I.
Nature & Purpose
ORGANIZING
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Determine what tasks 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.
It is a form of identifying the roles and relationships of each staff in order to delineate
specific tasks or functions that will carry out organizational plans and objectives.
It is the 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.
NATURE OF ORGANIZING
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Common Objectives
○ Every organization exists to achieve some common goals and targets of the
organization.
Division of Labour
○ Overall function of an organization in sub-divided into number of
sub-functions (various departments)
○ Each department is headed by a manager, who is solely responsible for the
function of the department.
Authority Structure
○ Graded series of arrangement in an organization, creates a series of superior
and subordinate relationship called chain of command
○ Responsibilities associated with various positions are defined.
Group of Persons
○ Work force of an organization constitutes an active environment in an
organization.
Communication
○ Every organization have fire flow of communication
○ These channels of communication are necessary for mutual understanding
and cooperation among members of an organization.
Coordination
○ Diverse efforts of various departments are integrated towards the common
goal through the process of coordination.
Environment
○ No organization works in a vacuum. Social, political, economic and legal factors
exert influence on the environment.
○ Besides, it is influenced by internal factors like materials, machines, level of
technology, economic measures, HR and many more.
Rules and Regulations
○ Every organization is governed by a set of rules and regulations for orderly
functioning of people.
PURPOSE OF ORGANIZING
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II.
To Facilitate Organization
○ Helps to earn highest profit
○ A properly designed organization facilitates both management and operations
of an enterprise.
Increase Efficiency of Management
○ A good organization will extract efficient work from an organization
○ Eliminates redundancy and motivates every employee
To Facilitate Growth and Diversification
○ Growth deals with expanding the scale of operation
○ Diversification means start of production of new type of products,
Optimistic Use of Resources
○ Detailed job specifications are prepared in order to match the job with the
men.
○ Right persons are placed in the right job.
Facilitate Coordination and Communication
○ Grouping of activity
Permit Optimum Use of Technological Innovations
○ Modifying authority relationship in wake of new developments
○ Provide adequate scope for innovation
Stimulate Creativity and Initiative
○ Provides the opportunity for the employees to show their hidden talent
Facilitate the Development of Managerial Ability
○ Trained to acquire a wide and variety experience in diverse activities through
job rotation.
Principles of Organization
2.1. Unity of Command
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Within the chain states that each person in the organization should take orders and
reports only to one person.
An employee may interact with many individuals in the course of the work but should
be responsible to only one supervisor.
2.2. Delegation of Responsibility
DEFINITION OF DELEGATION
● Delegation can be defined simply as getting work done through others or as directing
the performance of one or more people to accomplish organizational goals.
● Huston (2009) defines delegation as giving someone else the authority to complete a
task or action on your behalf.
● The North Carolina Nursing Administrative Code defines delegation as a “transfer or
hand-off to a competent individual, the authority to perform a task/activity in a
specific setting/situation” (Winstead, 2013, p. 9).
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Historically, the ANA and the NCSBN defined delegation differently, with the ANA
defining delegation as the transfer of responsibility for the performance of a task from
one person to another and the NCSBN defining delegation as transferring to a
competent individual the authority to perform a selected nursing task in a selected
situation (Huston, 2014).
Delegation can also provide learning or “stretching” opportunities for subordinates.
Subordinates who have not delegated enough responsibility may become bored,
nonproductive, and ineffective. Thus, in delegating, the leader-manager contributes to
employees’ personal and professional development.
LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH DELEGATIONS
Leadership Roles
1. Functions as a role model, supporter, and resource person in delegating tasks to
subordinates.
2. Encourages followers to use delegation as a time management strategy and
team-building tool.
3. Assists followers in identifying situations appropriate for delegation.
4. Communicates clearly when delegating tasks.
5. Maintains patient safety as a minimum criterion in determining the most appropriate
person to carry out a delegated task.
6. Plans ahead and delegates proactively, rather than waiting until time urgency is
present and crisis responses are required.
7. Conveys a feeling of confidence and encouragement to the individual who has taken
on a delegated task.
8. Is an informed and active participant in the development of local, state, and national
guidelines for unlicensed assistive personnel (UAP)/nursing assistive personnel (NAP)
scope of practice.
9. Is sensitive to how cultural phenomena affect transcultural delegation.
10. Uses delegation as a means for stretching and empowering workers to learn new skills
and be successful.
11. Works to establish a culture of mutual trust, teamwork, and open communication so
that delegation becomes a strategy health-care workers feel comfortable using to
achieve organizational, patient, and personal goals.
Management Functions
1. Creates job descriptions and scope of practice statements for all personnel, including
NAP, that conform to national, state, and professional recommendations for ensuring
safe patient care.
2. Is knowledgeable regarding legal liabilities of subordinate supervision.
3. Accurately assesses subordinates’ capabilities and motivation when delegating.
4. Delegates a level of authority necessary to complete delegated tasks.
5. Shares accountability for delegated tasks.
6. Consciously attempts to see the subordinate’s perspective to reduce the likelihood of
resistance in delegation.
7. Develops and implements a periodic review process for all delegated tasks.
8. Avoids overburdening subordinates by giving them permission to refuse delegated
tasks.
9. Provides recognition or reward for the completion of delegated tasks.
10. Provides formal education and training opportunities on delegation principles for
staff.
STRATEGIES FOR SUCCESSFUL DELEGATION
Plan ahead. Always make an attempt to delegate before you become overwhelmed.
In addition, always be sure to carefully assess the situation before delegating and to clearly
delineate the desired outcomes.
Identify necessary skill and education levels to complete the delegated task.
