Directing

The issuance of orders, assignments, and instructions that enable the nursing personnel to understand
what is expected of them.

Includes supervision and guidance so that nurses can maximally contribute to the organization’s goals in
general and to the objectives of nursing service, in particular.

Actuates efforts to accomplish goals and is connecting link between organizing for work and getting the
job done

Includes delegation of work to be performed, utilization of policies and procedures, supervision of

personnel, coordination of services, communication, staff development and decision making.

Elements of Directing

Delegation

The process by which a manager assigns specific tasks/duties to workers with commensurate authority
to perform the job; the workers in return assumes responsibility for its performance and is held
accountable for its results.

Ultimate responsibility and accountability rest with the manager.

Importance of Delegation

Managers can be freed of valuable time that can be well spent with other managerial functions

Trains and develop staff members who desire greater opportunities and challenges in their work;
thereby increasing work commitment and satisfaction.

Criteria for Delegation

Workers job description

Knowledge base

Ability to carry out task

Fairness to both employees and team

Principles of Delegation
Select the right person to whom the job is delegated. Make sure the employee is capable of doing the
job, with both responsibility and authority.

Delegate both interesting and uninteresting tasks. Jobs can be used to challenge, motivate, and increase
a person’s performance and commitment.

Provide subordinates with enough time to learn. Expertise can be achieved through training and
experience.

Delegate gradually. New employees may not be able to assume full responsibilities as employees who
have stayed longer on the job.

Delegate in advance. Specify goals and objectives to be met with a set time frame and specific results
expected.

Consult before delegating. Clarification minimizes problem and promotes teamwork.

Avoid gaps and overlaps. Gaps appear when a job is left with no one taking responsibility; overlap
happens when two or more people have responsibility for the same job.

What cannot be delegated

1. Overall responsibility, authority and accountability for satisfactory completion of all activities in
the unit.
2. Authority to sign one’s name is never delegated
3. Evaluating the staff and/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. Jobs that are too technical and those that involve trust and confidence.

Barriers to delegation

Reasons why nurse/ nurse managers do not delegate

Lack of confidence with staff

Feeling that they could do the task better and faster.

Fear of loss of control

Reasons why subordinates feel apprehensive in accepting delegated tasks (avoided if there is open
communication among staff)

Fear of criticism
Feelings of ineptitude

Thoughts of incompetence

Utilizing, Revising and Updating Nursing Service Policies and Procedures

 Policies, procedures, rules and regulations are the standing plans of an organization
 Policy manual promote consistency of action and stability by setting standards and uniformity,
thereby speeding up decisions, conserving time and preventing conflicts.
 Procedure manual outlines standard method of practice, which includes detailed plans for
nursing skills and includes steps in the proper sequence.
 Current and written manual should be available to all nursing personnel
 Being written through manuals and by personnel, periodic review and revisions should be done
by a committee of nursing personnel set on quality assurance and research

Supervision

 ‘To oversee or view directly’

 Provides guidelines for the accomplishment of a task or activity with initial direction and periodic
inspection of the actual accomplishment of the task and activity
 The active process of directing, guiding and influencing the outcome of a person’s performance
of an activity

Qualities of a Good Supervision

1. Good technical, managerial and human relation skills

2. Ability to communicate well in both 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
5. Familiarity with hospital and nursing policies that affect patient care
6. Good decision-making skills
7. Willingness to grow and develop
8. Ability to accept changes and consider them as challenges
9. Ability to motivate employees and provide opportunities for continuing professional growth and
development
10. Advocacy for nurses and nursing

Principles of Good Supervision

  It requires adequate planning and organization which facilitate cooperation, coordination and
synchronization of services.
 Gives autonomy to workers depending on their competency, personality and development
 Stimulates the workers ambition to grow into effectiveness
 Creates an atmosphere of cordiality and trust
 Considers the strengths and weaknesses of employees
 Strives to make the unit an effective learning situation
 Considers equal distribution of work considering age, physical condition and competence.

