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ORGANIZATION
INTRODUCTION:-
.
DEFINITION
Nursing Services:-
Nursing service is the part of the total health organization which aims at satisfying the nursing
needs of the patients/community. In nursing services, the nurse works with the members of allied
disciples such as dietetics, medical social service, pharmacy etc. in supplying a comprehensive
program of patient care in the hospital.

Nursing Services:-
WHO expert committee on nursing defines the nursing services as the part of the total health
organization which aims to satisfy major objective of the nursing services is to provide prevention
of disease and promotion of health.

Organizing:-
Organizing involves the process of deciding which levels of organization are necessary to
accomplish the objectives of a nursing division, department or services, or unit. For the unit, it
would involve the type of work to be accomplished in terms of direct patient care, the kinds of
nursing personnel needed to work to accomplish this work, and span of management or
supervision needed.

Organization:
Organization is the form of every human association for the attaintment of common purpose and
the process of relating specific duties or function in a whole.

[J D Mooney]

Organizational structure
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Organizational structure is pattern of interrelated posts connected by line of delegated authority.

[ Milward]

PRINCIPLES WORDS OF ORGANIZATION IN NURSING SERVICE

In the words of white (1995) the principles of organization suggest only working rules of

conduct which with experience seems to have validated. The responsible administrator must

know principles and apply them with judgment in items of his immediate situation. Henri Fayol

(1947) has defined these principles as “acknowledged truths regarded as preview on which to

rely”.

Mainly there are six principles of organization as follows:

1. Hierarchy

2. Span of control

3. integration vs. disintegration

4. Centralisation vs. decentralization

5. Unity of command

6. Delegation.

Hierarchy

Hierarchy means the rule or control of the higher to lower. Any organization is like a

pyramid, broadest at the base and tapering towards the top. In this pyramid there is hierarchy

Organization is essentially the division of functions among a given number of persons. The

distribution of functions and responsibilities is both horizontal and vertical. An organization

structure grows both horizontally and vertically. When additional levels are added in an

organization structure, it is called vertical growth. But when more functions or more positions

are added without increasing the number of level, it is called horizontal growth. Vertical
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distribution creates levels like to management, middle management, supervision and the evel

of specific performance. Strictly speaking, these levels cannot inherent superiority and

'eriority. However, due to the difference in nature of responsibility of various levels, the

deference in the salary scales as between different levels and difference in the qualifications

qualities of the personnel manning various levels, superior, subordinate relationship emerge in

the organization.

In other words, scalar principles is the vertical division of authority and definite

assignment of duties at various levels. Here the degree of authority and corresponding

responsibility will be defined.

'Hierarchy consist in the universal application of the superior-subordinate relationship

through a number of levels of responsibility reaching from the top to the bottom of structur

(White L D) Moony and Reilay call it "the scalar process’.

The scalar process is the vertical division of authority and definite assignment of duties

at various levels. The degree of authority and corresponding responsibility will be defined.

Each of the levels will be immediately subordinate to the next higher, e.g.
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Medical superintendent (1)

Nursing superintendent (1)

Dy. Nursing superintendent (3)

Asst. Nursing superintendent (6)

Staff Nurses (30)

The advantages of scalar principles of hierarchy will include:

 It is an instrument of organisational integration and coherence.

 The scalar chain serves as a channel of communication upwards and downwards.

 The rule of 'through the proper channel' created by the scalar principle ensures that

there will be no short circuiting procedures or ignoring .of the intermediate links.

 It establishes below the top executive, a number of subordinate.levels each of which is

centre of decision for specific matters of a less important nature.

 It helps to clarify and define the relative positions and responsibilities of each post in

the organization.

The disadvantages of hierarchy is the delay inevitably caused every proposal or action

must be laboriously climb up the various steps of the ladder and then descent down to get

disposed off, e.g. in a Directorate of Health and Family welfare service, a case worker of

Nursing section drafts a proposal for transfer of a Nurse, submits first to office superintendent,

then it goes to Asst. Administrative officer; then goes to Chief Administrative officer; finally
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reaches the Director, then draft approved by the director, reaches the case worker of nursing

section in the same way leading to delay Every organization must have its scalar chain but it

should work with proper confidence and loyalty between superior and subordinates at each

level, to reduce delay. Hierarchy provides the much needed channels of communications in the

organisation from the top to the bottom and from the bottom to the top. It is also built in device

to achieve consensus in the organisation. It also facilitates delegation of authority. The general

functions of hierarchical structure are (Appleby) as follows:

 Fixing the responsibility.

 Providing leadership with areas of description at successive levels.

 Providing means for exerting influence and exercising fellowship.

 Making any particular organisation and the general government manageable.

 Making it acceptable.

of the rival principles must be decided on its own merits according factors of the situation.

For example, formulating policy is centralization whereas implementation of policy

decentralization.

Unity of command

Unity of command means that no individual employee should be subject to the orders of

more than one immediate superior. The concept of unity of command requires that every member

of on organization should report to one and only one leader. Henri Fayol is a great advocate of this

principle, meant that an employee should receive orders from one superior only .when it is

jeopardy , order disturbed and stability threatened diversity of command may also result in the

subordinates playing off one superior against another or other. All this may cause confusion and

blurring of responsibility. It is true that command, orders or guidance should always come from
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one delegating supervisor, otherwise there are chances of shirking of duties, of abusing authority

and of evading accountability.