Nurses then must be aware of their state NPA (Nurse Practice Act) essential elements
regarding delegation, including the following:
● The state’s NPA definition of delegation
● Items that cannot be delegated Items that cannot be routinely delegated Guidelines
for RNs about tasks that can be delegated
● A description of professional nursing practice
● A description of licensed vocational nurse (LVN)/licensed professional nurse (LPN)
nursing practice and unlicensed nursing roles
● The degree of supervision required to complete a task
● The guidelines for lowering delegation risks
● Warnings about inappropriate delegation
● If there is a restricted use of the word “nurse” to licensed staff
In addition, the manager should know the official job description expectations for each
worker classification in the organization, as they may be more restrictive than the state
NPA.
Select capable personnel. Identify which individuals can complete the job in terms
of capability and time to do so. Remember that it is a leadership role to stretch new and
capable employees who want opportunities to learn and grow. Also, look for employees who
are innovative and willing to take risks. It is also important that the person to whom the task
is being delegated considers the task to be important. This does not suggest, however, that
skill and expertise are not needed. Leaders and managers should always ask the individuals
to whom they are delegating if they are capable of completing the delegated task and
validate this perception by direct observation.
Communicate goals clearly. This includes identifying any limitations or qualifications
that are being imposed on the delegated task. Knox (2013) notes that the delegator must
communicate specifically what, how, and by when delegated tasks are to be accomplished.
This communication should also include the purpose and goal of the task, any limitations for
task completion, and the expectations for reporting.
Empower the delegate. Delegate the authority and the responsibility necessary to
complete the task. Nothing is more frustrating to a creative and productive employee than
not having the resources or authority to carry out a well-developed plan.
Set deadlines and monitor progress. Set time lines, and monitor how the task is
being accomplished through informal but regularly scheduled meetings. This shows an
interest on the part of the nurse-leader, provides for a periodic review of progress, and
encourages ongoing communication to clarify any questions
or misconceptions.
Monitor the role and provide guidance. If the worker is having difficulty carrying out
the delegated task, the leader-manager should be available as a role model and resource in
identifying alternative solutions. Leaders should encourage employees, however, to attempt
to solve problems themselves first, although they should always be willing to answer
questions about the task or to clarify desired outcomes as necessary.
Evaluate performance. Evaluate the delegation experience after the task has been
completed. Include positive and negative aspects of how the person completed the task.
Were the outcomes achieved? Ask
the individual you delegated to, what you could have done differently to facilitate their
completion of the delegated tasks. This shared reflection encourages the development of a
mutually trusting and productive relationship between delegators and subordinates.
Reward accomplishment. Be sure to appropriately reward a successfully completed
task. Leaders are often measured by the successes of those on their teams. Therefore, the
more recognition team members receive, the more recognition will be given to their leader.
COMMON DELEGATING ERRORS
Underdelegating
● frequently stems from the individual’s false assumption that delegation may be
interpreted as a lack of ability on his or her part to do the job correctly or completely.
Delegation does not need to limit the individual’s control, prestige, and power; rather,
delegation can extend their influence and capability by increasing what can be
accomplished. In fact, delegation can be empowering, both to the person delegating
and to the person being delegated to.
● Another cause of underdelegating is the individual’s desire to complete the whole job
personally due to a lack of trust in the subordinates; some nurses believe that he or
she needs the experience or that he or she can do it better and faster than anyone
else, and indeed—sometimes, this is the case.
● Other individuals underdelegate because there is not enough time to delegate. It
takes time to delegate because the delegator must adequately explain the task or
teach their team member the skills necessary to complete the delegated task. The
problem is paradoxical because one of the main benefits of delegation is saving time
(Delegating, n.d.).
● Nurses also may underdelegate because they lack experience in the job or in
delegation itself. Other nurses refuse to delegate because they have an excessive need
to control or be perfect. The leader-manager who accepts nothing less than
perfection limits the opportunities available for subordinate growth and often wastes
time redoing delegated tasks.
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In addition, some individuals underdelegate because they fail to anticipate the help
they will need. In an ideal situation, the best time to delegate is before you become
overwhelmed (Huston, 2009).
Finally, some novice managers emerging from the clinical nurse role underdelegate
because they find it difficult to assume the manager role. This occurs, in part, because
the nurses have been rewarded in the past for their clinical expertise and not their
management skills.
Overdelegating
● In contrast to underdelegating, which overburdens the manager, some managers
overdelegate, burdening their subordinates. Some managers overdelegate because
they are poor managers of time, spending most of it just trying to get organized.
Others overdelegate because they feel insecure in their ability to perform a task.
● It is critical that the manager is sensitive to the workload constraints of his or her staff.
Staff should always have the right to refuse a delegated task. The servant leader
always asks the person they want to delegate to, if they have time to help, instead of
just assuming that their needs are greater than those of the staff member. Managers
also must be careful not to overdelegate to exceptionally competent employees,
because they may become overworked and tired, which can decrease their
productivity
Improper Delegation
● includes such things as delegating at the wrong time, to the wrong person, or for the
wrong reason. It also may include delegating tasks and responsibilities that are
beyond the capability of the person to whom they are being delegated or that should
be done by someone with greater expertise, training, or authority.
● Knox (2013) emphasizes that one of the most important aspects of delegation is
determining if a task should be delegated. In addition, Knox notes that the decision to
delegate a task must match the staff’s competency and level of supervision available.
Finally, Knox notes that appropriate delegation must include a consideration of who is
the most appropriate person is to delegate to. Delegating decision making without
providing adequate information is another example of improper delegation.
● Not everything that is delegated needs to be handled in a maximizing mode. Almost
all of these delegation errors could be avoided if the five rights of delegation,
identified by the American Nurses Association (ANA) and the National Council of State
Boards of Nursing (NCSBN) (n.d.), were followed.
2.3. Span of Control
DEFINITION OF SPAN OF CONTROL
● Span of control is the area of activity and number of functions, people, or things for
which an individual or organization is responsible.
