Chapter 7 DIRECTING

Learning Objectives:
Given relevant questions the student will be able to:
1. Discuss the principles of directing
2. Give examples of different directions of communications in management

Directing goes beyond giving orders and instructions, it is the final major step taken by the nurse manager to
ensure that the organization’s goals are accomplished.

The manager must ensure that she has assigned the work properly and that she has gotten the right person for
each task that needs to be accomplished.

To be able to work well, one should have a genuine interest in the task that needs to be accomplished, especially
if the task is a difficult one that may require sustained effort over a period of time.

It is also important that the employees chosen by the manager are able to get along harmoniously because
directing employees invariably depend on the relationships existing among them.

This is of particular relevance in a nursing care environment where continued interaction among the various
employees in the system is inevitable and necessary for the organization to function properly.

Directing
>is the act of issuing of orders, assignments, instructions to accomplish the organization’s goals and objectives.
>it involves the process of getting the organization’s work done.
>it entails explaining what is to be done, to and by whom at what time, how and why the task should be done.
>directing must be consistent with departmental policies to help personnel perform their duties safely and
efficiently.

Characteristics of good directions:

1. Directions must be clear, concise, consistent and complete.
2. Explain the rationale well and make sure it is understood.
3. The word used indicates their importance ex: must, shall & will. “may” denotes an action. “should” denotes
recommendation or mandatory.
4. Speak distinctly and slowly. Directions must come across as a request not a command, using specific tone and set of
words. Prioritize the task directed to be done by importance and time.
5. Avoid giving too many directions at one time.
6. Personalize direction and make sure it has been followed.

Tools in Directing:
Primary tool is the NCP. Policies, standards operating procedure and rules and regulations can also be tools.
Characteristics of the Nursing Care Plan:
1. It focuses on actions designed to solve or minimize the exciting problem.
2. A product of a deliberate systematic process.
3. Relates to the future.
4. Based upon the identifiable health and nursing problems.
5. Focus is holistic.
6. It aims to meet all the needs of the patient’s.

Principles of delegation:
1. Select the right person to whom the job is to be delegated.
2. Delegate interesting and uninteresting task.
3. Provide subordinates with enough time to learn.
4. Delegate gradually.
5. Delegate in advance.
6. Consult before delegating.
7. Avoid gaps and overlaps.

Elements of Directing:
1. Delegation
> it is the act of assigning to someone else a portion of the work to be done with corresponding Authority,
Responsibility and Accountability (ARA)
> An assignment is a task done without authority while a delegation is a task done with ARA

What cannot be delegated?

1. Overall responsibility, authority & accountability for satisfactory completion of all activities in the unit.
2. Authority to sign one’s name is never delegated.
3. Evaluating the staff or taking necessary corrective or disciplinary action.
4. Responsibility for maintaining morale or the opportunity to say a few words of encouragement to the staff especially
the new ones.
5. Job that are too technical and those that involves trust and confidence.

Why nurses Manager do not delegate:

1. Lack of confidence feels that they only could do the task faster and better.
2. Fear of loss of control if some of their duties are delegated.
3. Mistakes in delegation can be costly
4. Failure to delegate wisely increases management costs and contributes to personnel dissatisfaction.
5. Fear on the part of the director, of her own ability to delegate.
6. Fear of losing control of the staff.
 7. Fear of failing to get others to the work.
8. Fear of criticism

Common Delegation Errors:

1. Under delegating
This stems from the managers’ false assumption that delegation may be interpreted as the lack of ability on his or
her part to do the job correctly or completely.
2. Over delegating
At the other extreme end is over delegation. It unnecessarily burdens the subordinates with tasks that are either
inconsequential or irrelevant to the delivery of the goal
3. Improper Delegating
A manager should be able to determine the talents and capacities of his subordinate. Delegation of tasks and
responsibilities beyond which the person cannot perform property is improper delegation.

Nursing care assignment:

1. Functional nursing
> It is a task oriented in which a particular nursing function is assigned to each worker.
> Best use when there are many patients.
> Suitable for short-term use.
Advantages:
> Work is accomplished in a shorter time.
> Worker learns to work fast.
> Gaining skills faster in that particular task.
Disadvantage:
> Fragmentation of nursing care so holistic care is not achieved.
> Nurse accountability & responsibility is diminished.
> Patient cannot identify who their “real nurse” is
> Nurse-patient relationship is not fully developed.
> Evaluation of nursing care is poor.
> It is difficult to find a specific person who can answer the patients/relatives’ questions.
2. Total Care/Case Nursing
> One nurse is assigned to one client for the delivery of total care.
> The nurse plans, coordinates, implements, evaluates and document the nursing care during the patients illness.
> The duty nurse will be accountable for their own action.
3. Team Nursing
> A system of care in which a qualified professional nurse leads a group of nurses in providing nursing needs of a
group of patients through participative effort.
> Assigning of task to team members according to their job description.
4. Primary Nursing
> Responsible for the total care of a small group of patients from admission to discharge.
> Assumes 24 hrs responsibility for nursing care, secondary nurse execute the care plan during the afternoon and
night shift and on days when the primary nurse is on off duty.
> Primary and secondary nurses are free from administrative & housekeeping responsibility.
> Accountability, authority and autonomy rest with the primary nurse. So he communicates directly with the
members of the health care team within the hospital and community.

