DIRECTING THE NURSING SERVICE

Directing – refers to the manner of delegating assignments, orders and instructing to the
nursing personnel where the latter is made aware of the work expected of him/her. The nursing
personnel should be properly guided so they can contribute effectively and efficiently to the
attainment of the Nursing Service goals.
It includes the following:

 Supervision
 Problem solving and decision making
 Delegation – Scheduling of Assignments
 Utilization and revision of policies and procedures.
 Communication
 Coordination
 Staff development
 Conflict Management
 Change Management
 Team Building/Teamwork
SUPERVISION involves providing guidance and direction to the work in order to achieve a
certain purpose. Its main goal is to attain quality care for each patient and develop the
potentials of workers for an effective and efficient performance. It ensures that the major goal
in patient care is achieved.
PRINCIPLES FOR GOOD SUPERVISION:

 Focused on improving the staff’s work rather than on upgrading himself/herself

 Based on predetermined individual needs, requiring self-study by staff members as a
starting point in their growth and development.
 Planned cooperatively.
 Employs democratic methods. Adapt to the experience and ability of the staff member.
 Stimulates the staff for continuous self-improvement.
 Respects the individuality of the staff member.
 Helps create a social, psychological and physical atmosphere where the individual is free
to function
 Encourages the staff member to contribute in the attainment of his/her objectives.
SUPERVISORY TECHNIQUES

 Orientation
 Meetings/Conferences
 Purposeful Rounds
 Guides to workmanship such as administrative and supervisory manual, policy books,
procedure books, Instruction for kardex use, administration of medical treatment in
case of accident, schedule of professional and non professional personnel including
rotation hours and duties, model charts, descriptions.
SUPERVISORY TOOLS: Organizational chart, personnel policies, communication devices.
PROBLEM SOLVING AND DECISION MAKING
Decision making is developing commitment to a particular course of action. Consideration:
End to be accomplished and means to be used to accomplish this end. Decision making
relies on the scientific problem-solving process.
It is the process of selecting one course of action from alternatives, is a continuing
responsibility of nurse managers. Effective manager or leader is aware of the need for
sensitivity in decision making.
First step in decision making: Defining the problem. Next is analyzing the situation.
Managers should look beyond their own experiences and learn how others are solving
similar problems. A decision must be made and after it must be implemented. The decision
and procedures for its implementation should be explained to win the cooperation of those
responsible for the decision. After it is evaluation.
DELEGATION
A major element of the directing function of nursing management. Nurse Managers get the
work done through their employees. As nurse managers learn to accept the principle of
delegation they become more productive and come to enjoy the relationships with the
staff.
ELEMENTS:

 Responsibility entails an obligation to fulfill the work assigned to a certain position

 People will not perform the work unless they can make decisions related to it.
 The person given more authority to make the most of his/her own decision enjoys work
more and derives more personal satisfaction
 Accountability is the process of establishing an obligation to perform the work and to
make a decision within set limits.

FIVE RIGHTS:
 Right task
 Right circumstances
 Right person
 Right direction and communication
 Right supervision
 STEPS IN DELEGATION
 Describe the tasks/projects and procedures to be done
 Relay the description of the task
 Establish checkpoints: policies/standards, allocated resources, time frame and rounds.
 Establish dialogue before, during and after, for feedback on: clarifications,
attitude/feelings of the staff delegated with the task, judgment of delegation.

MATTERS THAT CAN’T BE DELEGATED

 Power to disciplines, responsibility for maintaining morale, overall control, jobs that are
too technical or duties involving a trust or confidence.
 Authority to sing one’s name is never delegated
 Evaluation of the staff or taking necessary corrective or disciplinary action.

NURSING TASKS NOT TO DELEGATED TO NON PROFESSIONALS

 Assessment, Planning of Nursing care and Evaluation, Implementation that requires
judgment, Health teaching and counselling, Medications.

SCHEDULING – Schedule is a timetable showing planned work days and shifts of nursing
personnel so that patient care is assured.
Factors to be considered in making schedules

 Adequate coverage for 24 hours, seven days a week.