● It also can be determined from the organization chart. The number of people directly
reporting to any one manager represents that manager’s span of control and
determines the number of interactions expected of him or her. Thus, there is an
inverse relation between the span of control and the number of levels in hierarchy in
an organization, i.e., narrower the span, the greater is the number of levels in an
organization (Juneja, 2013)
● The ideal span of control in an organization depends upon various factors, such as the
nature of the job, the manager’s abilities, the employees’ maturity, the task
complexity, and the level in the organization at which the work occurs. The number of
people directly reporting to any one supervisor must be the number that maximizes
productivity and worker satisfaction.
● With increased financial pressures on health-care organizations to remain fiscally
solvent and electronic communication technology advances, many have increased
their spans of control and reduced the number of administrative levels in the
organization. This is often termed flattening the organization.
MANAGERIAL LEVELS
● Top-level managers look at the organization as a whole, coordinating internal and
external influences, and generally make decisions with few guidelines or structures.
Examples of top-level managers include the organization’s chief operating officer or
CEO and the highest level nursing administrator.
○ Current nomenclature for top-level nurse-managers varies; they might be
called vice president of nursing or patient care services, nurse administrator,
director of nursing, chief nurse, assistant administrator of patient care services,
or chief nurse officer (CNO).
○ Some top-level nurse-managers may be responsible for non-nursing
departments. For example, a top-level nurse-manager might oversee the
respiratory, physical, and occupational therapy departments in addition to all
nursing departments. Likewise, the CEO might have various titles, such as
president and director. It is necessary to remember only that the CEO is the
organization’s highest ranking person, and the top-level nurse-manager is its
highest ranking nurse.
○ Responsibilities common to top-level managers include determining the
organizational philosophy, setting policy, and creating goals and priorities for
resource allocation. Top-level managers have a greater need for leadership
skills and are not as involved in routine daily operations as are lower level
managers.
● Middle-level managers coordinate the efforts of lower levels of the hierarchy and are
the conduit between lower and top-level managers. Middle-level managers carry out
day-to-day operations but are still involved in some long-term planning and in
establishing unit policies. Examples of middle-level managers include nursing
supervisors, nurse-managers, head nurses, and unit managers.
○ Currently, there are many health facility mergers and acquisitions, and reduced
levels of administration are frequently apparent within these consolidated
organizations. Consequently, many health-care facilities have expanded the
scope of responsibility for middle-level managers and given them the title of
“director” as a way to indicate new roles. The old term director of nursing, still
used in some small facilities to denote the CNO, is now used in many
health-care organizations to denote a middle-level manager. The proliferation
of titles among health-care administrators has made it imperative that
individuals understand what roles and responsibilities go with each position.
● First-level managers are concerned with their specific unit’s work flow. They deal with
immediate problems in the unit’s daily operations, with organizational needs, and
with personal needs of employees. The effectiveness of first-level managers
tremendously affects the organization. First-level managers need good management
skills. Because they work so closely with patients and health-care teams, first-level
managers also have an excellent opportunity to practice leadership roles that will
greatly influence productivity and subordinates’ satisfaction.
Examples of first-level managers include primary care nurses, team leaders,
case managers, and charge nurses. In many organizations, every registered
nurse (RN) is considered a first-level manager. All nurses in every situation
must manage themselves and those under their care.
One of the leadership responsibilities of organizing is to periodically examine the number of
people in the chain of command. Organizations frequently add levels until there are too
many managers. Therefore, the leader-manager should carefully weigh the advantages and
disadvantages of adding a management level.
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Centrality
● Centrality, or where a position falls on the organizational chart, is determined by
organizational distance. Employees with relatively small organizational distance can
receive more information than those who are more peripherally located. This is why
the middle manager often has a broader view of the organization than other levels of
management. A middle manager has a large degree of centrality because this
manager receives information upward, downward, and horizontally.
● Because all communication involves a sender and a receiver, messages may not be
received clearly because of the sender’s hierarchical position. Similarly, status and
power often influence the receiver’s ability to hear information accurately. An example
of the effect of status on communication is found in the “principal syndrome.” Most
people can recall panic, when they were school age, at being summoned to the
principal’s office. Thoughts of “what did I do?” travel through one’s mind. Even adults
find discomfort in communicating with certain people who hold high status. This may
be fear or awe, but both interfere with clear communication.
2.4. Departmentalization
DEPARTMENTALIZATION
workers performing similar assignments are grouped together for a common
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purpose. Promotes the specialization of activities, simplifies the administrator’s work,
maintain effective control.
● Departmentalization is defined as an organizational strategy used to divide similar
processes or specializations into smaller departments within a hospital. Specific jobs,
processes, tasks, and units are grouped together because of their similarities, meaning
that workers with specialized skills can address a broader range of assignments within
the same department while utilizing their abilities most effectively.
III.
Organizational Structure
Max Weber, a German social scientist, is known as the father of organizational theory. Weber
is also credited with the development of the organization chart to depict an organization’s
structure. Because the organization chart is a picture of an organization, the knowledgeable
manager can derive much information from reading the chart. For example, an organization
chart can help identify roles and their expectations.
In addition, by observing elements, such as which departments report directly to the chief
executive officer (CEO), the novice manager can make some inferences about the
organization. For instance, reporting to a middle level manager rather than an executive
officer suggests that person has less status and influence than someone who reports to an
individual higher on the organization chart. Managers who understand an organization’s
structure and relationships will be able to expedite decisions and have a greater
understanding
of the organizational environment.
In simple terms, an organizational structure depicts and identifies roles and expectations,
arrangement of positions, and working relationships.
3.1. Characteristics of Organizational Structure
Sample Organizational Chart
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The organization chart defines formal relationships within the institution.
○ Formal relationships, lines of communication, and authority are depicted on a
chart by unbroken (solid) lines. These line positions can be shown by solid
horizontal or vertical lines.
