for identifying desired standards of organizational performance.

2.      Regulatory Requirements – mandated by RA

3.      Skill Mix – percent or ratio of professionals to non professional

Ex: 40 FTE (20 RN + 20 non RN) = 50% RN mix

4.      Staff Support – staff support in place for the operations of the units or department.

5.      Historical Information – review of any data on quality or staff perception regarding the effectiveness of the previous staffing pattern

PATIENT CLASSIFICATION SYSTEM (PCS)

Ö Measuring tool used to articulate the nursing workload for specific patient or group of patients over a specific time.

Patient Acuity – measure of nursing workload that is generated for each patient.

Patient care is classified according to:

1.      Self care or minimal care patients are capable of carrying ADL, e.g., hygiene, meals etc.

2.      Intermediate or moderate care requires some help from the nursing staff with special treatments or certain aspects of personal care, e.g., patients with IV fluids, catheter, respirator, etc.

3.      Total care patients are those who are bedridden and who lack strength and mobility to do average daily living. Ex: patients on CBR, immediate post-op, with contraptions.

4.      Intensive care patients are those who are critically ill and in constant danger of death or serious injury. Ex: comatose, bedridden etc.

MODALITIES OF CARE CASE METHOD/NURSING CARE MODELS/METHODS OF CARE DELIVERY

Model	Advantage	Disadvantage
Case Method/Total Patient Care - oldest method of patient care delivery. It is taking care of individualized patient.	µ  Provides nurses with high autonomy and responsibility µ  Assigning patients is simple and direct µ  Holistic care given patients	µ  Each nurse can modify the care regimen which can cause confusion for the patient µ  Requires highly skilled personnel µ  Costly µ  Unsafe if nurse is unprepared
Functional Method - divides the nursing work into functional unit that is then assigned to members - nurse has a special task	µ  Increases individual aptitude and experience improves µ  Time saving µ  Increases productivity	µ  Can cause confusion on the part of the patient µ  May lead to fragmented care µ  Mutes the nursing process µ  Low job satisfaction µ  May overlook patients priority needs µ  N-P relationship is not fully developed µ  Evaluation of  nursing care is poor
Team Nursing - assign staff to teams that are responsible for a group of patients.	µ  Allows members to contribute their own expertise µ  Provides patient centered care µ  Patient’s nursing care needs are identified and met through NCP	µ  May lead to fragmented care µ  Finding time for team conference and care planning may be difficult to attain
Primary Nursing - care delivery models but clearly delineates the responsibility and accountability of a RN and designates RN as a primary provider of care to patients	µ  Increase autonomy on the part of the nurse µ  Increase ARA of the RN µ  Continuous care µ  Increased rapport and trust, establishes therapeutic relationship µ  Improves communication with members of the health team	µ  Unsafe if nurse is unprepared µ  Many RNs may initially lack experience and skill µ  Difficulty in recruiting and retaining enough RNs in times of shortages

SCHEDULING

Ö Timetable showing planned work days and shifts for nursing personnel.

Issues to consider in scheduling staff:

1.      Patient type and acuity

2.      Number of patients

3.      Experience of Staff

4.      Support available to the staff

Shifting Variations

Ö Traditional Shifting Patterns

ð  3 shift (8 hr shift)

ð  12 hr shift

ð  10 hr shift

Ö Weekend option

Ö Rotating work shift

Ö Self-scheduling – staff makes their own schedule

Ö Permanent work shift

Ö Floaters – “on-call”

Forty Hour Week Law – based on RA 5901

ð  No work, no pay

ð  Entitled to 2-week sick leave and off duty for 2 days

ð  Special Holidays – with pay

DIRECTING – act of issuing of orders, assignments, instructions, to accomplish organizational goals and objectives.

