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leadership

Nursing Care Management 105


Directing

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Maturity begins when we're content to feel we're right about something without feeling the necessity to prove someone else wrong.
~Sydney J. Harris

Directing

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DIRECTING is said to be a process in which the managers instruct, guide and oversee the performance of the workers to achieve predetermined goals.
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Directing

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The issuance of orders, assignments, and instructions that enable the nursing personnel to understand what are expected of them. Direction is said to be all those activities which are designed to encourage the subordinates to work effectively and efficiently.

Directions must be complete, understandable and given in a logical order. Written directions prevent misunderstandings Clear directions, follow up and supervision help maintain quality of work. Manner in which directions are given also determines to a large extent their acceptability and the extent to which the workers will be challenged to exert effort to do the job.

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Characteristics

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1. Pervasive Function - Directing is required at all levels of organization. Every manager provides guidance and inspiration to his subordinates. 2. Continuous Activity - Direction is a continuous activity as it continues throughout the life of the organization.

Characteristics

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3. Human Factor - Directing function is related to subordinates and therefore it is related to human factor. Since human factor is complex and behaviour is unpredictable, direction function becomes important. 4. Creative Activity - Direction function helps in converting plans into performance. Without this function, people become inactive and physical resources are meaningless.

Characteristics

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5. Executive Function - Direction function is carried out by all managers and executives at all levels throughout the working of an enterprise, a subordinate receives instructions from his superior only.

Characteristics

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6. Delegate Function - Direction is supposed to be a function dealing with human beings. Human behaviour is unpredictable by nature and conditioning the peoples behaviour towards the goals of the enterprise is what the executive does in this function. Therefore, it is termed as having delicacy in it to tackle human behaviour.

Elements of Directing

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Delegation Utilization of policies and procedures Supervision of personnel Coordination of services Communication Staff Development Decision Making

Delegation

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Process by which a manager assigns specific tasks/duties to workers with corresponding authority to perform the job.

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Appointing a person to act on ones behalf

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Delegation is entrusting authority, power and responsibility to another.

Why Delegate?

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Because successful delegation; Makes work easier Improves efficiency Increases employee effectiveness Develops employees who desires greater opportunities and challenges in their work Ensures that the right people do the right job

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Saves time Develop peoples skills and abilities Motivates people involved

Important Criteria for Delegation

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Workers job description Knowledge base Ability to carry out the task

Fairness not only to employee but to the team as a whole

Principles of Delegation

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Select the right person to whom the job is to be delegated Delegate both interesting and uninteresting tasks Provide subordinates with enough time to learn Delegate gradually Delegate in advance Consult before delegating Avoid gaps and overlaps

What to delegate?

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Things subordinate can do better Things subordinate needs to do for growth Operational work Things for which you dont have time

What cannot be delegated?

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Overall responsibility, authority, and accountability for satisfactory completion of of all activities in the unit. Authority to sign ones name is never delegated Evaluating the staff and/or taking necessary corrective or disciplinary action

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Responsibility for maintaining morale or the opportunity to say a few words of encouragement to the staff especially the new ones. Jobs that are too technical and those that involve trust and confidence.

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What you yourself is not able to do What you are directly contributing to your business

Work your subordinates cannot perform effectively


Management decisions Personal accountability

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Discipline of employees Recognition and praise Supervision of subordinates Long-term planning

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Reasons why nurse managers do not delegate


Lack of confidence in their staff Feeling that only they could do the task better and faster Fear of loss of control if some of their duties are delegated. Subordinates may be apprehensive in accepting delegated tasks for fear of criticism or incompetence .

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Want to be in the limelight Dont know how to delegate

How to Delegate?

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Identify the task Set goals for the task Decide who can do the task

Explain why the task has been delegated

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Communicate what you want to be done not the procedure Grant authority Feedback

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Nursing Care Assignment

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Also known as;


Modalities of nursing care Systems of nursing care Patterns of nursing care

Four methods

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Functional nursing care Total care nursing (case nursing) Team nursing Primary nursing
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Functional Nursing

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Task oriented, in which a particular nursing function is assigned to each worker. One RN is responsible for;
Administration of medication another for; Admission and discharges

One Nursing Aide/attendant is responsible for


changing of linen Hygienic care

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Functional Nursing

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Is best used when there are many patients and professional nurses are few. Suitable only for short-term use.
(see figure 10)

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Functional Nursing

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Advantages of functional nursing;


Allows most work to be accomplished in the shortest time possible Workers learn to work fast Because the tasks are repetitive, they gain skill faster in that particular task. Greater control over work activities and it is aimed at conservation of workers and cost. It is difficult to find a specific person who can answer the patients or relatives questions.

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Functional Nursing

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Disadvantages;
Fragmentation of nursing care; therefore holistic care is not achieved Nurses accountability and responsibility are diminished Patients cannot identify who their real nurse is Nurse-patient relationship is not fully developed Evaluation of nursing care is poor and outcomes are rarely documented

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Total Care or Case Method Nursing


One nurse is assigned to one patient for the delivery of total care. Nurse plans, coordinates, implements, evaluates and documents the nursing care. Used in private duty nursing (PDN), ICU cases, or for clients in isolation or for nursing students.
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Total Care or Case Method Nursing


Nurses are accountable for their actions. Provides holistic care. Works best when there are plenty nurses and patients are few. A set back is that nurses may not be familiar with other patients in other areas.
(see figure 11.)