2. Supervision
> Supervision is the process of guiding and directing the work to be done.
> It entails motivating and encouraging the staff to participate.

Principles of Good Supervision:

> To most workers, the supervisor is presumed as “the management” because of her constant presence and close
association with them.
The following are some principles of good supervision for supervisors and managers in general to remember.
a. Good supervision is focused on the improvement of work rather than upgrading the worker.
b. It is based on the lines of authority, organizational philosophy, vision/mission; the job description, policies and
standards, the needs of the individual.
c. Focuses on the degree areas of skill: conceptual, technical & interpersonal
d. It is cooperatively planned, and accepts both challenge and change.
e. It uses a democratic process.
f. The ultimate goal of good supervision is to provide safe, effective, quality care.
g. It considers the strength & weaknesses of an employee.
h. Stimulates critical thinking and creativity in patient care.

Responsibilities of Supervisors
> Supervisors have the duty to teach and motivate the staff, as well as facilitate their work.
> They should delegate work responsibilities and be available for consultation.
> They should also perform assessment and evaluation of work performance and conditions

3. Staff Development
> Staff development is a planned experience to help employees perform effectively, and to enrich their
competence in practice, education, administration and research it is re-training them for better performance in areas of
Skills, Knowledge, and Attitude (SKA).

Orientation:
> Planned & guided activities of an employee in an organization.
 It has to be done in the conference room or training room.
 Starts with the mission, vision, philosophy and objectives of the nursing service.
 Hospital policies on hiring, promotion, transfer, dismissal, job description & updating of licence.
> Tour around the hospital & assigned unit.
  “Shadowing”/”big sister”/”buddy” This practice gives the new staff chance to develop their skills and foster
the feeling of acceptance, belongingness and confidence in assuming duties &responsibility.
 Introduction to the unit personnel’s, unit policies, nursing standards & procedure.
 Assigning of clients, evaluation of activities, problems are discussed and implementation of solution.
> Assuming of greater responsibility. Mentors will instill proper values and attitude. Critical thinking to new staff
and to take a stand in ethical dilemmas in the unit.
> Give the staff opportunities to ventilate their frustration over role expectations, value & attitude conflict.

Functions and Staff Development:

> Staff Development serves several functions, some of the more critical of which are to:
a. Maintain staff efficiency and effectiveness
b. Create quality employees;
c. Meet the staffs needs and address their problems, such as deficiencies in knowledge , skills and attitude;
d. Motivated them and improve their self – confidence; and
e. Help prepare them for greater responsibilities, e.g. planning, orientation, continuing education, in-service,
patient education, advisory and research.

In-service Training and Continuing Education:

>In-service training is education for employees to help them develop their skills in a specific discipline or
occupation. In-service training takes place after an individual begins her work responsibilities.

4. Coordination
> This activity links the different components of an organization and leads them toward goal achievement. It creates
harmony on all activities to facilitate success of work. In a well-coordinated organization, everything has been
delegated to guard against leaving loose ends.
> Coordination with the Medical services re clients plan of care.
> Coordination with the Administrative service for repairs, maintenance of equipment, requisitions of supply, monthly
inventories.
> Coordination with Laboratory service for special procedures/preparations, collections of specimen & labelling.
> Coordination with Radiology service for proper scheduling of x-rays, and other special procedure.
> Coordination with the Pharmacy service for procurement of drugs especially narcotics.
> Coordination with the dietary service for the preparation of clients food, list of clients diet, special diets, preference
and restrictions.
> Coordination with the Medical Social services to assist clients with psycho-socio-economic problems.
> Coordination with the Medical record service for accurate documentation, completeness, safety & confidentiality.
> Coordination with Community Agency, institution & Civic Org. For follow ups.