Theoretically the principle of unity of command appears to be unassailable, in practice

it has some important exceptions to it. For example an individual employee is frequently

subjected to a dual control, i.e. one administrative and the other technical or professional. To

quote the head of the professional colleges of the Govt. has academic control by the

Universities and has administrative control by the respected Govt. .

Unity of command helps increasing co-ordination in the organisation. Co-ordination

means negatively the removal of conflicts, working at cross-purposes, and overlapping from

administration; positively co-ordination's aim is to secure co-operation and team work among

the numerous employees engaged in the work of the Organisation.

Delegation

Delegation implies transfer of certain specified functions by the superior to the

subordinates authority. The subordinate authority acts as the agent of the superior authority and

the superior always retains the right to issue directions to revise decisions. In other words,

delegation of responsibility always remains with the superior.

STEPS IN ORGANISATION IN NURSING

Activities and jobs form the basis of organisation which are used for designing an

organization structure. These activities are determined by the objectives and strategies and to the

performance of activities, persons trained in particular job are needed.

The steps in organisation are as follows:

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1. Determining and enumeration of objectives for each activity. The required activities are

spelled out from the objectives of the enterprise. The total work, operating and

managerial is broken down into component activities that are to be performed by all

personnel. The breakdown of activities is carried as far down as to determine job of each

individual.

2. Grouping and assigning activities: Correlated and similar activities are grouped into

division or departments first. And these divisional or departmental activities are further

divided into sections and jobs.

3. Allocation of fixed duties to definite persons. Definite job assignments are made to

different subordinates for ensuring certainty of work performance.

4. Delegation of authority: Corresponding to the nature of duties, commensurate authority

must be granted to the subordinate for enabling them to make adequate work

performance.

In brief the important steps in organising are:

a. Determination of objectives of each activity.

b. Deciding on the various types of activities to be undertaken within the framework

of the formulated plan to attain the goals of the organisation.

c. Grouping of activities according to them similarity, interrelationships,

competencies and capacities required in performance of these activities, its

importance in relation to attainment of goals.

d. Deciding different group of activities in terms of number of staff, the eligibility

requirement of staff, seating arrangement, the materials and supplies, machine

and equipments, funds and methods for maintaining the moral of employees.
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e. Determining the authority, responsibility and accountability of different members

of staff, which includes:

 determining the lines to authority with the channels of communication,

 the relationship between members, departments, supervisors, peers and

subordinates, . developing an organisational chart based on above,

 planning of the items listed above,

 allotment of duties to individuals.

f. Integration between the identified group of activities through authority

relationship and organised communication system.

Effective direction needs leadership. The need for leadership would be evident if use of

authority, power and influence by managers in any organisation. Authority may be defined as the

capacity of arising from formal position to make decisions affecting the behaviour of

subordinates. In other words, authority is the right to command and extract obedience from

others. It comes from organisations and it allows the leader to use power. Power is the ability to

exercise influence or control over others. In the functioning of a leader the ability to guide the

action of others is achieved through his authority. Carrying out of these decisions is

accomplished because of the power of the leader. There are various types of powers as follows:

Legitimate power comes to the leader when the organisation's authority is accepted. It

comes from the rules of the organisation, e.g. parents, teachers, managers, police etc. It is the

power inherent in one's position.

Expert power is the power of knowledge and skill of special kind that is important in
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getting the job done. A person's professional competence or knowledge has the expert power, e.g.

doctor, engineer, nurse, lawyer.

Charismatic power is the power of attraction or devotion, the desire of one person to

admire another. A subordinate feels a positive attraction towards a leader by identifying himself

with the leader, or gets influenced by the leader's attractive power, e.g. Indira Gandhi.

Reward poweris the present or potentiability to reward for worthy behaviour. Tangible

reward such as promotion, office space, time off from work, attractive work assignments, and

help to the subordinates. Psychological reward like praise, appreciation, approval and recognition

can be given by the leader or the superior to the subordinate, rewards power increases other

powers as stated above. In short, it is obtained by the ability to grant rewards to others.

Coercive power is the ability to threaten or punish. The leader can use tangible

punishments like dismissal, demotion, less rating, less satisfactory work, assignments etc.

Psychological punishments include criticism, avoidance, disapproval, satirical remarks on the

subordinates. In short coercive power based on the fear and punishment.

Expert power is gained through knowledge, expertise or experience. Having critical

knowledge allows a manager to gain power over others who need that knowledge. This type of

power limited to a specialized area, e.g. music.

Referrent power is power in individual has because others identify with leaders or with

what that leader symbolises. This type of power given to others through assumption with the

powerful. People also may develop referrent power because others perceive them as powerful.

Informational power is gained when someone has information that another needs. This

source of power is obtained when individual has information that others must have to accomplish

their goal.
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Feministic power or self power is the power, in which an individual gains over his or her

own life. This is a personal power that comes from maturity, ego, indegration, security in

relationship and confidence in one's impulse.

The following are the leadership roles and management functions in any organisational

authority and power in any organisation. Here the leader's roles includes that he or she:

 Creates a climate that promotes followers hip in response to authority.

 Recognises the dual pyramid of power that exists between the organisation and its

employees.

 Uses a powerful person to increase respect and decrease fear in subordinates.

 Recognises when it is appropriate to have authority questioned or to question authority.

 Is personally comfortable with power and the political area.

 Empowers other nurses.

