Unit-three

Organizing Nursing Care

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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 systems
List the advantages and disadvantages of
various types of nursing care delivery systems
Discuss 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 ognal goal.
B. Organization structure-refers to the
lines of authority, communication and
delegation.

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.

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
employees 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 pace
Pattern of worker skill and
knowledge
The amount of work interdependence

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 orgn.
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Organization structure

The principal purpose for defining orgn

diagram is to clarify chain of command,
span of ctrl, official communication, and
linkage for on dpt personnel.
It is customary to show formal orgn
structure in a diagrammatic form with a
three dimensional model having depth,
height, and width.

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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Organization structure

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 dont flow.
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Organization structure
The orgn 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 ognal structure

Characterized by unspoken, often covert

Lines of communication and authority
r/ships not depicted in the orgnal chart
The informal structure develops to meet
individuals needs for friendship, a sense
of belongingness, and power

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1. Informal ognal 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 orgn, b/c they facilitate
the passing of information.
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1. Informal ognal structure

The information may be a rumor, but the

best way to combat rumor is by free flow
of trustful information.
The informal orgn can help to serve the
goal of formal orgn 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
orgn.
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2. Formal ognal structure

An ogns formal structure is depicted in its

ognal chart i.e. provides a blue print,
representing formal relations, functions and
activities.
The primary significance of formal orgnal
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 orgnal structures

1.
2.
3.
4.

Line pattern/relationship
Line and staff pattern/relationship
Matrix orgnal structure
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 orgnal
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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1. Line pattern/relationship
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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1. Line pattern/relationship
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 outsiders
b/c of rigidity.
Causes passivity and dependency in staff
members and autocratic b/r in manager.

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1. Line pattern/relationship
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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2. Line and staff

pattern/relationship

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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2. Line and staff

pattern/relationship
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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2. Line and staff

pattern/relationship
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 orgnal structure, which casts
incumbents in the role of social isolates.
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3. Matrix orgnal 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
orgnal 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 orgnal structure

When a matrix orgn 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 orgn 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
envt. Relevant for the given orgns.
B. Closed system:-self contained, no
interaction with the external envt. Not
relevant for a given orgns.

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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 system
1. Input or importation of energy.
2. Through put or process
3. Out put
4. System of cyclic events
5. Negative entropy

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System theory
Characteristics of system
6. Information input/feedback
7. Homeostasis or steady state
8. Differentiation
9. 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 methods
A.Case method.
B.Functional method.
C.Team method.
D.Primary nursing method.
II- The advanced method
A.Case management

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I- The traditional methods

A. 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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A. Case/Total Patient Care/

method
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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A. Case/Total Patient Care/

method
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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B. Functional method
Advantage
Specialty of care
Experienced or qualified staff care
Timely care is given for the pt
Care is provided economically and efficiently
Minimum number of professional nurses
required
Tasks are completed quickly
Useful in emergency situations

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B. Functional method
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 doesnt 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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D. Primary nursing
Advantage
o Increase job satisfaction, Continuity of care
o Improves the quality of care, if the
individual is well qualified
o Allows independent decision making
o Support nurse-client communication
o Encourage discharge planning
o High-quality, holistic patient care
o Establish rapport with patient
o RN feels challenged and rewarded.
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D. Primary nursing
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 method

A. Case management

Most recent.
Evolved from other system.
It is a process of monitoring an
individual patients 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 patients 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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A. Case management
Advantage
Totality of care
Continuity of care
Job satisfaction
Improves nurse responsiveness to clients
changing needs
Independent decision making

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A. Case management
Disadvantage
Exhaustive
Increase personnel cost
It requires highly qualified and
experienced individual

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