Understanding and working in organization

Organization-

• Define as a formally constituted group of people who have identified tasks and who work together to achieve a specific purpose defined by the organization.

• All organization have purpose and structure

• To understanding of how the organization in which you are employed is structured. You need to ask these questions:

• To whom do I report?

• To whom can I delegate?

• To whom do I go with a problem or concern?

• How do I report error?

• Who will evaluate me ?

• Am I responsible for evaluating someone else?

These and many other questions are answered by understanding the organization’s structure and function

Understanding organizational structure and function

organizational structure means the way in which a group is formed, it’s

chains of command, it’s lines of communication, and the process by which decision making occurs.

The formal working relationships and identifies who is accountable and responsible for various jobs that make the organization viable

• The organization is hierarchically arranged, with people employed in the defined roles within the organization having different levels of power (or authority) and rank from what others have.

• Max Weber (father of organizational theory)

He place high value on bureaucracy (the administration of institutions through departments or subdivisions managed by sets of officials who followed an inflexible routine) and it’s importance in the operation of an organization.

• Gardner, 1995 referred to bureaucracy as a closed, rational system that focuses on internal interactions and places emphasis on organizational order and control

• It does not take into consideration the complexity of multifaceted health care organizations of the twenty-first century.

• Kotter (1995) states “a central feature of modern organizations is interdependence, where no one has complete autonomy, where most employees are tied to many others by their work, technology, management system, and hierarchy.”

• This is certainly true in today's health care facilities.

• The structure of any organization is designed to allow it to accomplish its purposes in an efficient and effective way.

Organizational Function

is the way interactions actually occur within the organization

• It is often complex and may be related to characteristics of the employees as well as to the planned structure of the organization itself.

Types of organizational structure

• Tall or centralized structure

• Flt or decentralized structure

• Matrix structure

Two other approaches that affect structure:

- Adhocracy

- Shared government

Chief administration

Vice-president

Patient services

Vice-president

Business & finance

Vice-president

Plant operation

Plan service housekeeping budging billing outpatient inpatient

2 1 1 1 2 2 1 2 1 2 1 2

Tall structure • It also called centralized, because most of the

decision-making authority and power is held by a few persons in central positions that typically are found at the top of the chart.

Advantages:

• The ability of an individual to be an expert in the narrow area over which he or she is responsible, such as intravenous (IV) therapy

• Use fewer skilled individuals-----they supervised others who carry out standardized procedures

because the supervisor has fewer people to supervise, close supervision is possible

• Disadvantages:

• Most skilled individuals may end up doing nothing but supervising

• The very closely supervised people may feel stifled and in extreme cases even mistrusted

• Difficult communication-----it must pass through many layers,

• And the person with authority for decision-making may be quite far removed from the actual situation

• Implementation of a decision may be excessively delayed

• Some communication never reach the individual who might be able to make a decision for change when that is needed

administration

District 2 District 3 District 4

• Flat or decentralized structure

District 1 District 5

• Flat or decentralized structure • In type of organization, decision-making is

commonly spread out among many people • Close supervision is not possible when supervisor

responssible for many people • Manager relies on individuals to make independent

decision individuals have an opportunity to develop their own abilities and autonomy

• People see the organization as more humanistic • The result is greater job satisfaction for the

majority of the individuals

• Decentralized organization is the simplification of communication pattern, which flow easily from lower levels to higher levels in a direct manner.

• Less chance of communication becoming lost or distorted

• Speed with which the organization can respond to problems or new opportunities

• Disadvantages of decentralization

• The individual in charge may have so many individuals with whom to relate that the various parts of the organization do not work together as effectively as desired

• The manager may lack critical information to make decision at that higher level

• Managers may have lack expertise in the wide variety of operations making inappropriate decisions

• A greater need for on going education of individuals within the organization to enable them to make good decision

• Many health care organization are moving toward more decentralization models for nursing services

Matrix structure

president

Vice-pres.

marketing

Vice pres.

finance Vice pres. Vice-Pres.

development. Vice-pres.