 Assists staff in using appropriate political strategies.

Functions include that he/she:

 Uses authority to ensure that organisational goals are met.

 Uses political strategies that are complementary to the units and organisations

functioning.

 Builds a power base adequate for the assigned management role.

 Maintains small authority power gap.

 Is knowledgeable about the essence and appropriate use of power.

 Maintains personal credibility with subordinates.

 Serves as a role model of the empowered nurse.

ORGANISATIONALSTRUCTURE AT SERVICE SIDE

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Organisation means the formal structure of authority calculated to define, distribute, and

provide for the co-ordination of tasks and contributions to the whole.

Each organisation has a formal and an informal structure that governs work flow and

interpersonal relationship. The formal structure is planned and publicised whereas the informal

structure is unplanned and covert.

An organisation's formal structure is the official management of positions into patterns of

working relationship that co-ordinate the efforts of workers with diverse tasks and abilities. The

formal structure of nursing department should be determined by the nurse executive and nurse

managers with input from various nurse specialists; should support agency goals and nursing

philosophy and objectives.

The informal organisation structure consists of unofficial relationships among workers

that influence work effectiveness. The formal structural diagram is a system of power and

control, a map of communication channels, and a scheme for assigning tasks to the most

qualified workers. The main purpose of the defining and updating diagram is essential to clarify

chain of command, span of control, official communication channel, and liaison links for all

department personnel.

Medical Superintendent
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CNO

DNO DNO DNO DNO

ANO ANO ANO ANO ANO ANO ANO ANO ANO ANO ANO ANO

SN SN SN SN SN SN SN SN SN SN SN SN
(10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10) (10)

CNO-Chief Nursing Officer DNO-Deputy Nursing Officer ANO-Asst. Nursing Officer

SN-Staff Nurses

Line Organisation Structure

A purely hierarchical chain of command in which each employee is supervised by and is

responsible to a single, clearly identified superior. Pure line structure operation analyses the

principles of classic or traditional, organisational theory, which are:

1. The organisation structure should be as simple as possible to facilitate understanding of

role relationship.

2. The organisation structure should provide clear-cut authority and responsibility for each

position.

3. The work of each employee should be confined to a single function, or group of similar

functions, because specialisation fosters efficiency.

4. The activities and functions of each employee should clearly contribute to achievement

of overall goals of organisation.

5. Related functions should be grouped under a single supervision.

6. Each worker should take orders from and be accountable to only one supervisor.
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7. To ensure horizontal co-ordination, institutional rules and policies should be formulated

by the top administrator.

The line authority is a direct authority exercised by a supervisor over his subordinates and

the flow of authority is always downward. In its implicity, unity of control, better discipline,

fixed responsibility, flexibility and prompt decision will be possible.

In practice, an organisation's line functions sometimes we come across lack of

specialisation, overloading of works, inadequate communication and favouritism.

Line relationship exists between a superior and the subordinates immediately and

directly responsible to him. In nursing, staff nurses who perform the basic work of the nursing,

that is direct patient care. The middle level manager, like head nurses supervisors are

responsible for programmed decision making and direction of day-to-day operation. The

nursing personnel at the top CNO or Directors are responsible for non-programmed decision

making such as goal setting, programme planning and performance evaluation.

Line and Staff Organisations

A staff function is an activity that is separated from the chain of command to permit a

high degree of specialisation. The staff authority is created for giving specialist advice to the line

superiors, and flow of authority is always upward. It has no power in the organisation. Staff

relations are those which arise where an individual is acting as the representative of a superior.

This individual is not vested with authority in her/his own rights but in acting for and on behalf

of the person who the authority is vested. A staff officer's specialisation confers the status of

expert in a narrower sphere of management. A cynical definition of a staff specialist is one whose

preparation and experience confer more and more knowledge about fewer and fewer subjects.

The staff officers serve one of these functions-service, advisor, control, e.g. assistant nursing
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officer, (HN) incharge, in, service is a service specialist, who serves line division by orienting

and training of staff nurses. An assistant nursing officer who is incharge of planning advises line

manager/supervisor in setting goals and planning of method to achieve goals. Like this, staff

officer advises the line officers in planning, organising, control and directing and other

managerial affairs.

It is believed that the best system to adopt in any progressive and elite organisation is the

line and staff organisation. Here there is a provision for having experts, advice available to

management, which in turn increases efficiency of supervisors and also there is chance of

advancement to its employees. Here there is a scope for staff need to assume line authority may

lead to frictions, and if they do not give sound advice leads to problems, which hinders the

attainment of objectives properly.

Functional Organisation

Functional organisation is a system of organisation in which functional departments are

created at the institutional level to deal with the problems of concerned at each successful level,

e.g. in an hospital

Medical Superintendent

Chief Nursing Officers

Nursing Nursing Nursing Nursing Nursing

recruitment finance training office relations

Thus line and staff organisation is that key management functions that the chief

executive has neither skill or time to execute well, are delegated to functional experts who can

devote full time to the assigned function without being distracted by responsibilities of day-to-

day management of personnel and material.

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A nursing organisation increases in size, it may evolve from a pure line, to a line and

staff and finally to the functionalised line and staff structure. In functional line and staff

organisation, the expert is responsible for a specified management function such as staffing,

policies, quality improvement, or staff development, has authority to command line managers to

implement needed actions that relate to the expert's specified functions.