5. Communication
>Communication ensures common understanding. It is a process by which a message is sent, received and
understood as intended.
> Some of the ways to communicate involve informal talks, planned appointments, telephone calls, interoffice
memos, letters, reports, informal staff meeting, planned conferences, mass meetings or general assemblies, bulletin
board notices posters, exhibits, displays, and visual aids (Corrado,1994)

Barriers to effective Communication

The barriers to effective communication can be physical, social or psychological, semantics and interpretations.
a. Physical Barriers – these are environmental factors that prevent or reduce the opportunities for
communication, for example distance and noise.
b. Social/Psychological Barriers – they are blocks or inhibitors to communication that rise from the
judgments, emotion and social values of people for example stress, trust, fear, defensiveness.
c. Semantics – there are words, figures, symbols, penmanship, interpretation of messages through signs and
symbols. Symbols may have a variety of meaning and the symbolize chosen from among the many.
d. Interpretations – these are defects in communication skills of verbalizing, listening, writing, reading and
telephoning.

Types of Communication:
1. Verbal communication = Speak slowly, clearly to prevent confusion and have immediate response.
2. Written communication = Clear, correct, complete and concise. It comes in the form of memoranda, hospital orders,
documentation, records, policies, and procedures.

Non-Verbal communication:
1. Personal appearance 3. Facial Expression 5. Touch
2. Intonation of voice 4. Posture & gait

Lines of Communication in Nursing Service:

Upward communication proceeds from the subordinates(staff nurse) to the superiors. (grievance procedure,
written report, incidental report, statistical report)
Horizontal communication proceeds from the team to the patient’s family, community workers, peers, department.
(endorsement, rounds, meetings, referrals between dept or services)
Downward proceeds from an authority or manager to his subordinates. (institutional workers)
Diagonal communication/outward flows throughout different hierarchical levels. (patient, families, relatives,
visitors, community)

Management Levels in Nursing Service

Top level of management is the director and the administrator of nursing service. (administrative)
Middle level is the nurse supervisors and coordinators.
First line managers consist of the head nurses, unit managers, senior staff nurses.
Operating level are the staff nurses, student nurses, nursing attendants.

6. Evaluation
 > An important role of the manager is to determine performance in advance and state desired outcome of what
has been done.
>The purpose of evaluation is to determine how far or how many of the organization’s objectives were
accomplished.
Purposes of Evaluation
a.Provide constructive feedback;
b.Determine progress and worthiness of individual nurse for greater responsibilities; and
c. Serve as basis for promotion and increase in salary or other similar rewards.
Evaluation is also meant to:
a.Recognize and further develop strengths;
b.Minimize weaknesses;
c. Provide security for patients, personnel, agency and the community; and
d.Develop a fair employment practice and performance appraisal process that is in accordance with law.
Different Types of Evaluation
a. Outcome or product evaluation which takes note of the response of patients after nursing care is done.
b.Process evaluation, nursing actions are examined, to determine if client goals have been met or have not
been met.
c. Structure evaluation, the goal is to obtain feedback on the systems such as financial and material resources,
nursing personnel, policies and procedures.
Legally Sound Performance Evaluation
It has often happened that employees have sued their organizations over employment decisions based on
questionable performance appraisal results. Although it is nearly impossible to be certain that an appraisal system is non-
discriminatory.
a.It should be in writing and carried out at least once a year.
b.The information should be shared with employee.
c. The employee should have the opportunity to respond in writing to the appraisal, and in this connection a
mechanism to appeal or question the results of the appraisal must be allowed.
d.The manager should have adequate opportunity to either directly observe the employees job performance
during the course of the evaluation period or, in the event of lack of adequate contact, the manager must be
able to gather information from other sources.
e.Anecdotal notes on the performance should be kept throughout the evaluation period. These notes should be
shared with the employee during the course of the appraisal period.
f. The evaluator should be trained to carry out the appraisal process, including.
 What constitutes reasonable job performance
 How to complete the form and
 How to carry out the feedback interview

CHANGE PROCESS
> Change means substituting one thing for another, experiencing a shift in circumstances that causes differences
or becoming different from before.
Steps In The Change Process
1. The change process begins or is initiated when one perceives a need for change.
2. This person then initiates group interaction, which is to identify external and internal forces for change.
3. During this interaction, the beneficial activities
a. To state the problem;
b. Indentify constraints;
c. List change strategies or possible approaches to problem solving;
d. To select the best change strategy; and finally
e. Formulate as a group a plan for implementation and or develop or select tools for evaluation.
Wholesale change of a system is never a good idea. It is important to implement any radical change one step at a time.
After the implementation of the change it is important to then evaluate the overall results of the change and make such
adjustments as may be necessary.