Financial s.

Plan & marketing

pt. serv. Develop.

• Matrix structure

Are most often found in very large , multifaceted organizations.

These may be seen as autonomous units within a hospital established to offer special type of services, such as women’s centers which might include obstetricians and weight loss specialists, psychologists and psychiatrists plastic surgeons, or sports medicine centers.

The goal is to attract more patients who will appreciate having all the services available in one area and involves a team approach

• Matrix structure cont.

• Ford and randolph (1992) discuss the difficulty that continues to exist in defining a matrix organization

• They suggest that matrix management often is whatever a company defines it to be and state that project management has likewise come to mean a variety of things .

• That is either tall or flat and is thought of as the functional structure.

• Project structure overlies the matrix structure, creating two directions for lines of authority, accountability, and communication or a multiple command system.

• These structures may also be referred to as cross-functional.

• Functional managers (or line managers) have the responsibility of maintaining adequate staffing, developing or acquiring skills needed to support the projects, and providing for evaluation and career development of personnel.

• The project manager directs the project team that develops project standards and management practices and oversees their application to the various projects

• Advantages of matrix structure

• Bring together wide expertise and often generates more creative solutions as a result of flexible use of human resources.

• The team managers learn more about one another’s concern, and this involvement may also improve their working relationships, functional integration, and skill development.

• Advantages are derived from creation of horizontal communication linkages that solve information processing problems.

• Communication is improved by the close contact with all organizational groups, which is required of managers to assure project success

• disadvantages of matrix structure • Can result in areas of leadership conflict, poor communication, lack of

understanding of roles and expectations, cost created by dual authority, and concern regarding personal evaluation.

• Dual-reporting relationships may also be a concern. Individuals within the organization may report to at least two managers, the nursing manager and the project director. This can lead to confusion and conflict, and ambiguity: a price individuals may have to pay for working in a matrix

• A team member who will be evaluated by both the team leader and the base department manager may feel a conflict and find it frustrating to be asked to do more than is realistic within the time allotted.

• Persons working in a matrix organization need good interpersonal skills and training because they will be working in a collegial rather than a hierarchical relationship.

• Power balance between the two structures may become a concern.

• Adhocracy structure • This type of structure uses teams of specialists who are organized to

complete a particular project or task.

• Composed primarily of highly specialized professionals,

• The work is delegated by a director to members of the project team who provide particular expertise.

• The team are creative , flexible, and fluid.

• The role of the leader is to create the process for effective problem solving and is based on the belief that the best thinking come from team effort.

• Team of this nature work especially well when trying implement change

• This structure might be seen in hospice organizations, and community health

Relationship with organization

Authority and Accountability Defined

• Authority: refers to the official power an individual has to approve an action, to command and action, or to enforce a decision.

• Formal authority is conferred by virtue of an explicit set of expectations , such as those found in job descriptions, the manager agrees to meet.

• Informal authority come from promises the manager makes that are often left implicit, such as the expectation that the individual will be trustworthy, competent, considerate, and demonstrate values and skills that are predictable.

• The concept of authority is associated with power, because it legitimizes the right of the manager or supervisor to give direction to others and expect them to comply.

• In bureaucratic organizations----authority originates at the top of the organizational hierarchy and works its way down.

the expectation that the subordinates will follow direction from the manager

• A second view of authority---- is

the acceptance theory

it proposes that a leader earns authority from the subordinate.

It is a bottom-up approach in which the subordinate gives authority to the manager

In reality, in the best-working organizations, perhaps it is a bit of both.

• Accountability refers to the process of answering for what occurs in an ethical and legal sense, it represents an obligation to perform certain activities and duties.

It may use this term interchangeably with responsibility.

When the nurse delegates task to others remains accountable---or legally liable---for the outcome.

Ex. Registered nurse assign the task of taking blood pressure.

RN. Is still responsible and accountable for

- assuring correct reading

- and appropriately documented

• The structure of the organization helps designate the authority and accountability of all persons working within that body.