There have been several changes taking place in the health care delivery systems, made

the line, line and staff as functionalised line and staff structures are less effective. Due to these

developments, a new type of formal organisation structure "Adhocracy” or matrix structure, has

been adopted by more innovative nursing organisations. Matrix organization is a relatively flat

hierarchical structure in which a constantly changing projects team organisation is

superimposed on a fully functionalised line and staff organisation structure.

Orgnisation chart of District McGann Hospital, Shimoga

District Surgeon

N/s Gril RMO Deputy Surgeons

M/S Gr II N/S Gr/II M/S Gr/II Chief Pharm (Med Surg Orth OBG Ped Psy
(Wards) (OT & Spl) (OPD) Gr Ph Dental)

SSN SSN SSN Sr Ph Asst Surgeons Off Secy

SN SN SN Off Supld
Jr Ph

Group D Group D Group D FDA

Lab. Tech X/ray tech Refractionist SDA

Organisation is the diagrammatic representation of the different positions in the hierarchy

of an institution, showing the channels of communication and the formal lines of authority

among these positions. In other words it gives the executives and the employees or the managers

and the subordinates a bird's eye view of:

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 the relationship between the various departments and divisions.

 as well as those that exist between the different position in the management levels and

grassroot level employees in an organisation.

It also provides opportunity to all from the top level administrators to the work force, to

understand their positions, roles and to whom they are accountable and/or answerable. The

characteristics of organisation chart will include:

 It must be a diagrammatic presentation.

 It must denote the principal lines of authority between different positions within the

enterprise.

 It must show the interrelationship between various functions and authority positions.

 It must denote the channels of communication between the various position and between

the executives and the subordinates.

So an organisation chart helps in many ways in an organisation which includes;

 It serves as a tool for the management and enables each employee for his/her placement

and relationships in the organisation.

 It serves as an employees, to whom they are accountable and answerable.

 It provides basis for classification of personnel and evaluation system, where it plays

role of detecting deficiencies and inconsistencies.

Advantages of organisation chart includes:

 Maps lines of decision making authority.

 Helps people to understand their assignments and those of their co-worker.

 Reveals to managers and new personnel how they fit into the organisation.

 Contributes to sound organisational structure.

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 Shows formal lines of communication.

Disadvantages of organisation chart includes, it

 Shows only formal re1ationship.

 Does not indicate degree of authority.

 May show things as they are supposed to be or used to be rather than as they are.

 Possibility exists of confusion, authority with status.

Organisation chart is a picture of an organisation. The knowledgeable manager can derive much
information by reading the chart. It can help to identify roles and their expectations. Organisation
chart defines formal relationships within the institution. Formal relationships, lines of
communication and authority are depicted on a chart by unbroken lines. These line positions can
be shown by either horizontal or vertical unbroken lines. Horizontal unbroken lines represent
communication between individuals with similar spheres of responsibility and power, but different
functions. Vertical unbroken lines between positions denote the official chain of command, the
formal paths of communication and authority. Those having greatest decision making and
authority are located at the top; those with the least are at the bottom. The level of position on the
chart also signifies power and status. Dotted or broken lines on the organisation chart represent
'staff' positions. Because these positions are advisory, a staff member provides information and
assistance to manager but has limited organisational 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 specialisation that would be impossible for
any manager to achieve alone. Advisory (staff) positions do not have inherent legitimate authority.
ORGANIZATIONOF NURSING SERVICE:
An organizational structure for a division of nursing must meet the needs of that division an
written in the statements of mission, philosophy, vision, values, and objectives. Before the
structure. Before the structure is changed, the nurse mangers should engage in a systematic
analysis as well as do some sound thinking about altering the organization’s design and structure,
starting with objective and strategy.

AtNational level:-
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Nurse are general no involved in making policies that govern their status and practice. Most of the
decisions concerning nurses and nursing care are made by other people i.e ministry of health and
family welfare. There is also a nursing advisor to the govt. of India.
Organizational set-up at directorate – general of health service,(recommended by high power
committee)and the institutions which come under the central government are given below:

DGHs

Addl DG(PH AddlDDG(N) Addl DG(M)

DDG(N)

ADG ADG ADG

(Community Nsg. Services) (Nsg. Edu& research) (Hospital Nsg

services)

DADG DADG DADG

(CommunityNsg. Services) (Nsg. Edu& Hospital) ( Nsg services)

CmmunityNsg.officer Principal/Tutor school of Nsg Nsg suptd.

P.H.N Supervisor Senior Tutor Dy.Nsg Suptd.

P.H.N Tutor Asst.NsgSuptd.

LHV Clinical instructor Ward sister

ANM Staff

At State Level:
Recommended organizational set-up at state /union territory level
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Secretary Health

Director nursing services

Joint/Deputy director nursing services

ADNS ADNS ADNS

Community Nsg.Nsg. Educ. and Research Hospital Nsg
Services

DADNS DADNS DADNS

Community nursing NsgEdu.and Res Nursing service

Dist.Nsg officer principal, school of Nsg. Nsg suptd.

P.H Nsg officer Senior Tutor Dy.NsgSuptd.

P.H.N and PHC Tutor Asst. Nsg Suptd.