■ Solid horizontal lines represent communication between people with
similar spheres of responsibility and power but different functions.
■ Solid vertical lines between positions denote the official chain of
command, the formal paths of communication and authority. Those
having the greatest decision-making authority are located at the top;
those with the least are at the bottom. The level of position on the chart
also signifies status and power. A solid vertical line also indicates unity
of command, wherein employees have one manager to whom they
report and to whom they are responsibly..
○ Dotted or broken lines on the organization chart represent staff positions.
■ Because these positions are advisory, a staff member provides
information and assistance to the manager but has limited
organizational authority.
Used to increase his or her sphere of influence, staff positions enable a
manager to handle more activities and interactions than would
otherwise be possible.
■ These positions also provide for specialization that would be impossible
for any one manager to achieve alone.
■ Although staff positions can make line personnel more effective,
organizations can function without them.
Centrality, or where a position falls on the organizational chart, is determined
by organizational distance.
■ Employees with relatively small organizational distance can receive
more information than those who are more peripherally located.
■ This is why the middle manager often has a broader view of the
organization than other levels of management. A middle manager has
a large degree of centrality because this manager receives information
upward, downward, and horizontally.
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Advantages of Organizational Charts
1. Maps lines of decision-making authority.
2. Helps people understand their assignments and those of their coworkers.
3. Reveals to managers and new personnel how they fit into the organization.
4. Contributes to sound organizational structure.
5. Shows formal lines of communication.
Limitations of Organizational Charts
1. Shows only formal relationships.
● Because organization charts show only formal relationships, what they can
reveal about an institution is limited. The chart does not show the informal
structure of the organization. Every institution has in place a dynamic informal
structure that can be powerful and motivating. Knowledgeable leaders never
underestimate its importance because the informal structure includes
employees’ interpersonal relationships, the formation of primary and
secondary groups, and the identification of group leaders without formal
authority. These groups are important in organizations because they provide
workers with a feeling of belonging. They also have a great deal of power in an
organization; they can either facilitate or sabotage planned change. Their
ability to determine a unit’s norms and acceptable behavior has a great deal to
do with the socialization of new employees. Informal leaders are frequently
found among long-term employees or people in select gatekeeping positions,
such as the CNO’s secretary. Frequently, the informal organization evolves from
social activities or from relationships that develop outside the work
environment.
2.
Does not indicate degree of authority.
● Organization charts are also limited in their ability to depict each line position’s
degree of authority. Authority is defined as the official power to act. It is power
given by the organization to direct the work of others. A manager may have
the authority to hire, fire, or discipline others. Equating status with authority,
however, frequently causes confusion. The distance from the top of the
organizational hierarchy usually determines the degree of status: the closer to
the top, the higher the status. Status also is influenced by skill, education,
specialization, level of responsibility, autonomy, and salary accorded a position.
People frequently have status with little accompanying authority. Because
organizations are dynamic environments, an organization chart becomes
obsolete very quickly. Grover (1999–2013) suggests that most organizations are
constantly changing, with people taking on new jobs, getting hired, and
getting fired, so trying to keep an organization chart current is almost
impossible.
3.
Are difficult to keep current and may define roles to narrowly.
● It is also possible that the organization chart may depict how things are
supposed to be, when in reality, the organization is still functioning under an
old structure because employees have not yet accepted new lines of authority.
● In addition, organization charts may too rigidly define the jobs of people
working in that organization (Grover, 1999–2013). Some employees may look at
the organization chart and determine that the responsibilities there are their
only responsibilities, when the reality is that most employees will on occasion,
have to assist with work that is not a formal part of their job description.
4. Defines authority, but not responsibility and accountability.
● Another limitation of the organization chart is that although it defines
authority, it does not define responsibility and accountability.
○ A responsibility is a duty or an assignment. It is the implementation of a
job. For example, a responsibility common to many charge nurses is
establishing the unit’s daily patient care assignment. Individuals should
always be assigned responsibilities with concomitant authority. If
authority is not commensurate to the responsibility, role confusion
occurs for everyone involved. For example, supervisors may have the
responsibility of maintaining high professional care standards among
their staff. If the manager is not given the authority to discipline
employees as needed, however, this responsibility is virtually impossible
to implement.
○ Accountability is similar to responsibility, but it is internalized. Thus, to
be accountable means that individuals agree to be morally responsible
for the consequences of their actions. Therefore, one individual cannot
be accountable for another. Society holds us accountable for our
assigned responsibilities, and people are expected to accept the
consequences of their actions. A nurse who reports a medication error
is being accountable for the responsibilities inherent in the position.
3.2. Theories
Organizational theory is the study of the structures of organizations. Three major theories
contribute to this study – classical organizational theory, human relations or neo-classical
theory, and modern organizational theory. Over time, the emphasis in organizational theory
has shifted from stiff, hierarchical structures rampant in the industrial age to broader, more
flexible structures more prevalent in the technological, modern age.
Classical Organizational Theory
● Classical organization theory is the oldest theory of organization and represents the
merger of scientific management, bureaucratic theory and administrative theory.
● Scientific management theory has four basic principles, and the Bureaucratic theory
and administrative theory expanded on these principles.
■ a scientific method exists to perform each task;
■ select, train and develop workers for each task;
■ closely supervise employees; and
■ Management's role is planning and control.
● This theory originates from the writings of classical management thinkers such as
Taylor and Fayol.
○ The classical writers viewed organization as a machine and individuals working
in it as different components of this machine. They believed that efficiency of
organization can be increased by making each individual more efficient.
■ It deals with formal organizational structures.
■ It focuses on objectives and tasks and not on the human beings
performing tasks.
■ It aims at maximizing control.
■ It emphasizes on the direction of the detection of errors occurring and
then correction.