Strategies for Managing Change

1. Empirical-Rational
> Empirical-Rational strategies for change management are based on the assumption that people are rational and
behave according to rational self interest.
2. Normative Re-educative
> Normative-reeducative strategies are based on the assumption that people are consistent to their commitment
to socio-cultural norms and values.
3. Power-Coercive
> Power coercive strategies involve the compliance of the less powerful with leadership, plans and direction of the
more powerful.

Resistance to Change (reasons)

> lack of trust
> vested interest
> fear of failure
> loss of status or income,
> misunderstanding
> belief that change is not necessary. The manager may then take steps to handle this resistance.

CONFLICT
> Conflict is a natural, inevitable condition and is often a perquisite to change in people and organizations.
> Conflict is a consequence of real or perceived differences in goals, values, ideas, attitudes, beliefs, feelings and
actions.
Types of Conflict
1. Competitive conflict
 > This occurs when two or more groups attempt the same goal and only one group can attain them. It is defined by a
victory for one side and a loss for the other. The process by which such conflict is resolved is determined by an asset of
rules.
2. Disruptive conflict
> This takes place in an environment filled with fear, anger and stress. There is no mutually acceptable set of
rules and the goal of each party is the elimination of its opponent.
3. Interpersonal conflict
> This takes place between two or more individual.
4. Intrapersonal
> This occurs within one person.
5. Intra group
> Feeling of unfairness from among the staff.

Sources of Conflict
Human Interaction:
1. Competition 2. Domination 3. Provocation

Conflict arises from differences in skills, knowledge, values, interest, and scarcity of resources or leadership styles.

Conflict Resolution
There are several ways to achieve conflict resolution
1. Dominance and Suppression or win-lose strategy
> is a method that represses rather than settles conflict, creating a win-lose situation in which the loser is left feeling
angry and antagonistic.
2. Restriction
> is an autocratic, coercive style that often leads to an indirect and destructive expression of conflict.
3. Smoothing Behavior
> is more diplomatic way of suppressing conflict wherein on persuades the opponent to give in to the other side.
4. Avoidance Behavior
> creates a situation in which there are no differences.
5. Majority Rule
> resolves conflict by majority vote.
6. Compromise or Consensus Strategy
> is a method where each side agrees upon solutions that meet everyone’s needs.
7. Integrative Problem-solving
> is a constructive process in which the parties involved recognize that conflict exists and openly try to solve the
problem.
8. A Win-Win Strategy
> focuses on goals and attempts to meet the nee ds of both parties.
9. A Lose-lose Strategy
> is one in which neither side wins; the settlement reached to both sides.
10. Confrontation
> is regarded as the most effective means of resolving conflict in which it is brought out in the open and attempts are
made to resolve it through knowledge in reason.
11. Negotiation
> is a technique where conflicting parties give and take on various issues.
12. Accommodation
> self-sacrifice.
13. Collaboration
> seeing mutual attention to the problem & utilized talents of all parties. Focuses on problem solving to find mutual
satisfying solutions. It is useful in situation where goals are too important.
14. Competition
> Suppression of conflict through authority-obedience approach. The supervisor exerts power at the expense of the
subordinate.
15. Smoothing
> Ignoring of disagreements so that harmony is maintained.
16. Withdrawing
> one party is removed to resolve an issue.
17. Forcing
> an immediate end to the conflict but leaves the cause of the conflict unresolved.

TEAM BUILDING
> A team is a group of people brought together for the purpose of sharing and applying their individual skills
towards the achievement of goals.
> Team Building is where the members of this team work together toward achieving goals faster and more
productively.

Characteristics of an Effective Team

An effective team must be able to:
1.Have define goals,
2.Work cooperatively towards achieving and collaboratively towards achieving these goals,
3.Have agreed goals that reflect members’ needs and values,
4.Have a good definition of its members’ roles.

There are several task roles of the group members

1. Initiator-contributor - One, who redefines problems and offers solutions, clarifies objectives, suggests agenda items and
maintains time limits.
2. Information Seeker - Pursues descriptive bases for the group’s work.
3. Information Giver - Expands information given by sharing experiences and making inferences.
4. Opinion Seeker - Explores viewpoints that clarify or reflect the values of other members’ suggestions.
5. Opinion Giver - Conveys to group members what their pertinent values should be.
6. Elaborator - Predicts outcomes and provides illustrations or expands suggestions, clarifying how they could work.
7. Coordinator - Links ideas or suggestions offered by others.
8. Orienter - Summarizes the group’s discussions and actions.
9. Evaluator critic - Appraises the quantity and quality of the group’s accomplishments against set standards.
10. Energizer - Motivates group to accomplish, qualitatively and quantitatively, the group’s goals.
11. Procedural technician - Supports group activity by arranging the environment and providing necessary tools.
12. Recorder - Documents the group’s actions and achievements