 Staggered vacations, holidays and weekends.
 Long stretches of consecutive workings; evening and night shifts
 Floating and
 Adequate mix of nurses and nursing attendants.
Types of Scheduling:

 Centralized Schedule – A centralizing staffing system is impersonal, done by the chief of

nursing service or designate, who develop a master plan for nursing personnel.
 Decentralized Schedule – the shift and off duties are arranged by the middle and lower
level of management.
 Cyclical Schedule – cover a designated number of weeks called the cycle length and is
repeated thereon.
ASSIGNMENT – assigning nurses to specific groups of patient. It is based on their specific
knowledge and skills, job description, interest, and patient’s nursing needs.
Basic Principles:

 The basic assignment must be made by the Senior Nurse

  Must be planned on a day to day basis
 The Senior Nurse must know the nursing needs of each patient and the appropriate
time required to care for him/her.
 The Senior Nurse must know the capability of each worker and the type of work the
latter is expected to do. He/she must also be familiar with the worker’s working habits,
such as the worker’s speed, thoroughness and organization of work.
The process of guiding registered nurse for nursing positions is covered by Article VI, Section 23
(Civil Service Rules and Laws) on Recruitment and Selection of Employees. – “It states that
opportunity for government employment shall be open to all qualified citizens and positive
efforts shall be exerted to attract best qualified to enter the service.”
COMMUNICATION
The thread that binds an organization together by ensuring a common understanding.
Organizational charts are the basis of formal communication. (picture in messenger)
Dimensions: Communications of the different groups in the organizational structure is usually
tri-dimensional because it portrays three dimensions of vision.
Height: This is the vertical (up and down) or two way communication.

 Downward Communication means flow come from higher to lower authority. In the
Nursing Service, the Chief Nurse and his/her assistant communicate with all supervising
nurses. In their absence the person next in rank takes their place. A
 Upward Communication. It is a two way flow of information because it is a
communication circuit wherein message of the sender is taken by the receiver.
 Breadth. Horizontal communication is best illustrated in conferences or discussions
between the different members of the health team.
 Depth is represented by the communication which flows in and out of the organization
including the visitors, patients, families, friends and the community.
Types of Communication:
In the hospital, communication is carried out through oral and written reports following
standard lines of communication.

 Verbal Communication – the most effective means of communication. It provides a

means whereby the nursing personnel are best informed of plans, development,
changes, and/or problems within the hospital an/of the Nursing Service. (Patient
contact, Individual conferences, Group Conferences and Staff Meetings;
 Written Communication – provides a reference from which nurses get instructions or
guidance. It serves as a record of standards of practice. It should be easy to understand.
(Memoranda or memos, directives, manual of operations, records and reports).
COORDINATION
Includes all activities that enable work group members to work together harmoniously. It
requires frequent information exchange between leaders and subordinates. It is necessary to
unite, facilitate and synthesize resources.
Interwoven with the following elements of administration: Planning, Organizing, Staffing,
Directing and Controlling.
Interdepartmental Coordination is the process of coordinating the nursing service with the
various disciplines of the hospital enhances close collaboration leading to the achievement of
the hospital’s goal.
Pointers for Effective Coordination:

 Responsibilities should be clearly defined and understood by all.

 Policies, guidelines and SOPs on inter-departmental relationships should be established
and made available to all
 Channels of communications should be followed.
The Nursing Service coordinates with: Medical Services, Radiology, Laboratory,
Administration, Medical Records, Dietary, Pharmacy and Social Work Service or Other
Institution.
STAFF DEVELOPMENT
Is a vital part of good program management. It contributes directly to the organizational
effectiveness and efficient by developing skills unavailable through the existing recruitment
sources, improving employee performance and providing them with the knowledge, skills and
abilities to accommodate changes in technology and program direction.
Human Resource Development Program – The quality service rendered by the nursing
personnel depends on the knowledge, skills and attitude. The Chief Nurse is responsible for the
quality of service rendered by nursing personnel, to ensure that staff accountabilities and
responsibilities are consistent with their qualifications, trainings, experience, education,
registration and licensure.
Scope of Human Resource Development