LHV Clinical instructor Ward sister

ANM Staff nurse

At district level
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Recommended organizational set- up at the district level

Director nursing services

Deputy director nursing services

Asstt Director nursing services

DyAsstt Director nursing services

DMO DisttNsg Officer DHO

Officer (Community)

Asst Dist Nsg officer

AsstDistNsofficer Hosp and NsgEdu.
(Community)
principal Tutor

. Dist PNO

Nsgsuptd/ Dy.NsgSuptd P.H Nsg officer

.

Asst.NsgSuptd Tutor HN Supervisor(CHC)

Ward sister Clinical instructor PHN(PHC)

Staff nurse HIV/ Hs

LHV

ANM

Norms recommend for nursing services in hospital setting :

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 Nursing supertendent—1:200 beds (hospital with 200 or more beds)

 Deputy Nursing supertendent --- 1:300 beds( wherever beds are over 200)
 AsstNursing supertendent----1:150 beds ( wherever beds are over 150)(7:1000)
 Ward sister/Ward supervisor—1:25 beds 30% leave reserve.
 Staff nurses for wards ---1:3 (or 1:9 for each shift) + 30% leave reserve.
 For nurses OPD and emergency etc---1:100 patients (1 bed :5 outpatient ) + 30% leave
reserve.
 For intensive care units ---1:1(or 1:3 for each shift) + 30% leave reserve.

Norms recommend for community nursing services:

 1 ANM for 2500 population (2 sub-centres).
 1ANM for 1500 population for hilly areas.
 1 health supervisor for 7500 population (for supervision of 3 ANMs).
 1 Public health nurse for 1 PHC(30,000 population to supervise 4 health supervisors).
 1Public health nursing officer for 1,00,000 population (community health centre).
 Two Distric public health nursing officers for each district.

ROLE AND FUNCTION OF A NURSE ADMINISTRATOR/MANAGER IN

ORGANISA TIONAL STRUCTURE

Roles

1. Evaluates the organisational structure frequently to determine if management positions

can be eliminated to reduce the chain of command.

2. Encourage employees to follow the chain of command and gives counselling and

guidance to enable them Jo do so.

3. Supports personnel in advisory (staff) positions.

4. Models responsibility and accountability for subordinates.

5. Assists nursing staff to see how their roles are congruent with and complement the

common organisational tasks.

6. Facilitates informal group structure.

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7. Encourages upward communication.

8. Explains organisational culture to subordinates.

9. Counsel employees who do not follow chain of command.

Organizing Work at the Unit Level

The greatest influence of first- and middle-level managers on the organizational phase of

the management process takes place at the unit or departmental level of the organization. It is

here that organizing the work to be done and implementing the delivery of patient care occurs.

Historically, many variables have influenced the manner in which patient care has been

organized. For example, the cost of nursing services, the supply of professional nurses, the

requirements of changing demographics, and increased technology have all played a part in

changing trends in the design of patient care delivery models. As new models for organizing care

appear to the literature, it is important for managers to remain current with the new trends, but it

is equally important for managers to discern fads from trends (Curtin, 1994). In the past

managers often adopted a new work redesign without fully understanding that particular model

of patient care delivery or the necessary resources to implement it, and ended up modifying the

model in a manner that rendered it ineffective. Managers must assess their unit environment and

financial and personnel resources and have a thorough understanding of the many models of

patient care delivery before undertaking work redesign (Fralic, 1992)

A well-designed delivery system helps the manager meet organizational goals in an

effective and efficient manner. This involves using resources wisely, coordinating activities with

other departments, and appropriately assigning committees. How activities are organized can

impede or facilitate communication, flexibility, and job satisfaction.

An Historical Perspective of Modes of Organizing Patient Care

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Throughout the history of nursing there have been many methods of organizing nursing

care for patients and frequently models were modified from their original design to fit the

individual organization. The five most commonly known models are: 1) case method nursing or

total patient care, 2) functional nursing, 3) team nursing, 4) primary nursing, and 5) case

managed care.

Although some of these methods were developed to organize care in hospitals,.

most can be used in many settings. The "best" organizational mode depends on the skill and

expertise of the staff, the availability of registered "professional" nurses, the acuity of the

patients being treated, the economic constraints of the organization, and the complexity of the

tasks to be completed.

CASE METHOD NURSING

Case method nursing or total patient care is the oldest method of organizing patient care. In

case method nursing, care providers assume responsibility for meeting all the needs of assigned

patients during the time they are on duty. At the turn of the nineteenth century, case method

nursing was practiced both at home and in hospitals. A great deal of medical and nursing care for

the wealthy and middle class occurred in the home, and hospitals were used primarily by the

poor and very acutely ill.

During the Depression of the 1930s people could no longer afford home care and

individuals began utilizing hospitals. During that time nurses and student nurses were the

caregivers in hospitals and public health agencies. As hospitals grew during the 1930s, case

method (total patient care) nursing continued to be the primary means of organizing patient care.

A diagram of the case method organizational structure is shown in Figure

9-1.
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Case method nursing is still widely used, both in hospital units where there is an all-

professional staff such as an intensive care unit, and in home health agencies. It provides high

autonomy and responsibility for nurses. The lines of responsibility and accountability are clear

and the patient theoretically receives holistic and unfragmented care during the time the nurse is

on duty. In terms of assigning patients, it is simple and direct and does not require the

coordinating needed in other patient care delivery methods (Tappen, 1995).