Techniques to Facilitate Good Supervision

 Observation
 Spot Checking
 Patient Inquiry
 Environment checking
 Feedbacking

Participatory Management

Supervising nurse assumes the role of a mentor, role model and facilitator

Advantage

Delegation of authority to head nurses and increased responsibility to staff nurses

Mutual trust and support with provision of self-supervision

Participation increases individual and organizational capacities to learn, adapt and develop towards
excellence

Disadvantage

Changing perception of employees about previous authoritarian management

Occasional failures in fixing responsibilities

Leading

 ‘to guide and show the way”

 Leadership in nursing is necessary to guide nursing personnel to a specific goal, that is the
provision of quality nursing care to patients
Leadership roles

Top-Administrator

Middle – Supervisors / Clinical Managers / Clinical Coordinators

First Line – Head Nurses / Senior Nurses

Operational – Staff Nurses / Nursing Attendants

Leadership Qualities

 Has striking personality and charisma

 Has sense of purpose and direction
 Possesses power of ready speech
 Enthusiastic about the purpose of the group and devoted to the cause
 Has keen insight of human nature
 Displays courage, persistence and decisiveness
 Cheerful and energetic / even-tempered
 Technical mastery of the job
 Intelligent, versatile, and has keen sense of humor
 Has moral vision, integrity and idealism

Leadership Styles

Autocratic Leadership

 Directive or bureaucratic
 High concern for task but low for people
 Gives orders and expects adherence to policies and procedures

Democratic Leadership (Participative or Consultative)

 People-oriented
 Collaborative efforts and joint efforts exist
 Leader consults subordinates in solving problems and decisions are done by the group

Laissez-faire Leadership (Permissive or Liberal)

 ‘Let-alone’ style
 Free-rein managers leaves workers without supervision
 Effective in highly motivated professionals

Leadership skills

To be an effective leader, one must possess the following skills:

Personal behavior skills – sensitivity and empathy to others

Communication skills – converse and listen to others

Organization skills – assist in planning, share responsibilities, implement plan and evaluate results

Self-analysis skills – self awareness and value empowerment

Theories of Leadership

Situational Theory Leadership

 Leader behaves according to a given situation which may vary from one setting to another
 Leader’s style matches the situation and its needs
 There are 5 kinds of leaders under this theory:
o Natural Leader – leader in spite of himself
o Charismatic Leader – inspires people
o Rational Leader – inspires people
o Consensus Leader – perceives what is acceptable to all
o Tyrant Leader - dominates by force

Trait Leadership

 Leaders are born with certain leadership quality that enables them to be successful leaders
 Leaders are gifted with qualities to get along well and persuade others
 Six categories of leadership traits are as follows:
o Physical – height, weight, bearing, facial features
o Background information – education, social status, experience
o Intelligence – knowledge, logic, judgment, wit
o Personality – decisiveness, authoritarianism, extroversion, alertness, aggressiveness,
enthusiasm, independence, self-confidence
o Task orientation – persistence, responsibility, need for achievement, supervisory activity
o Social characteristics – popularity, prestige, tact, diplomacy

Transactional vs. Transformational Leadership

Transactional Leaders

 Focus on management tasks with trade offs to meet goals

 No shared values, no cause of examination, and no contingency reward

Transformational Leaders

 Visioning as a mark to set direction for picture of ideal future

 Identifies common cause and shares value and committed
  Inspire with long-term vision and empowers others

MOTIVATION

 All humans are motivated by different goals, ambitions and aspirations

 Motivation is a force with an individual that influences strength and direction of behavior
 The amount and quality of work accomplished by the manager directly reflect their motivation
and that of their subordinates
 In setting a motivating environment, managers must create conditions that encourage
independent work, competitive reward system, role modeling and guidance
 Good managers inspire teamwork, consider employee’s uniqueness, communicate clearly and
effectively the expectations from each worker