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Team Nursing

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A decentralized system of care A qualified professional nurse leads a group of nursing personnel in providing the nursing needs of a group of patients/clients through participative effort. Team leader assigns patients and tasks to team members according to job description. Intent is to provide patient-centered care, through nursing diagnosis and implementation of planned care.

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Team Nursing

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Team conference
Involves all members of the health care team. Through written conferences and written nursing care plans improves communication and develops leadership potential

Disadvantage:
Can lead to fragmentation of care. Time for team conferences and care planning is sometimes difficult to attain. Only the team leader has significant responsibility and authority, and care may resemble functional method if the leader does not keep members involved.

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Primary Nursing

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A form of assigning responsibilities for patient care, an extension of the principle of decentralization of authority. Each registered nurse is responsible for the total care of a small group of patients from admission to discharge. Primary nurse assess the patients needs for care, sets goals, writes an NCP, administers plan of care, evaluates the outcomes of care and makes necessary changes or adjustments as necessary.

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Primary Nursing Care

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The primary nurse assumes 24 hour responsibility for nursing care, secondary or associate nurses execute the NCP during the afternoon and night shifts and on days when the primary nurse is off-duty. Primary and secondary nurses are freed from administrative and housekeeping responsibilities to maximize their time for patient care. See figure 13.

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Primary Nursing Care

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Head nurses role in this kind of assignment shift from taskmaster, decision-maker and coordinator of patient to role model, consultant, and quality control expert for the primary nurse in the unit. Advantages
Provision of or increased autonomy on the part of the nurse increasing motivation, responsibility, and accountability Assures continuity of care Makes available the increased knowledge of the patients psychosocial and physical needs Leads to increased rapport and trust between the nurse and the patient thereby establishing therapeutic relationship

Includes communication with members of the health team Eliminates the use off nursing aides in the provision of direct nursing care.

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Primary Nursing Care

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Disadvantages
Increases staffing and costs since all aspects of patient care is done by the professional nurse. Studies show that money is saved when non-nursing duties are performed by persons other then professional nurses.

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Other Nursing Assignments

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Modular Method
Modification of team and primary nursing Differs from team nursing in that the RN provides direct nursing care with assistance of aides. Professional nurse provides leadership, support and instruction to the non-professional nursing personnel Similar to primary nursing that each pair of team nursing personnel is responsible for the care of patients from admission to discharge, following discharge and throughout any subsequent admissions to the same institution. Greatest responsibility falls on the registered nurse who assesses the patients needs, plans and implements care and assesses outcomes including guiding and instructing his/her partners.

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Other Nursing Assignments

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Case management
A system of patient care delivery that focuses on the achievement of outcomes within effective and appropriate frames and resources. Focuses on an entire episode of illness, crossing all settings in which the patient receives care. Care is directed by a case manager who ideally is involved in a group practice. He is responsible for the assessment of patients and family, establishes the nursing diagnosis, develops the NCP, delegates nursing care to associates, activates interventions, coordinated and collaborates with interdisciplinary team and evaluates outcomes of care. In institutions these activities are done prior to admission and continue to about two or three weeks after discharge. Examples are prepaid health care plans and Health maintenance (HMOs) Relationships must be nurtured between the case manager and physicians, primary nurses, public health nurses and interdisciplinary staff.

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Supervision

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Supervise
Comes from the word supervide meaning to oversee or view directly For the attainment of a service that is both efficient and effective. Active process of directing, guiding, and influencing the outcome of a persons performance of an actvity.

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Supervision

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Legal implications that pertain to delegation and supervision.


Doctrine of Respondeat superior let the superior answer for the acts of the subordinate. The delegator is accountable for the assessment of the situation, supervision, follow up, intervention and corrective action.

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Supervision

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Legally means
Personally observing a function or activity , providing leadership in the process of nursing care, delegating functions or activities, while retaining accountability, evaluating and ensuring that the nursing care provided is adequate and delivered appropriately.

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Qualities of good supervision


1. Good technical, managerial and human relation skills 2. Ability to communicate well both in spoken and written language and ability to listen; 3. Firmness with flexibility to adjust to the needs of the situation 4. Fairness in dealing with employees
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5. Familiarity with hospital and nursing policies that affect patient care 6. Good decision making skills 7. Willingness to grow and develop 8. Ability accept changes and consider them as challenges 9. Dignified and pleasing personallty
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10. ability to motivate employees and provide opportunities for continuing professional growth and development; and 11.Advocacy for nurses and nursing

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Principles of goof supervision


1. Good supervision requires adequate planning and organization which facilitate cooperation, coordination and synchronization of services 2. Good supervising gives autonomy to workers depending on their competency, personality, and commitment. It fosters the ability of each worker to think and act for himself.

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3. Good supervision stimulates the workers ambition to grow into effectiveness. It provides for opportunities and incentives for staff education and continuous professional growth and development 4. Good supervision creates an atmosphere of cordiality and trust. It creates a suitable environment for productive work

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5. Good supervision considers the strengths and weaknesses of employees. 6. Good supervision strives to make a unit an effective learning situation. It provides a teaching-learning environment where learners are stimulated to exercise critical thinking and creativity especially in patient care.

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7. Good supervision considers equal distribution of work considering age, physical condition and competence. It ensures that no one is over burdened or given unreasonable pressure achieve results as these cause demoralization and low morale.
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