● However, over time academics and practitioners began to view classical organization
theory as too rigid and authoritative. It focused on structure and economic rewards
and ignored individual freedom and the working environment.
Human Relations or Neoclassical Organization Theory
● Human relations theory is also called neoclassical theory. Beginning with the
Hawthorne studies in the 1920s, this theory focuses on the emotional and
psychological components of people’s behavior in an organization.
● This theory uses some of the beliefs of classical theory as its base but expands those
beliefs to incorporate other principles.
○ Key principles include emphasizing differences between people to create
different effective motivators.
○ It also involves resolving creative conflict to help develop new ideas and build
stronger working relationships.
○ Another principle involves emphasizing social interactions, participative
management and decision-making. Learning "soft" business skills, such as
interpersonal communications, leadership, project management and team
management are important for business owners who want to use a more
employee-centered approach to management.
● The neoclassical school focuses on human beings and their organizational behavior. It
believes that human behavior in organizations is greatly influenced by formal as well
as informal relations.
○ The organization is a social system composed of several interacting subsystems
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The social environment on the job affects people and is also affected by the
people.
Integration between organizational and individual goals is a must.
Money is one of the motivators but not the sole.
Human beings are not always rational. They behave rationally as far as rewards
from their job are concerned.
Two-way communication is necessary for sound functioning of the
organization.
Teamwork is essential for cooperation and higher productivity. But it can be
achieved only through a behavioral approach.
Modern Organizational Theory
● Modern organization theory comprises two theories: contingency theory and systems
approach theory.
● Modern theories tend to be based on the concept that the organization is a system
which has to adapt to changes in its environment. This theory considers interactions
between people within an organization and the surrounding environment, as well as
the interpersonal interactions between members of the organization.
● In modern theory, an organization is defined as a designed and structured process in
which individuals interact for objectives .
● This theory views the organization as a system comprising many subsystems, such as
managerial, technical, and social.
● It regards individuals as complex beings who can be motivated in a multitude of ways.
● It is dynamic in interaction with the structure. It is constantly subject to change as the
environment changes. An organization adapts itself suitably to the changing
environment and it survives.
● It is both macro and micro in its approach. It is micro when considered with respect to
the entire nation or industry. It is macro with respect to internal parts of the
organization.
● It ensures better flow of communication at all the levels and ensures effective control.
Modern Organization Theory – Systems Theory
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An organization is considered a dynamic system that evaluates acts and
interacts with the environment.
■ Organizations operate as open systems in dynamic equilibrium as they
constantly adjust and adapt to changes in their environment.
● The foundation of the modern systems theory is the principle that all of an
organization's components interrelate nonlinearly, therefore making a small
change in one variable impacts many others.
● The organization consists of interacting and interdependent subsystems.
Each subsystem is defined with its objectives, structure, processes and
promises.
■
A small change can cause a huge impact on another variable or large
changes in a variable can cause a nominal impact. The interdependent
nature of the parts of the organization suggests that anything that
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affects the functioning of one aspect of the organization will affect the
other parts of the organization.
System approach theory helps to improve the operations in an organization
through understanding the nature of the interdependence that exists within
the different parts and how to improve the diverse processes.
In organizations, all the factors are considered systems that work towards
attaining the set goals and objectives, but they function independently.
○ The functions in an organization work towards achieving the overall
goal, but each is different from the rest. The organization is flexible to
accommodate the needs of the environment in which it operates to
achieve its goals.
3.3. Forms
Centralized
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Centralization refers to the concentration of management and decision-making
power at the top of the organizational hierarchy for the purpose of coordinating
financial, human, and other business resources.
In organizations with centralized decision-making, a few managers at the top of the
hierarchy make the decisions and the emphasis is on top-down control.
The vision or thinking of one or a few individuals in the organization guides the
organization’s goals and how those goals are accomplished.
Execution of decision-making in centralized organizations is fairly rapid.
Decentralized
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In decentralization, formal decision-making power is distributed across multiple
individuals or teams.
Decentralized decision-making diffuses decision-making throughout the organization
and allows problems to be solved by the lowest practical managerial level. Often, this
means that problems can be solved at the level at which they occur, although some
delays may occur in decision-making if the problem must be transmitted through
several levels to reach the appropriate individual to solve the problem.
As a rule, however, larger organizations benefit from decentralized decision-making.
○ This occurs because the complex questions that must be answered can best
be addressed by a variety of people with distinct areas of expertise.
○ Leaving such decisions in a large organization to a few managers burdens
those managers tremendously and could result in devastating delays in
decision-making.
3.4. Types of Organization Structure
Line Structure
●
●
Bureaucratic organizational designs are commonly called line structures or line
organizations. Those with staff authority may be referred to as staff organizations.
Both of these types of organizational structures are found frequently in large
health-care facilities and usually resemble Weber’s original design for effective
organizations. Because of most people’s familiarity with these structures, there is little
stress associated with orienting people to these organizations. In these structures,
authority and responsibility are clearly defined, which leads to efficiency and simplicity
of relationships.
These formal designs have some disadvantages. They often produce monotony,
alienate workers, and make adjusting rapidly to altered circumstances difficult.
Another problem with line and line-and-staff structures is their adherence to chain of
command communication, which restricts upward communication. Good leaders
encourage upward communication to compensate for this disadvantage. However,
when line positions are clearly defined, going outside the chain of command for
upward communication is usually inappropriate.
Ad Hoc Design
● The ad hoc design is a modification of the bureaucratic structure and is sometimes
used on a temporary basis to facilitate completion of a project within a formal line
organization. The ad hoc structure is a means of overcoming the inflexibility of line
structure and serves as a way for professionals to handle the increasingly large
amounts of available information. Ad hoc structures use a project team or task
approach and are usually disbanded after a project is completed. This structure’s
disadvantages are decreased strength in the formal chain of command and
decreased employee loyalty to the parent organization.