TYPES OF MOTIVATION

Intrinsic – comes from within the person; example: values, personality

Extrinsic – Enhanced by environmental or external reward; example: promotion, salary increase,

benefits, bonuses

Motivational Theories

 Maslow’s Hierarchy of Needs

 Herzberg’s Two-factor Theory
o Nurse Managers must use two factors to recruit and retain staff. These are:
 Hygiene factors (dissatisfiers) – working conditions (e.g. salary, quality of
supervision, job security, supervision) which promotes growth and prevent lost
productivity
 Motivating factors (satisfiers) – relate to the job itself which includes
opportunities for advancement (e.g. challenges, recognition, achievement)
 McClelland’s Three Basic Needs Theory
o People possess 3 basic needs in varying degrees:
 Achievement – strong desire to overcome challenge, to grow, to excel and
succeed; eager for responsibility, have need for competence, take calculate risk
and desire concrete feedback
 Power – desire to be in control and to get others to behave contrary to what
they would normally do; thinks of how to gain authority, dominate decisions and
manipulate others
 Affiliation – desire to work in a pleasant environment and for friendly, close
relationships; seeks meaningful friendships, wants respect, avoid opposition and
interested in high morale
Expectancy Theory (Victor Vroom)

 This theory indicates that felt needs of individuals in work settings are increased if a person
perceives positive relationship between effort and performance.
 Motivated behavior is further increased if there is a positive relationship between good
performance and outcomes and rewards
 Managers should provide specific feedback about positive performance.

Operant Theory (B.F. Skinner)

 Motivation is controlled by conditions in the external environment instead of internal desires

 A given stimulus/reinforcement may consequently increase or decrease the likelihood of a
behavior’s recurrence; may be positive (increased occurrence) or negative (decrease recurrence)
 A positive reinforcement is more effective than the negative one, given that it is provided after
desired behavior

Equity Theory (J. S. Adams)

 Employees assess fairness by considering input and the rewards they have in comparison with
others
 If comparison is deemed equal, the person feels fairly treated
 Perceived inequity causes tension, which negatively motivates employee to resolve it by
reducing input, changing the basis of comparison or by resigning
 A manager should be attentive to the perceived equity of the reward system

Theory X

Based on the assumptions that employees don't really want to work, lack ambition, only work to collect
a paycheck, and need constant supervision.

Theory X in the workforce is best suited for organizations that have strict protocols, regulations, and task
oriented jobs.

Works well in organizations with a rigid hierarchical structure such as a manufacturing industry where
there is little room for creativity and deviation.

Theory Y

Theory Y is based on the assumptions that employees want to work, want to take responsibility, and do
not need much supervision.

Theory Y promotes an organizational culture of trust and open communication as well as enables
employee engagement and creativity.

Therefore, Theory Y works well in organizations that depend on creativity and innovation.
Theory Z

Devised by Ouchi upon Theory Y and democratic approaches

In the case of Theory Y, the manager would take suggestions from workers, but would keep the power to
implement the decision. Theory Z suggests that the manager's ability to exercise power and authority
comes from the worker's trusting management to take care of them, and allow them to do their jobs.

Has humanistic viewpoint and focuses on developing better ways of motivating people through:

 Collective decision-making – decision of each member is taken into consideration

 Long-term employment – working in various department of only one organization throughout
their entire career
 Slower promotion – allows time for evaluation of employee’s contribution
 Indirect supervision – subtle direction with workers being a part of the organizational culture
 Holistic concern – trust, fair treatment, strong commitment and loyalty are valued; with great
attention to employee’s health, well-being and performance

Effective Strategies for Motivating Nurses

• Share the big picture. Communicate the organization’s mission clearly and consistently and let
your executive team know how you, your unit, and your nurses fit into this picture. Sharing
overall company goals can help nurses feel like their work is part of something bigger and
encourage them to set personal goals.

• Involve nurses in decision-making. Solicit your nurses’ input on decisions directly impacting
their work, patient care, or the unit’s processes. Encourage team members to participate in
committees on staffing, workplace violence prevention, and patient safety. And provide
autonomy to make clinical decisions within their scope of practice so they feel trusted,
empowered, and motivated to perform their job well.

• Focus on how you communicate. Establish a supportive and approachable presence and
implement regular meetings to grow interpersonal relationships. You’ll encourage a culture of
recognition by offering frequent, actionable feedback. Clear expectations regarding care,
productivity, and professional conduct are also essential. Then provide ongoing feedback,
highlighting areas of improvement and success rather than waiting for a yearly performance
review. That advice will help your team set challenging yet achievable goals and expectations
that align with their personal and organizational objectives.