• Indicates who gives instructions to whom and who must answer for the actions that follow.

• Problem arise in organizations when people are asked to be responsible for certain outcomes but are not provided with authority with which to accomplish the goals.

• Organizations are healthier when the structure and function are well described, authority is appropriately provided to match responsibilities, and this information is known to all involved.

• Chain of command

• It identifies the path of authority and accountability from one individual with top administrative authority to the individuals at the very base of the organization.

• It also referred to as organizational hierarchy

The nursing administrator

gives directions to and evaluates

the performance of

the assistant administrator

who in turn gives direction to and

evaluates the performance of

the nursing manager

• Frequently use the language “report to” which indicates that the nurse manager is accountable for his or her activities to the nursing administrator.

• As registered nurse, you will likely have the responsibility of giving direction to an overseeing the activities of the practical nurse and the nursing assistant, and in turn, report to you

• Channels of communication

• defined as the patterns of message giving within an organization, and they typically correspond to the

chain of command.

• Formal communications are not supposed to skip or loop any levels

• In bureaucratic organization it is generally considered improper and inappropriate to skip or bypass any of the levels in the communication system

• Channels of communication cont.

• Not all communication follows these formal pathways.

• others ,especially those that involve subordinates in decision making, encourage communication outside those lines if the desired action would be accomplished more efficiently.

• Effective function often requires that a manager communicate directly with individuals at many different positions in the organization

• Span of control----means the number of individuals a person is responsible for managing

• A narrow span of control----the individual will be responsible for only a few people and perhaps one or two task areas

this individual is likely to be an expert

in the task area (IV therapy)

Wide span of control----if given responsibility for the IV team, the emergency dept., and the staffing office,----this person could not possibly be a clinical expert in every area and it is unlikely to be involved in providing direct care in those departments.

• Factors affecting appropriate span include:

1. Size of the organization

2. Its philosophy

3. Services provided

4. Availability of resources (human resources)

5. The manager expertise and ability

6. The skill and experience of the employees

7. The task to be accomplished

8. The level in which the organization at which the position occurs

• Job descriptions • It is a written statements, found in policy

manuals that describe the duties and functions of the various jobs within the organization.

• They outline the scope of authority,

responsibility, and accountability involved in each position.

• It should provide

1. the broad general guidelines under which the individual will function

2. the basis for performance evaluation of the person working in that role

• The job description for a nurse in an outpatient clinic will be quite different from that for a nurse in critical care.

Organizational charts

• It is used to depict the structure of the organization

• It identifies to whom various individuals within the organization report

• It is a graphic, pictorial means of portraying various roles and patterns of interaction among parts of the system

Organizational chart-----

Presents the formal structure of an organization

Showing relationships of people or departments to one another

Providing information on the size of the organization

Provide the formal chain of command

Lines of communication

And the authority for decision making

Organizational chart-----

• Is typically represented by boxes stacked in a pyramid-shaped chart

• The greater authority exists at the top of the chart (often a single box)----- referred to as executives, administrators or the management

• and declines as you move toward the base of the structure (many boxes)----referred to as staff or employees

• The level between the top and the base known as middle management----a group responsible for coordinating and controlling activities of a specified group of workers

• Line connect positions on the organizational chart

• Solid connecting lines—represent communication relationship between

individuals or departments.

• Vertical lines----referred to as lines of authority and accountability.

• Lines of authority----represent the responsibility of individuals to supervise other officially----moving downward

• Line of accountability----called reporting relationships----a responsibility to report to another person

• Line connect positions on the organizational chart—cont.

• Horizontal solid lines indicate the communication between individuals with similar levels of authority within the organization----- such as a the unit manager on a surgical unit and the unit manager on a medical unit (work together to reach certain objective within the organization)

• Dotted lines (or broken)----represent communication relationship rather than authority relationships.-----such as nursing unit manager and house-keeping supervisor

• Part of the organization that do not have connecting lines

Such as the communication line between the administrator of nursing and the administrator of house-keeping. The communication could then move across from the nursing department to the house-keeping department and then down the house-keeping structure to the appropriate person.