Matrix Structure
● A matrix organization structure is designed to focus on both product and function.
Function is described as all the tasks required to produce the product, and the
product is the end result of the function. For example, good patient outcomes are the
product, and staff education and adequate staffing may be the functions necessary to
produce the outcome.
● The matrix organization structure has a formal vertical and horizontal chain of
command. There are less formal rules and fewer levels of the hierarchy, a matrix
structure is not without disadvantages. For example, in this structure, decision making
can be slow because of the necessity of information sharing, and it can produce
confusion and frustration for workers because of its dual-authority hierarchical design.
The primary advantage of centralizing expertise is frequently outweighed by the
complexity of the communication required in the design.
Service Line Organization
● Similar to the matrix design is service line organization, which can be used in some
large institutions to address the shortcomings that are endemic to traditional large
bureaucratic organizations. Service lines, sometimes called care-centered
organizations, are smaller in scale than a large bureaucratic system. For example, in
this organizational design, the overall goals would be determined by the larger
organization, but the service line would decide on the processes to be used to achieve
the goals.
Flat Designs
● Flat organizational designs are an effort to remove hierarchical layers by flattening the
chain of command and decentralizing the organization. Thus, a single manager or
supervisor would oversee a large number of subordinates and have a wide span of
control. In good times, when organizations are financially well off, it is easy to add
layers to the organization in order to get the work done, but when the organization
begins to feel a financial pinch, they often look at their hierarchy to see where they can
cut positions.
● In flattened organizations, there continues to be line authority, but because the
organizational structure is flattened, more authority and decision making can occur
where the work is being carried out. Many managers have difficulty letting go of
control, and even very flattened types of structure organizations often retain many
characteristics of a bureaucracy.
IV.
Organizational Chart
4.1. Types
Structural
●
shows the various components of the organization and outlines the basic
interrelationships.
Functional
●
reflects the functions and duties of the components of the organization and indicates
the interrelationships of these function. Within the boxes is the function statement,
which should be clear, inclusive and written in the present tense.
Position
●
specifies the names, positions, and titles or ranks of the personnel.
4.2. Uses/ Purpose of Organizational Chart
A chart is a diagrammatic form that shows important aspects of an organization including
the major functions and their respective relationships, the channels of supervision, and the
relative authority of each employee who is in charge of each respective function.
●
●
It provides a quick visual illustration of the organizational structure. The drawing
shows how the parts of the organizations are linked.
It shows lines of formal authority, areas of responsibility, and accountability. It shows
or establishes relationships among individuals, groups, and departments. It helps
identify the limit of authority.
●
●
●
●
●
●
●
●
V.
It emphasizes the important aspect of each position. And guides new employees in
understanding how their positions fit in the organization.
It clarifies who supervises whom and to whom one is responsible. It divides the work
to be done into specific jobs and departments. The organizational chart coordinates
jobs into units.
It provides a clue to lines of promotions.
It provides starting points to help in organizational planning and changes
It is used to evaluate strengths and weaknesses of the current structure
It allocates and deploys organizational resources.
It facilitates management development and training.
It describes channels of communication and improves communication.
Modalities of Nursing Care / Patient Assignment System
5.1. Case Method
●
●
●
●
●
Case method or Total patient care is the oldest mode of organizing patient care.
Nurses assume total responsibility during their time on duty for meeting all the needs
of the assigned patient. Referred to as the case method of assignment because
patients may be assigned as cases.
At the turn of the 19th century, total patient care was the predominant nursing care
delivery model. In addition to providing traditional nursing care, because care was
generally provided at the patient’s home, the nurse was also responsible for cooking,
house cleaning, and other activities specific to the patient and family.
During the great depression (1930s), the service of home care became unaffordable for
the majority and people began using hospitals for care that had been previously
performed by private-duty nurses in homes. During this time, nurses and students
were the caregivers in hospitals and in public health agencies.
As hospitals grew during the 1930s and 1940s, providing total care continued to be the
primary means of organizing patient care. This method is still widely used in hospitals
and home health agencies, and can be said to have evolved to what we now call
private duty nursing.
This organizational structure provides nurses with high autonomy and responsibility.
Assigning patients is simple and direct and does not require the planning that other
methods of patient care delivery require. The lines of responsibility and accountability
are clear. The patient therefore will theoretically receive holistic and unfragmented
care during the nurse’s time on duty.
Disadvantages
● Some disadvantages include confusion to the patient if a shift system is integrated.
Each nurse per shift may have a different care regimen and/or may modify the
previous one. Therefore, if there are three shifts, the patient could receive three
different approaches to care, which may result in confusion for the patient.
● To maintain quality care, this method requires highly skilled personnel and thus may
cost more than some other forms of patient care. Some tasks performed by the
primary caregiver could also be accomplished by someone with less training at a
lower cost.
● One of the greatest disadvantages of total patient care delivery occurs when the nurse
is inadequately prepared or too inexperienced to provide total care to the patient,
because of the lack of colleagues that can act as second opinion.
● In the early days of nursing, only registered nurses (RNs) provided care; currently,
many hospitals assign LVNs/LPNs as well as unlicensed healthcare workers to provide
much of the nursing care. This is commonly due to the fact that the coassigned RN
may have a heavy patient load, therefore, little opportunity for supervision may exist
and this could result in unsafe care.
5.2. Functional Nursing
●
The functional method or sometimes called Task Nursing evolved primarily as a result
of World War II and the rapid construction of hospitals. Because nurses were in great
demand overseas and locally, a nursing shortage developed and ancillary personnel
were needed to assist in patient care. These relatively unskilled workers were trained
to do simple tasks and gained proficiency through repetition. In contrast with case
●
●
●
●
method nursing, personnel were assigned to complete certain tasks rather than care
for specific patients.