• Recognize and reward hard work. Offer competitive wages and benefits and reward
exceptional performances with incentives or bonuses. Ensure wages align with industry
standards through periodic salary reviews but implement other practical tactics to provide
ongoing motivation. Recognizing and appreciating your staff’s achievements with thank-you
notes and peer recognition can help reinforce your appreciation.
 • Create a positive work environment. Does your workplace culture encourage meaningful
conversation and relationship building? A positive work environment requires ongoing
nurturing by celebrating desired behaviors and not tolerating negative behaviors like bullying
or incivility. You may have invested time in developing your organization’s culture, but your
nursing staff may perceive things differently. Don’t wait for a valued member’s exit interview
to find out there’s room for improvement. Seek input regarding the work environment and
challenges. By encouraging feedback, you demonstrate that their opinions matter, which can
help increase engagement and motivation.

• Promote mental and physical wellness. Provide your team with the well-being
resources needed to perform their job effectively by offering wellness programs, stress
management classes, and counseling services. Educate them on the importance of self-care
practices. Focusing on their patients could prove challenging if your nurses are overwhelmed
by mental or physical stressors.

• Encourage nurses to address safety concerns. Create a culture that prioritizes staff and patient
safety and makes nurses feel comfortable reporting safety issues without fear of retaliation.
Ensure that their confidentiality is protected and promptly address matters to demonstrate
the organization’s commitment to safety.

• Foster a work-life balance. Encourage nurses to develop positive coping methods and practice
self-care to prevent burnout and compassion fatigue. Emphasize that the organization
recognizes the importance of remaining motivated and satisfied. Ensure appropriate staffing
and if possible, minimize overtime and offer flexible scheduling options. This ensures staff
safety and helps maintain a positive work-life balance.

• Offer development opportunities. Provide professional development opportunities for those

looking to advance their careers. Give them access to mentoring and coaching programs,
training sessions, workshops, conferences, and continuing education. Supporting these
investments shows you value your team’s growth.

COMMUNICATION

 Communication is the transmission of information, opinions and intentions between and among
individuals
 Communication is universally used in interactions between patients and colleagues alike
 It facilitates work, increases motivation, affects change, optimizes patient care, increases
worker’s satisfaction, and facilitates coordination

Principles of Effective Communication

1. Clear lines of communication serve as linking process by which parts of the organization are
unified towards goal achievement
 2. Simple, exact and concise messages ensure understanding of the message to be conveyed.
3. Feedback is essential to effective communication.
4. Communication thrives best in a supportive environment which encourages positive values
among its personnel
5. A manager’s communication skill is vital to the attainment of the goals of the organization.
6. Adequate and timely communication of work-related issues or changes that may affect jobs
enhance compliance.

Three Types of Communication

A. Verbal – involves spoken words; must be spoken slowly, enunciated clearly and easily
understood by the listener
B. Written – comes in form of a memo, hospital order, documentation and the like; must be clear,
correct, complete, concise and easily understood by the reader/s
C. Non-verbal communication – transmission of message without use of words
a. Personal appearance – gives the general impression of personality and self concept;
nurses should be neat and clean and carry their uniform with pride and dignity
b. Vocal intonation – provides emphasis to message
c. Facial expression – a smile establishes immediate rapport and invites trust and
confidence in the nurse
d. Posture and gait – indicates physical wellness and confidence
e. Touch – a way of caring; gentle touch conveys care
f. Distance – gives a hint of intimacy and space needed between conversations; may vary
depending on the person and people listening

Lines of Communication

Communication is described as two-way (sender-receiver), but four dimensional in case of organization

 Downward Communication
o Superior to subordinate
o Aims to impart what the personnel need to know, what they are and why they should
do something
o Includes policies, rules and regulations, handbooks, memos, job description and the like

 Upward Communication
o From subordinate to the upper echelon members
o Usually in form of feedback to show extent of activities and communication
o Examples are written reports, incidence reports and statistical reports
 Horizontal Communication
o Flows between peers, personnel or department on the same level
o Used most frequently in the form of endorsements between shifts, nursing rounds,
journal meetings, and conferences/referrals between departments
 Outside Communication
o Flows from caregivers to patients, their families and communication
 o Public relations, discharge instruction, and health education are examples of this
communication