Although care is not fragmented while the nurse is on duty, each nurse caring for the patient

may modify the care plan. Therefore, if there are three shifts, the patient may receive three

different approaches to care. This often results in confusion for the patient. In order to maintain

quality care, this method requires more highly skilled and better paid nursing care personnel than

some other forms of patient care organization. Many argue effectively that some tasks performed

by the primary caregiver could be accomplished by someone with less training and therefore at a

lower cost (Dietz. 1994).

Charge Nurse

Nursing Staff
Nursing Staff
Nursing Staff

Patients/ Clients
Patients/ Clients
Patients/ Clients

Perhaps the greatest disadvantage to this method occurs when the caregiver is

inadequately trained/ prepared to provide total care to the patient. During nursing shortages~ and
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economic downturns many hospitals employ health care workers who are not registered nurses

as providers of care. A registered nurse is coassigned, but because the RN may also be assigned a

heavy patient load, there may be little opportunity for supervision. This has the potential to result

in unsafe care.

FUNCTIONAL NURSING

The functional method of delivering nursing care evolved as a result of World War II.

Nurses were in great demand in both the war effort and at home. Because of the shortage of

registered nurses, many ancillary personnel were used to assist in the care of patients. These

relatively unskilled workers were trained to perform simple tasks, at which they became quite

proficient on repetition (Huston and Marquis, 1989). 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 linen, and bathing patients.

This form of organizing patient care was thought to be temporary, as it was anticipated

that when the war ended hospitals would not need ancillary workers. However, the baby boom

that occurred immediately following World War II continued to leave the country short of nurses.

Thus, hospitals continued to use employees with a variety of skill levels and education.

Presently, most health care organizations still employ a great many different types of health care

workers with varied skills and educational preparation, making it necessary to have different

functions or tasks assigned to different skill levels. For instance, one nursing unit might have an

unlicensed assistive personnel (UAP) responsible for taking temperatures and a highly trained

nurse clinician responsible for maintaining and inserting all intravenous therapy.

Charge Nurse
 26

RN Medication
nurse
RN treatment
nurse
Nursing
assistants/
Hypienic care
Clerical /
Housekeeping

Patients/ Clients

Most administrators consider functional nursing to be an economical means of providing

care to patients, and increased use of UAP is evident in contemporary hospitals (Huston, 1996).

In the past it was felt that quality care and a holistic approach to nursing suffered under

functional nursing delivery. However, there are those who argue that by assigning UAP to the

nurse, and not the patient, quality of care can be maintained (Joel, 1994). A major advantage to

functional nursing is in its efficiency. Tasks are completed quickly and there is little confusion

regarding job responsibilities. Functional nursing allows care to be provided for patients with a

minimum number of registered nurses. There are many areas within the health care industry

where functional structure works well and is still very evident. An example is the operating

room.

Functional nursing, however, may lead to fragmented care and the possibility of

overlooking priority patient needs. Functional nursing may also result in low job satisfaction, as

some workers might feel unchallenged and under stimulated in their designated functions.

Functional organization can also be more costly because of the need for many coordinators, and
 27

employees often focus only on their own efforts with less interest in overall results.

TEAM NURSING

Team nursing was introduced in the 1950s in an effort to decrease the problems

associated with functional organization of patient care. It was felt that, despite a continued

shortage of professional nursing staff, a system for delivering patient care had to be developed

that reduced the fragmented care which accompanied functional nursing. Team nursing structure

is shown in Figure 9-3.

In team nursing, ancillary personnel work together to provide care to a group of Patients

under the direction of a professional nurse the team leader. As the coordinator of the team, the

registered nurse is responsible for knowing the condition and needs of all the patients assigned to

the team, and for planning the care of each patient. The team leader's duties vary depending on

the needs of the patient and the work to be accomplished. These duties may include assisting

team members, giving direct personal care to patients, teaching, and coordinating patient

activities.

Charge nurse

Team leader
Team leader
 28

Team leader

Team leader
Team leader
Team leader
Team leader
Team leader
Team leader

Through extensive team communication, comprehensive care can be provided for

patients despite a relatively high proportion of ancillary staff. This communication is approached

informally by the team leader with individual team members and formally through the regular

scheduling of team conferences for patient care planning. A team should be small (four to five

members) or it will revert to more function – based organization.

Team nursing is usually associated with a democratic style of leadership. Group members

are given as much autonomy as possible while performing assigned tasks, although responsibility

and accountability are shared collectively by the team. The necessity for excellent

communication and coordination skills makes team nursing organization difficult to implement

and requires great self – discipline on the part of team members (Marquis and Huston, 1996).

Team nursing allows team members to contribute their own special expertise or skills in

caring for patients, and team leaders should use their knowledge about each specific team

members abilities in making patient assignments. This recognition of the individual worth of all

employees as well as the autonomy given to team members results in high job satisfaction.

Disadvantages to team nursing care are associated primarily with improper

implementation rather than with the philosophy itself. Frequently insufficient time is allowed

for team care planning and communication. His can lead to unclear lines of responsibility as well
 29

as errors and patient care can become fragmented. For team nursing to succeed, the team leader

must be an effective communicator, have good organizational and leadership skills, and be an

excellent practitioner. If the team leader does not possess these trails, the team will be

ineffective.