Examples of functional nursing tasks were checking blood pressures, administering
medication, changing linens, and bathing patients. RNs became managers of care
rather than direct care providers and “care through others” became the phrase used
to refer to this method of nursing care.
This functional form of organizing patient care was thought to be temporary, as it was
assumed that when the cold war ended, hospitals would not need ancillary workers
anymore. However, the baby boom and the resulting population growth immediately
following World War II left many countries short of nurses. Thus, employment of
personnel with various levels of skills and education persisted and proliferated as new
categories of healthcare workers of many educational backgrounds and skill levels.
The benefits of this method include it being an economical and efficient means of
providing care. This is true if the quality care and holistic care are not regarded as a
significant factor. One of the other major advantages of functional nursing is its
efficiency; tasks are completed quickly, with little confusion regarding responsibilities.
Functional nursing does allow care to be provided with a minimal number of RNs, and
in many areas, such as the operating room, the functional structure works well and is
still very much in evidence. Long-term care facilities also frequently use a functional
approach to nursing care.
During the past decade, however, the use of unlicensed assistive personnel (UAP), also
known as Nursing Assistive Personnel, in healthcare organizations has increased.
Many nurse administrators believe that assigning low-skilled tasks to UAP frees the
licensed nurses to perform more highly skilled duties and is therefore more
economical; however others argue that the time needed to supervise the UAP
negates any time saving that may have occurred.
●
Most modern administrators would undoubtedly deny that they are using functional
nursing, yet the trend of assigning tasks to “low-skilled” workers, rather than to
professional nurses, resembles, at least in part, functional nursing.
5.3. Primary Nursing
●
●
●
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●
Primary nursing, also known as relationship-based nursing, was developed in the late
1960s, uses some of the concepts of total patient care and brings the RN back to the
bedside to provide clinical care.
The primary nurse assumes 24-hour responsibility for planning the care of one or
more patients from admission or the start of treatment to discharge or the
treatment’s end.
When the primary nurse is not on duty, associate nurses, who follow the care plan
established by the primary nurse, provide care.
Although originally designed for use in hospitals, primary nursing lends itself well to
home health nursing, hospice nursing, and other health-care delivery enterprises as
well.
An integral responsibility of the primary nurse is to establish clear communication
among the patient, the physician, the associate nurses, and other team members.
Disadvantages
● An inadequately prepared or incompetent primary nurse may be incapable of
coordinating a multidisciplinary team or identifying complex patient needs and
condition changes.
● It sometimes has been difficult to recruit and retain enough RNs to be primary nurses,
especially in times of nursing shortages.
● Shorter lengths of stay
● Increasing numbers of part-time positions
● Variable shift lengths
● Pragmatic need to provide holistic, coordinated care to human beings
Interprofessional Primary Health Care Teams
● Sibbald, Wathen, Kothari, and Day (2013) note primary health-care teams (PHCTs) are
interprofessional teams that include, but are not limited to, physicians, nurse
practitioners, nurses, physical therapists, occupational therapists, and social workers,
who work collaboratively to deliver coordinated patient care.
● “Team-based models of PHCT delivery have been created to achieve (or work toward)
several benefits to the health system, health care providers, and patients, including
better coordination of care, increased focus on collaborative problem solving and
decision making, and a commitment to patient-centered care” (Sibbald et al., p. 129).
● The desired outcomes for PHCTs are reduced mortality and improved quality of life for
patients, a reduction in health-care costs, and a more rewarding professional
experience for the health-care worker.
5.4. Team Nursing
●
●
●
●
●
●
●
●
Ancillary personnel collaborate in providing care to a group of patients under the
direction of a professional nurse. As the team leader, the nurse is responsible for
knowing the condition and needs of all the patients assigned to the team and for
planning individual care.
The team leader’s duties vary depending on the patient’s needs and the workload.
Team nursing resulted from the belief that a patient care system had to be developed
to reduce the fragmented care that accompanied functional nursing despite a
continued shortage of professional nursing staff in the 1950s.
Through extensive team communication, comprehensive care can be provided for
patients despite a relatively high proportion of ancillary staff.
A team should consist of not more than five people, or it will revert to more functional
lines of organization.
Group members are given as much autonomy as possible when performing assigned
tasks, although the team shares responsibility and accountability collectively.
Team nursing also allows members to contribute their own special expertise or skills.
Disadvantage: Insufficient time is allowed for team care planning and communication.
○ This can lead to blurred lines of responsibility, errors, and fragmented patient
care.
The Multidisciplinary Team Leader Role
● One of the recommendations of the 2010 Institute of Medicine Report, The Future of
Nursing, was to expand the opportunities for nurses to lead and diffuse collaborative
improvement efforts with physicians and other members of the health-care team to
improve practice environments
● Nagi et al. (2012) note, however, that implementation problems are common in
multidisciplinary or multi professional teams since mutual respect and collaboration is
not a given.
● Multidisciplinary teams require an efficient means of communication about patient
goals, progress, and problems.
5.5. Modular Nursing
●
●
●
●
●
●
●
●
●
Most team nursing was never practiced in its purest form but was instead a
combination of team and functional structure.
Modular nursing is a modification of team and primary nursing.
It is sometimes used when there are not enough registered nurses available.
Their tasks are to coordinate and provide comprehensive care.
The size of modules and the number of patients in them may vary.
○ In large modules, nursing staff work together; in small modules, they work
independently.
Modular nursing uses a mini-team
○ Each group of patients (usually eight to twelve) is nursed by a small team of
nurses consisting of two or three staff members.
○ Each team must be led by a senior nurse or registered nurse, if available.
■ The leader’s responsibilities include giving and receiving shift reports at
changeover and offering help to (and receiving it from) the leader of
another team.
○ Auxiliary nurses are assigned to the modules where the need is greatest.
Members of the modular nursing team are sometimes called care pairs.