• Limitation of the organizational chart

• It does not show the informal structure (grapevine) of the organization----such as

• social activities outside the organization

• Unwritten rules and expectations regarding communication, dress, etc.

• It is difficult to keep current as the individuals in various positions change

• Other factors unique to organizations

• Mission Statement

• It is the aims or function that the organization plan to accomplish

• Identifying the group to whom the services are directed

• Specify who sponsors the organization

• Mission statement of

1- a small community hospital may indicate:

– To serve the health care for needs of the immediate community,

– Provide first-line diagnosis,

– Care for commonly occurring illnesses

2- a large university hosp. may have:

- encompasses research,

- teaching,

- care for rare or complex problems

These two organizations will establish:

- different priorities for spending

- choose different technologies

- structure their staff in different ways

See and read Display 2-1 and 2-2

• Statement of philosophy

• It flows from the purpose or mission statement and provide statement of beliefs and values

• It is identified as a listing of

- value

- goals or objectives

The philosophy along with the mission statement, provide the a benchmark against which an organization’s performance can be evaluated.

• Policies, protocols, procedures, and standards of care

Policy— is designated plan or course of action to be taken in a specific situation.

• Written policies usually can be found in a policy manual that is available within each department or on a computer network.

• You may have greater or lesser need to refer to the policies.

Special care units, such as birthing rooms and emergency departments, have more need to refer to policies than does an area in which care is more standardized.

- reporting on animal bites,

- managing the care of rape victims,

- reporting gunshot wounds

• Protocols------ is a detailed standard plan for

patient care,

such as a protocol relating to the general management of the patient with a dog bite.

Procedures----- spell out how a particular nursing activity is to be completed, often described in number of steps or processes

Standard of care-----are specific, detailed plans of care for individuals with a specific health problem.

The purpose of standard of care is

To establish the best practice

To eliminate as much variation as possible

The standards of care become the basis for determining the level of care delivered and for quality improvement within the organization as well as for cost analysis.

Standards of Nursing Practice

Are authoritative statements that describe a common or acceptable level of professional nursing performance.

• Organizational effectiveness-----refer to how well an organization accomplishes the purposes for which it exists.

Structuring Nursing Care Delivery Systems

1. The variety of systems used for nursing care delivery

2. The need to control costs

3. The increasing professional role of the registered nurse,

4. the increasing emphasis on employee job satisfaction

These represent the reasons for the multiplicity of approaches to care.

Methods of care delivery:

The case method

The functional method

Team nursing

Modular care

Total patient care

Primary nursing

Partnership models

Case management

The case method

It was predominant organizational structure for nursing care delivery at the beginning of the twentieth century.

The nurse was hired to:

Care for an individual patient

Providing all the care needed

Often living in the home with the family

assuming other household responsibilities such as cooking for the patient and family

Doing light housekeeping

Nurse work long hours with poor wages

The advance technology and increasing cost made case method care impractical

Home health care do use this form of nursing care

nurse does not live in the home

personal care provided by the home health agency

a registered nurse does the assessment,

planning, skilled intervention, and supervision

The functional method

It emerged around 1930 when the US. Saw a tremendous growth of hospitals around the nation

This method allowed for the care of greater number of patients.

The head nurse assigned various nursing tasks to different nurses in that unit.

One nurse might take all temperatures, change the dressings, and apply hot compresses (the treatment nurse)

Another might give all the medications and chart them (the medication nurse)

The assignment varied depending on the:

• The size of the units

• The number of the patients

• The number of the personnel

• The skill level of the personnel

The personnel all reported to the head of the nurse who give the report to the next shift

The advantage of the functional method :

• Economical and efficient

The disadvantage:

• Patients were often confused about who was caring for them

• Pt. did not know to whom to address questions if they had concerns.

The functional method is effective in situations in which there are few registered nurses and other must provide direct care

Such as: the licensed practical nurse may be assigned to specific skilled tasks such as medication administration and treatment. Nursing assistants provide the personal care.