ü  Delegation – entails responsibility

ü  Assignments – no responsibility

Elements of Directing

1.      Communication

2.      Delegation

3.      Motivation

4.      Coordination

5.      Evaluation

Communication – exchange of ideas, thoughts or information through verbal speech, writing and signals

Barriers in communication

1.     Physical Barriers

ð  environmental factors that prevent or reduce the opportunities for communication. Ex: Distance and Noise

2.     Social and Psychological Barriers

ð  blocks or inhibitors of communication that rise from the judgment, emotions, social values of people.Ex: stress, trust, fear, defensiveness

ð  internal climate (values, feelings, temperament and stress levels) and external climate (weather, timing, temperature, lack of validation to the message).

3.     Semantics

ð  words, figures, symbols,penmanship and interpretation of the message through signs and symbols.

4.     Interpretations

ð  Defects in communication skills by verbalizing, listening, writing, reading and telephony

Channels of communication

Channel	Definition
Upward	Subordinates to superior
Downward	Superior to subordinates
Horizontal	Message flow in same hierarchal positions
Diagonal	Managers interact with personnel and managers of different departments or groups
Outside	Messages are sent from the team to patients, family and friends to the community

Delegation

Ö Act of assigning to someone else a portion of the work to be done with corresponding authority, responsibility and accountability (ARA).

Ö According to ANA, it is the trabsfer of responsibilities for the performance of the task from one person to another

Ö Much of the work of manager is accomplished by transferring the responsibilities to subordinates

Good Reasons for Delegation

1.      Manager delegate routine task so that they are free to handle problems that are more complex or require higher level of expertise

2.      Delegate routine task if someone else is better prepared or has greater expertise or knowledge in solving the problems

Managers who do not delegate

1.      Does not trust

2.      Fear of mistake

3.      Fear of criticism

4.      Fear of own ability to delegate

Common Errors in Delegation

1.      Underdelegating – systems from the manager’s false assumptions that delegation maybe interpreted as a lack of ability on his part to do the job correctly and competently

Reasons:

a.       Managers believe that they can do the work faster and better

b.      Managers believe that the responsibility may be rejected if delegated

2.      Overdelegating – subordinates become overburdened which may lead to dissatisfaction and low productivity

Reasons:

a.       Managers who are lazy

b.      Manager who are overburdened and exhausted

Improper Delegation – delegating at the wrong person, time, tasks and beyond the capability of the subordinates.

Steps in Effective Delegating

1.      Plan ahead

2.      Identify necessary skills and levels

3.      Select most capable personnel

4.      Communicate goal clearly

5.      Empower the delegate

6.      Set deadlines and monitor progress

7.      Model the role and provide guidance

8.      Evaluate performance

Motivation – whatever influences our choices and creates direction, intensity, and persistence in our behavior.

Supervision – guiding and directing the work to be done. It entails motivating and encouraging the staff to participate in the activities to meet the goals and objectives for personal development in making the work better.

Coordination – arranging in proper order. It creates harmony in all activities to facilitate success of work

Conflict Management

Conflict – internal and external discord that results in from differences in ideas, values or feelings between 2 or more people. It arises because of differences in economic and professional values.

Two Main Types

1.      Competitive  Conflict – 2 or more group the same goal and only one group can attain them

Management: Set Goals

2.      Disruptive Conflict – takes place in environment filled with anger, fear and stress. There is no mutually acceptable set of rules and the goal of each party is the elimination of each opponent.

Conflict Resolution Strategies

1.     Use of dominance and Suppression

ð  Win loose strategy

ð  Looses feels angry

2.      Restriction – autocratic coercive style that uses indirect and obstructive expression of conflict.

3.      Smoothing Behavior – persuades the opponent in a diplomatic way

4.      Avoidance Behavior – 2 parties are aware of the conflict but choose not to acknowledge or attempt to resolve it.

5.      Majority rule – unanimous decision

6.      Compromising – consensus strategy where each side agrees solutions

7.      Interactive Problem Solving – constructive process in which the parties involve recognized that conflict, assist and openly try to solve the problems

8.      Win-Win Strategy – focuses on goals and attempts to meet the needs of both parties.

9.      Lose-Lose Strategy – neither side wins

10.  Confrontation – most effective means of resolving the conflict. Resolves through knowledge and reason brought out in an open.

11.  Negotiation – “give and take”