Patient care units are typically divided into modules or districts, and assignments
are based on the geographical location of patients.
The same team of caregivers is assigned consistently to the same geographic
location.
Advantages
● Keeping the team small in modular nursing and attempting to assign personnel to
the same team as often as possible should allow the professional nurse more time for
planning and coordinating team members.
● In addition, a small team requires less communication, allowing members better use
their time for direct patient care activities.
● It provides better communication and cooperation among staff on the unit and
nursing productivity (i.e. time spent in direct nursing care and communication) is
high.
● Advantages of this model center on the physical layout of the assignment and the
ease of working in such an environment.
Disadvantages
● Accountability within modular nursing is reduced because it spans eight-hour
rather than 24-hour accountability and there is less direct nurse-to-nurse
communication. Final accountability is divided between the nurse in charge of the
unit and the leader of each module.
● Disadvantages center on the need to have consistent numbers of staff members in
such a physical environment.
Summary:
Modular nursing uses mini-teams, typically an RN and unlicensed health-care worker(s), to
provide care to a small group of patients, usually centralized geographically.
Nurses are stationed near the patients. The essential components of modular nursing are as
follows:
● A module consists of a group of staff members and a group of patients.
● Patients are grouped by spatial or floor plan clustering.
● Nurse/patient assignment is standardized by cluster.
5.6. Case Management
Case Management
● Case management is another work design proposed to meet patient needs.
● It is a model that mixes both process and care delivery.
● Case management is defined by the Case Management Society of America (CMSA) as
“a collaborative process of assessment, planning, facilitation, and advocacy for options
and services to meet an individual’s health needs through communication and
available resources to promote quality cost-effective outcomes” (CMSA,
2008–2016,para. 58).
○ Nurses address each patient individually, identifying the most
cost-effective providers, treatments, and care settings possible.
○ The case manager helps patients access community resources, helps patients
learn about their medication regimen and treatment plan, and ensures that
they have recommended tests and procedures.
○ In hospital nursing it focuses on the achievement of patient outcomes within
an effective and appropriate time frame.
■ It is focused on the entire illness episode and can cross all units in
which the patient receives care.
■ The assigned case manager works with the assigned nursing staff to
coordinate patient progress through the transition of care pathway.
■ The patient will have a specific ‘care MAP’ (multidisciplinary action
plan) or critical path based on an appropriate diagnosis-related (DRG)
category.
● The care MAP is a combination of a critical pathway and a
nursing care plan.
● They provide a written system with the daily needs of the patient
and family, followed by all healthcare providers to change
practices, increase efficiency, facilitate outcomes and reduce
cost.
● The care MAP indicates times when nursing interventions
should occur.
● All health-care providers follow the care MAP to facilitate
expected outcomes.
● The case manager will implement the care plan and
communicate with all nurses, doctors and other healthcare
●
●
●
providers. The team of healthcare providers will work together to
reduce the length of the patient’s stay in the hospital.
● Critical paths serve as tools to case managers to achieve
patients’ outcomes and provide a framework of what to expect
each day of hospitalization.
■ If a patient deviates from the normal plan, a variance is indicated. A
variance is anything that occurs to alter the patient’s progress through
the normal critical path.
○ The case management model also extends beyond the hospital setting, with
case managers working with patients and families in all transitions of care.
■ Some institutions use case managers in partnership with chronically ill
patients at high risk for continued hospital readmissions.
■ The case managers work with the patients to coordinate the entire
spectrum of care in all settings.
■ Case management has been associated with decreased readmissions
for chronically ill patients.
Case managers are often population-based, so that one case manager may work
with all surgical patients within a hospital, although some institutions do use
unit-based case managers.
The case manager is assigned to the patient on admission and follows the patient for
the entire hospital stay and performs all post-hospital care coordination. Not all case
managers are nurses.
Some feel that the role of case manager should be reserved for the advance practice
nurse or RN with advanced training.
○ Board certification as a case manager is available to any individual with a
professional license such as an RN, licensed clinical social worker, or
pharmacist or at least a 4-year degree in a health or human service area, or a
professional certification such as a certified rehabilitation counselor (CRC) or
certified disability management specialist (CDMS) . . . and with completed
supervised field experience in case management (Commission for Case
Management Certification, 2016).
Advantages
● Provides a professional practice model for nurses
● Is cost-effective
● It provides well-coordinated care for patients with complex healthcare problems.
● Outcomes can be improvised
● Length of patients’ hospitalization may decrease.
● Efficient use is made of the different services.
● Nurses experience a sense of satisfaction, as patients receive high-quality, coordinated
care
Disadvantages
● May lead to fragmented communication
● Needs to be integrated into the care delivery model
●
●
●
●
●
●
May lead to nurses caring for patients to become more skills focused if the case
manager makes all the decisions
Financial
barriers
are
experienced,
as nursing case management is
revenue-protecting, not a revenue-generating activity
Some nursing case managers experience a lack of administrative and information
support.
Education and preparation of nursing case managers are not firmly established; there
seem to be insufficient nurses trained in this specialist field.
There is a concern that ‘the art of nursing’ may disappear, with patients moving
quickly through the hospital.
Other implementation challenges associated with case management nursing revolve
around confusion related to the specific job of the case manager because case
management entails different roles and functions in different settings.
○ For example, in some settings, case managers participate in direct care or have
direct communication with patients. In others, the case manager is an
advocate for patients, although the patient may have no direct knowledge or
interaction with that individual.
Summary:
Case management is a collaborative process that assesses, plans, implements, coordinates,
monitors, and evaluates options and services to meet an individual’s health needs through
communication and the use of available resources to promote quality and cost-effective
outcomes. Although the focus historically for case management has been the individual
patient, the case manager employed in a DM program plans the care for populations or
groups of patients with the same chronic illness
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