Team Nursing

• Was introduced in the 1950s when the tremendous nurse shortage.

• With team nursing, an identified team leader, who is an experienced registered nurse,

was assigning care of patients to team members who typically have various level of education.

Team members could be:

registered nurse

practical nurse

nursing assistant

nursing student (sometimes)

The team leader give report to the team that assumed care on the next shift.

Advantage of team nursing

Team conference at which all members of the team met, discussed, and planned the care of all patients assigned to the team.

The leader report to the head nurse who had overall responsibility for managing the unit

Typically each unit had two or three teams depending on the size of the unit and the number of the patients

• The system work fairly well if the team leader had leadership skills and if there was always time for team conference.

• If these factors were lacking , it had few advantages over the functional method

Modular Care

• Gain popularity during the mid-1980s.

• It is dependent on structural and spatial changes in health care facilities that would enable nurses to stay close to the bedside.

• Patient care units were divided into modules, and the same team of care providers was consistently

assigned to each module.

Total patient care Become popular in the 1970s and 1980s.

In which a registered nurse or licensed practical nurse is assigned to all care needs of a group of four to six patients.

Nurses feel a greater sense of control, autonomy, and involvement in patient care.

Focusing on the total patient, more emphasis was placed on the holistic approach to care rather than tasks or procedures.

During the shift only

disadvantages

become more difficult to implement when technological advances resulting in patients

Total pt. care is currently used in intensive care units, labor and delivery units and other settings in which pts. Have very high acuity

Primary Nursing

• Began in the late 1970s, peaking in the late 1980s.

• With primary care , one nurse was assigned the responsibility for the care of a patient from the time the pt. was admitted to the hospital until the pt. was discharged.

• The primary nurse

• developed and updated nursing care plan

• Performed care and pt. teaching

• Provide discharge planning

Advantages Pts. Experience fewer complications

Pts had shorter lengths of stay

RN did not spend time delegating and supervising.

Providing a high quality of care to the clients

Allowing maximum autonomy to the nurse

Nurses usually experienced a high level of job satisfaction

Disadvantages Expensive because of the number of professional required to assure its

implementation.

Need to educate new staff for this role (big expense)

Partnership Models

Partnership is that of a registered nurse and a licensed practical nurse, pt. care is shared with the registered nurse who is planning and directing the care.

Case Management

• Results in the monitoring of an individual patient’s health care by the case manager for the purpose of maximizing positive outcomes and containing costs.

• Case manager typically follows the pt. from the diagnostic phase through hospitalization, rehabilitation, and to home care, assuring that pt. care goals will be realized.

• Case management goes beyond primary nursing to add responsibility for managing pt. interaction with the entire health care system

Case management requires

1- nurse be well prepared for the role,--- educationally and experientially

2- they must possess good interpersonal skills Case managers are usually employed by a particular

institution Nurse case managers are hired by insurance

companies and by families Case managers ,do assessment, determine what services are needed and then research and recommended appropriate resources.

The informal organization It is essential to functioning of the system The informal organization operates with great

flexibility, pay little attention to boundaries, and carries the bulk of communication relating to the organization’s internal politics

It is social in nature arise within the formal

organization to meet the needs of the people within an organization

Such as 1- meeting social Needs 2- accomplishing goals 3- providing communication 4- preserving values

Informal leaders arise within organization and able to influence others.

These informal leaders may make an important contribution to the organization’s functioning,

but they may also be counterproductive.

Other problems that may originate within the informal organization include distortions in communication, support for nonproductive behavior, and resistance to accepting new individuals within the social structure.

Organizational Climate And Culture

The organizational climate is how employees perceive the organization.

The organizational culture is the sum total of values, formal and informal communications, and other factors that affect how an organization operate.

Organizational Climate And Culture Effect of policies

- Effect of the behavior of manager

- The informal organization and climate

- Changing the organizational culture and climate

both organizational culture and climate are not static