The original design of team organization has undergone much modification in the last 25

years. Most team nursing was never practiced in its purest form, but was instead a combination

of team and functional structure. Recent attempts to refine and improve team nursing have

resulted in the concept of modular nursing. His concept uses a smaller group of staff (two or

three members) and provides care to a fever number of patients. It is hoped that by keeping the

team very small there will be more involvement of the professional nurse in planning and

coordinating care. It is felt that by assigning UAP to the team leader and not assigning them to

the patient to carry out a task, the professional nurse will retain greater control and the care will

not be fragmented (Dietz 1994). Additionally, less communication is required with a small team

which allows team members more efficient use of their time for direct patient care activities.

PRIMARY NURSING:

Primary Nursing developed in the early 1970’s utilizes some of the concepts of total

patient care or case method nursing. As originally designed this method required an all RN staff

for implementation. In primary nursing the registered (primary) nurse assumes 24 hour

responsibility for planning the care of one of more patients from the time that patient is admitted

or treatment is begin to the time that patient is discharged or treatment ends. During work hours

the primary nurse provides total direct care for that patient. In the absence of the primary nurse,

care is provided by associate nurse who follow the care plan established by the primary nurse.

Although designed for use in delivering care in hospitals, this structure for care delivery
 30

lends itself well to home health nursing, hospice nursing and other health are delivery

enterprises. An integral responsibility of the primary nurse is to establish clear communication

between the patient, the physician nurse is to establish clear communication between the patient,

the physician caring for that patient, the associate nurses, and other members of the health care

team. Although the primary nurse establishes the care plan, feedback is sought from other

individuals in coordinating the patients care. The combination of clear interdisciplinary group

communication and consistent, direct patient care by a relatively small nursing staff allows for

holistic, high quality patient care.

Job satisfaction is high in primary nursing although the method is difficult to implement.

Implementation difficulties occur because of the degree of responsibility and autonomy required

of the primary nurse. However, for these same reasons, once nurses develop skill in primary

nursing care delivery they typically feel challenged and rewarded.

The disadvantages of primary nursing, as in team nursing, lie primarily in its improper

implementation. An inadequately prepared or insufficiency educated primary nurse may be

incapable making the decisions necessary to coordinate a multidisciplinary team or may lack the

practitioner skills necessary to identify complex patient needs as well changes in patient

condition.

When originally implemented, an all-RN staff was shown to be no more costly than other

modes of delivery, although there has been some difficulty in recruiting and retaining the number

of nurses required for this method of care especially in times of nursing shortages. However,

with the increase in registered nursing salaries and studies. However, with the increase in

registered nursing salaries and studies showing that 23-40% or a nurse’s time is spent in work

inappropriate to his or her role (Joel, 1994; Huston, 1996) it has become more difficult for
 31

managers to justify in all RN staff, LVNS-LPNs are used as associated nurses in some facilities,

and as partners in others (Eriksen et al., 1992), although the function of the primary nurse should

be reserved for the registered nurse.

Physician Charge nurse Hospital resources

Primary nurse

Patient / client

Associate nurse Associate Associate nurse

(evenings) nurse (nights) (As needed)
(Days)

One of the greatest disadvantages in primary nursing has been that many nurses are

neither comfortable with nor adequately prepared for the position of primary care nurse. Because

the rationale of primary nursing is sound, some organizations are attempting to implement the

underlying concepts of primary nursing while differentiating the roles of nurses within their

organization. This patient care delivery system is termed differentiated nursing practice.

Registered nurses are assigned to work within the role structure and responsibilities that

correspond to their capabilities. Capabilities are measured by skill, knowledge, and motivation

rather than level of education. Differentiated nursing practice is still too new to determine

whether it has met the intended goals: to improve nurse retention, quality of care, and fiscal

outcomes (Malloch, Milton, and Jobes, 1990).

Case Management
 32

Case management is the latest work design proposed to meet patient needs. There is

much confusion regarding the term, as it has had several different meanings since it first came

into use. Lyon (1993) makes an effort to clarify and define case management, stating it is not a

nursing care delivery model such as team nursing and primary nursing care. Instead, case

management is a role that was originally developed in community heath settings and later

enlarged as a result of the managed care concept developed by HMOs (Lyon, 1993).

However, hospitals and other health agencies often use the term case management to

define a client-centered model of care that uses critical pathways to help plan patient care

(Bower, 1992). When used as an organizational model, case management is similar to primary

nursing, in that one individual nurse is responsible for coordinating the activities and care of a

patient.

Zander (1988) lists four essential components of case management: I) achievement of

clinical outcomes within a prescribed time frame, 2) the care giver acts as the case manager, 3)

episodic nurse-physician group practice that I transcends units or departments. and.4) active

participation of the patient and family in setting goal' and evaluation. However, it differs from

primary nursing in two ways. First, although the case manager uses the nursing process, the pri-

mary focus is on planning, coordinating, and evaluating care. There is less control of the patient

care and more collaboration (Zander, 1994). The case associates assigned to the care deal more

directly with assessment and intervention. Second, unlike primary nursing, in case management

it is recognized that not every patient needs a case manager (Kramer, 1990).

The limited studies on patient care management have shown positive out comes for both

clients and staff (Lamb and Stempel, 1994). However, the literature continues to show much

confusion about both the role of the case manager and the definition of case management, and it
 33

remains to be seen how the term will ultimately be defined. Although, Lyon (1993) is probably

correct when she says that case management is more a monitoring of client resource utilization

and should not be called a delivery system, the reality is that many organizations are using the

term to define a system of patient care delivery.