 Training Needs Assessment – The needs of the organization or that of the personnel is
assessed to determine what type of program is to be offered.
 Program, Development and Evaluation – Consider the benefits, the type of program
accomplished, the behavior attained and that expected economic cost/benefit the HRD
training will bring.
 Training and Development – involves acquiring knowledge, developing competencies
and skills, and adopting behaviors that will improve performance in current jobs.
  Organizational Development --- involves the diagnosis and design of systems to assist an
organization with planning change.
 Career Development – involves activities and processes for mutual career planning and
management between employees and organizations.
 Organization Research and Program Evaluation- an exploration of methods to evaluate,
justify and improve on HRD offerings.
 The HRD Professions and Professional Organization – plan to list and briefly describe the
principal HRD organizations, their missions and goals, and their addresses and contacts.
Training and Staff Development Programs – staff development activities consist of the
training and education provided by an employer to improve employee’s occupational
knowledge, skills and attitudes.
ORIENTATION – all newly employed personnel are entitled to be oriented to the hospital as a
total institution and specifically to the Nursing Service. It usually includes a tour to the hospital
setting as well as information on the vision, mission, philosophy, goals, objectives and structure
of all hospital and the Department of Nursing.
RECRUITMENT – Is the process of actively seeking out or attracting applicants for existing
positions. Although at any given time an organization may have an adequate supply of RNs to
meet the demand, historical data support the idea that recruitment should be an on-going
process.
PROMOTION – to encourage applicants, notifications of job opportunities should be posted in a
central location along with the specific qualification standards for each position and the
procedure for submitting the written application.
NURSE RETENTION – hospitals must redirect their energies and resources from short-term, stop
gap recruitment efforts to long-term retention efforts. Hospitals will have to learn to retain
those productive nurses in whom hospital has already invested time and money.
TEAM BUILDING – is the process of gathering the right people and getting them to work
together for the benefit of a project. Having the right core team can make or break a project.
The team could include:

 People who understand the project very well

 People who are technical experts
 People who can provide objectivity in the process and outcome.
Factors to consider in selecting team members:

 Committed to the common purpose and goals

 Enthusiastic
 Optimistic
  Creative, Flexible and Open Minded
 Proactive
 Cooperative
 Respectful of the values, beliefs and opinions of others.
TEAM BUILDING PROCESS

 PHASE 1
Conduct self-awareness enhancement seminar, seminar on leadership and
management, work with participants to develop the skills required to most effectively
lead their teams and work cooperatively with the participants so they recognize the
skills and attributes that are important in a leadership position, and, through this
process, also learn to recognize their own strengths and opportunities for improvement.
 PHASE 2
Development of appropriate leadership styles, tools and strategies for specific health
care facilities, analyze team strengths and weaknesses, structure a plan of action, set
team goals using a team approach, help members understand the role of individual
team membership, show team how to meet the needs of the overall group and develop
the skills needed to implement the action plan.

The role of the leader enhances:

 Communication
 Mindset and attitude
 Creative problem solving
 Delegation
 Management of team members emphasizing the effect of the part on the whole
 Crisis management.
CONTROLLING THE NURSING SERVICE
CONTROLLING
The last step in the management process. It involves setting standards, measuring performance
against those standards reporting the results, and taking correction actions. Control should be
designed for specific situation and should report potentials or actual deviations promptly
enough for corrective actions to be effective. It should determinable, verifiable and flexible,
because alternative flexible plans help achieve flexible controls.
It is the use of formal authority to assure the attainment of the purpose of action to the fullest
extent possible. It leads nursing administrator to view the delivery of nursing care as the
institutional control of processes that brings sick patients back to good health.
The administrative process of controlling aims to verify whether everything occurred in
conformity with the plans adopted, instructions issued, and principles established. The
following are control measure by the Nursing Service Administrators:

 Performance Appraisal
 Continuous Quality Improvement
 Records and Reports
 Discipline
 Conflict Management
 Risk Management
Guidelines for Controlling

 Determine what information requirement of the Nursing Service is needed which will
help in evaluating performance, relating progress to program schedules, maintaining
status of funds, staff, plan equipment, supplies and materials.
 Establish a system to generate required data
 Develop standards for cost, quality and production for individual work operations
 Set up a system of control using records and reports to collect and summarize this
information for administrative use
 Develop a system of operational audits.
 Determine the information required regarding the program’s effect on the community
and provide its collection.
 Provide a system whereby management stress of the organization is controlled through
the establishment of long range objective and short range goals.
 Formulate a human resource development program.
PERFORMANCE APPRAISAL
It is a periodic formal evaluation of how well personnel have performed their duties during a
specific period.
Purposes of Evaluation

 Determines job competence

 Enhances staff development and motivate personnel towards higher achievement
 Discovers the employees aspirations and to recognize accomplishments
 Improve the communications between managers and staff associates and to reach on
understanding about the objectives of the job and agency
 Improves performance by examining and encouraging better relationship among nurses.
 Aids the managers coaching and counselling
 Determines training and developmental needs of nursing personnel
 Make inventories of talents within the organization and reassess assignments
 Selects qualified nursing personnel for advancement and salary increases
 Identifies unsatisfactory employees.
(Performance Evaluation Flow Chart)
Characteristics of an Evaluation Tool – the evaluation tool should be objective, reliable and
sensitive.
Methods of measuring performance may be done formally or informally.
Formal Evaluation Devices:

 Anecdotal Recording – describes the nurse’s experience with a group or a person, or in

validating technical skills and interpersonal relationships.
 Simple ranking – it requires the evaluator to rank the employee according to how/she
fared with his co-workers with respect to certain aspects of performance.
 Performance Checklist – consists of a list of performance criteria (one for each of the
most important tasks in the employee’s job description) with corresponding blanks
wherein the evaluator is asked to indicate, for each criterion, whether the nurse has or
has not the desired or approved behavior
 Graphic Rating scale – includes a series of items representing different activities or tasks
included in the nurse’s job description. Checking the appropriate point on a numerical
scale.
Frequency of evaluation – Bi annual (every 6months: January to June and July to December)
NURSING SERVICE STANDING COMMITTEES
The utilization of standing committees whose main purpose is to establish for safe and
effective nursing care is one of the many tools contributing to the effective performance of the
Nursing Service.
The different standing committees within the Nursing Service are the following

 Standards, Policies and Procedures Committee

 Recruitment, Selection, Promotion, and Evaluation Committee
 Staff Development Committee
 Nursing Audit Committee
 Complaints and Grievance Committee
 Research Committee
 Health and Safety Committee
 CQI Committee
 Infection Control Committee and Others
RECORDING AND REPORTING
Records are hospital administrative tools used in collecting data directed towards the
attainment of the objective of its sections and department.
Essential Points in Keeping Records:

 Accurate, adequate and up to date

 Clear, brief and concise
 Provide relevant facts for evaluation and study
 Filled chronologically by subjects to facilitate accessibility and effective use of data
 Records and reports may be temporarily or permanent and policies should be provided
for their disposition.
 Record forms must be maintained at all times.
HANDLING COMPLAINTS
Listening to the complainant helps diffuse the situation. The nurse manager or another
organizational representative may then explain what can and cannot be done and try to
negotiate with the complainant for an agreement or a solution. It is important to be specific. All
incidents must be properly documented.

 Listen openly
 Do not speak until the person has had his/her say
 Avoid reaching emotionally
 Ask for his or her expectation about a solution to the problem
 Explain what you can and cannot do to solve the problem
  Agree on specific steps to be taken and specific deadlines.
EMPLOYEE DISCIPLINE
One method of controlling an employee’s behavior is by invoking official disciplinary
procedures.
Employee’s Code of Conduct – for effective discipline to take effect, the employee should be
aware of the institutional rules and regulations that govern his/her behavior. Those should be
clear and concise and should be incorporated in an employee’s handbook or manual that is
given to new workers during induction or orientation.
(Steps of Progressive Discipline picture)
DISCIPLINARY CONFERENCE
A combination of directive and non-directive interviewing techniques should be used in
conducting a disciplinary conference. It is anxiety provoking for both the supervisor and the
employee who is being reprimanded.
DUE PROCESS
In reprimanding employees, the Chief Nurses should adhere with the due process and ensure
the fair treatment of his/her subordinates.
CONFLICT MANAGEMENT
Maybe defined as a struggle or contest between people with opposing needs, ideas, values or
goals. Conflict might escalate and lead to non-productive results, or conflict can be beneficially
resolved and lead to quality final products.
Three primary categories of conflict:
INTRAPERSONAL occurs within the person. It involves an internal struggle to clarify
contradictory values or wants. For managers, responsibilities to the organization, subordinates,
consumers, the profession, and they may sometimes conflict.
INTERPERSONAL happens between two or more people with different values, goals and beliefs.
INTERGROUP occurs between two or more groups of people change. e, department, or
organizations.
Before managers can or should attempt to intervene in conflict, they must be able to assess its
five stages accurately:

 FIRST STAGE: LATENT CONFLICT

 - Implies the existence of antecedent conditions, such as short staffing and rapid
change. In this stage, conditions are ripe for conflict, although none has actually
occurred and many never occur.
 PERCEIVED CONFLICT
- This happens if conflict progresses. Perceived or substantive conflict often involves
issues and roles. It is recognized logically and impersonally by the person as
occurring. Sometimes conflict can be resolved at this stage.
 FELT CONFLICT
- When the concept is emotionalized. Felt emotions include hostility, fear, mistrust,
and anger. It is also referred to as affective conflict. It is possible to perceive conflict
and not feel it.
 MANIFEST CONFLICT
- Also called Overt Conflict, action is taken. The action may be to withdraw, compete,
debate or seek conflict resolution. If conflict reaches this stage, it is difficult to bring
about conflict resolution without the use of other resources.
 CONFLICT AFTERMATH
- Final stage in the conflict process. This aftermath may be more significant than the
original conflict if the conflict has not been handled constructively. There is always
conflict aftermath, positive or negative. If the conflict is managed well, people
involved in the conflict will believe their position was given a fair hearing. If the
conflict is managed poorly, the conflict issues, frequently remain and may return
later to cause more conflict.
(CONFLICT MANAGEMENT FLOW CHART)
CHANGE MANAGEMENT
Initiating and coordinating change requires well-developed leadership and management skills.
Leaders/managers must be expert planners. This includes planning for changing needs. Not only
must leader/managers be visionary in identifying where change is needed in the organization,
but they must be flexible in adapting to change they have directly initiated or by which they
have been indirectly affected.
LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN PLANNED CHANGE
THE LEADER

 Visionary in identifying areas of needed change in the organization and the healthcare
system
 Demonstrates risk taking in assuming the role of change agent
 Demonstrates flexibility in goal setting in a rapidly changing healthcare system
 Anticipates, recognizes, and creatively problem-solve resistance to change
 Views change as a challenge and opportunity for growth
  Possesses role-models high-level interpersonal communication skills in providing
support for followers undergoing rapid or difficult change.
 Demonstrates creativity in identifying alternatives to problems; and
 Demonstrates sensitivity to timing in proposing planned change.
MANAGEMENT FUNCTIONS:

 Forecast until needs with an understanding of the organization’s and units legal,
political, economic, social and legislative climate.
 Recognize the need for planned change and identifies the options and resources
available to implement that change.
 Appropriately assess the driving and restraining forces when planning for change
 Identify and implement appropriate strategies to minimize or overcome resistance to
change.
 Seek subordinates’ input in planned change and provides them with adequate
information during the change process to give them some feeling of control.
 Support and reinforce the individual efforts of subordinates during the change process
 Identify and use appropriate change strategies to modify the behavior or subordinates
as needed