Selecting the Optimum Mode for Organizing Patient Care

In a recent study of health care delivery systems, eight models were identified, but the

most common models still in use in hospitals were total patient care, team nursing, and primary

nursing care (McLaughlin, Thomas, and Barter, 1995). Unfortunately, many nursing service

departments have a history of selecting modes for organizing patient care based on the latest fad

rather than by objectively deciding what is the best mode for a particular unit or department.

Because change always introduces an element of stress, it is important to evaluate the

effectiveness of the current mode of patient care delivery to determine whether there is a need for

work redesign prior to instituting change in the organizational structure. The amount of resources

necessary for work redesign is tremendous and should not be undertaken lightly (Ritter and

Tonges, 1991; Fralic, 1992; Porter-O'Grady, 1996).

In determining the effectiveness of the present system, the following questions should be

asked.

1. Is the organization of patient care delivery providing the level of care stated in the health

organization's philosophy? Does it facilitate or hinder meeting other goals of the

organization?

2. Is the delivery of nursing care organized in a manner that is cost effective?

3. Does the patient care delivery system provide patient, as well as family, satisfaction?

(Satisfaction and quality care differ; either may be provided without the other being
 34

present.)

4. Does the organization of patient care delivery provide some degree of fulfillment and role

satisfaction to nursing personnel?

5. Does the patient care delivery system allow implementation of the nursing process?

6. Does the structuring of care delivery facilitate adequate communication between all

members of the health care team?

If the present system of organizing patient care reveals deficiencies, the manager

needs to examine the available resources and compare those with the means necessary for the

change. Nursing managers often choose a delivery system that requires a high percentage of

professional nurses, only to discover adequate resources are unavailable, resulting in a failed

plan change. There must be a commitment on the part of top-level administration and a

majority of the nursing staff for a change in patient care delivery to be successful.

Because health care is multidiscipinary, the patient care delivery system used will

impact heavily on many other individuals outside the nursing unit itself; therefore, those

affected by a change in organizing patient care must be involved. This includes other

departments, the medical staff, as well as the health care consumer.

Last, the human elements that have great bearing on the success or failure of a change

in the work place should be examined before there is a modification in work organization.

There are many pitfalls inherent in restructuring job design. Remember that all people are

different and not every nurse desires a challenging job with the autonomy of personal

decision making. There are a great many simultaneous interacting forces in an employee-job

design relationship (Fralic, 1992). Satisfaction in the work place does not only occur because

of role fulfillment; it also takes place as a result of social and interpersonal relations. The
 35

change agent redesigning the organization of the work needs to consider how the following

elements will be changed as a result of the reorganization.

1. How will autonomy as well as individual and group decision making be altered by the

reorganization? Who will be affected? Will there be a decrease or increase in autonomy?

2. How will social interactions and interpersonal relationships change?

3. Will there be a modification in what the employee views as their unit of I work? Will

there be a change from a partial unit of work to a whole unit? 'I (For example, total

patient care is a whole unit of work, team nursing is ? I a partial unit of work.)

4. Will the change require a wider or more restrictive range of skills and abilities?

5. Will the redesign produce a change in how employees receive feedback on their

performance, either for self-evaluation or by others?

6. Will there be changes in communication patterns?

Whenever the patient care delivery system is altered some or all of the listed elements

will be affected. That is not to say that change should not occur, but only that managers must first

evaluate all the variables that interact with the but before proceeding with the reorganization of

the patient care delivery system.

CONCLUSION:
Most organization structure differ in some manner,it is important for mangers to understand the
structure where their management takes place. Hence analyzationof organizationstructure
enhances the effectiveness of nursing services including the symptoms of malorganisation.

BIBLIOGRAPHY
 36

1.Chandran S Jith . Organizational behavior. 1st ed. NewYork :Vikas publishing house
pvt.ltd;1995 p-366-379.
2.Basvanthappa B.T . Nursing administration.2nd ed. New Delhi: Jaypee brothers medical
publishers Pvt ltd;2009 p-64-85
3.Goel S.L. Shalini Rajaneesh. Management technique principles and practices. New Delhi
:Deep&Deep publishers pvt ltd;2001 P-392-93
4.Gulani K.K. Commmunity Health Nursing principles and practices.1st ed. New Dehi : Kumar
publishing house ; 2007 p-606-610
5.Marquis L Bessie. Huston J Carol. Management decision making for nurses. 3rd ed. New York:
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7. www.sph.umn.edu/hpm/ nursing services PDF/Adobe Acrobat
8.http://www.businessdictionary.com/definition/organizational-structure
9.http://www.indiancouncil.org.in
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13. Prasad LM. Organizational Behaviour. 2nd ed. New Delhi: Sultan Chand and Sons; 1994

SAMPLE ORGANIZATION CHART: Baby memorial hospital

Board of directors

Medical Staff

Administrator
 37

Director of Controller of Administrator Director of

nursing financial affair of general auditory
service service

Unit supervisor Nursing office

shift supervisor

Shift charge nurses

Admitting Laundry Clinical Lab

Medical Surgical 3
units 42 beats
Emergency Business Housekeeping Central
Room office Supply
Psychiatric 1 unit
14 beds
Operating Payroll Maintenan Medical
Room ce Records
Pediatrics 1 unit 14
beds
Recovery Switch- Dietary Pharmacy
Room board
Obstetrics 1unit 14
beds
Purchasing
Labor and Respiratory
Delivery Therapy
Newborn Nursery
1 unit 14 beds
Social Physical
Services Therapy