COORDINATION

Unites personnel and services toward a common objective

Synchronization of activities among the various services and departments enhances collaborative efforts
resulting in efficient, smooth and harmonious work

Prevents overlapping of functions, promotes good working relationships, and ensures work schedules
are accomplished as targeted

Coordination with Various Hospital Departments

Medical Services

 Know medical staff in their respected units and their time of rounds
 Know the basic information of the patients handled, their disease, and their medical and care
regimen
 Provide adequate feedback of the progress of the patients condition is essential
 Problems should be reported promptly to the medical staff with a prior independent interaction
done

Administrative Services

 Budget plan proposals for staffing, facilities and resources should be furnished
 Requests on repairs and maintenance of equipment and facilities and other processes should be
recorded
 Requisitions for supplies and equipment, inventories and replacements should be duly noted
and reported

Diagnostic Departments (Laboratory and Radiology)

 Requests should be done and provide necessary assistance if necessary

 Orient patients of the procedures in advance so they can prepare and for the examinations to
run smoothly
 Always refer to the procedure manual for preparations needed, especially those which you are
not familiar

Pharmacy

 Pharmacy should provide list and references of available medications/drugs and procurements
for guidance
  Yellow prescription drugs should be dealt with seriously, and must include prescriptions with
complete information to avoid problems

Dietary Department

 Diet lists should be passed to the department, taking into consideration some specialized diets
of select patients
 Feedbacks on preparations, preferences and arrangements may also be done

Medical Social Service

 Refer patients with socio-economic concerns/problems, which includes those needing financial
assistance, medication requests and other type of concerns

Medical Records

 Ensure the accurateness of data documented in the patients’ chart

 Charts should be safeguarded, and forwarded within 24 hours after discharge to the Medical
Records Department

Conflict in Organizations

Occurs when two or more parties feel themselves in opposition

Interpersonal process that arises from disagreements over the goals to attain or the methods to be used
to accomplish those goals.

Can occur within an employee, between individuals or groups, and across organizations.

Types of Conflict

Intrapersonal Conflict – conflict occurring within oneself; mainly caused by role conflicts, confusion and
inability to cope; may deeply affect a person’s physical and emotional state

Interpersonal Conflict – arises between individuals when self-concept, ideas, goals or values is/are
threatened/challenged/damaged, causing serious upset and relationship deterioration

Example: Temperaments of two persons are incompatible and their personalities clash

Failure of communication or differences in perception

Intergroup Conflict – may occur between/amongst groups/department arising from different viewpoints,
group loyalties, competition for resources, power struggle and image establishment.
Effects of Conflict

 May result in either productive or non-productive outcome

Positive

 Stimulates search for improved approaches that lead to better results

 It energizes employees to be more creative and experiment with new ideas out of their comfort
zones
 Hidden problems are brought to surface, prompting the need to be confronted and resolved

Negative

 Causes unnecessary tension between parties involved

 May cause holistic damage to physical, emotional and social aspects if left unattended
 Can potentially jeopardize the function of other people or the department itself

Resolution strategies

 Avoiding – physical/mental withdrawal from the conflict. This approach reflects a low concern
for either party’s outcomes and often results in a lose-lose situation.
 Smoothing – accommodating the other party’s interests. This approach places greater emphasis
on concern for others, usually to one’s own detriment, resulting in a lose-win outcome.
 Forcing – using power tactics to achieve a win. This strategy relies on aggressiveness and
dominance to achieve personal goals at the expense of the concern for the other party, resulting
in a win-lose situation.
 Compromising – Searching for middle ground or being willing to give up something in exchange
for gaining something else. This strategy reflects a moderate degree of concern for self and
others, with no clear cut outcome.
 Confronting – facing the conflict directly and working it throught to a mutually satisfactory
resolution. Also known as problem-solving or integrating, this tactic seems to maximize the
achievement of both party’s goals, resulting in a win-win outcome. Viewed as a true resolution
approach, since this method addresses the basic differences involved and eventually removes
them through creative problem solving.

Guidelines for Conflict Resolution through Confrontation

 Agree on the common goal: to solve the problem.

 Commit yourself to fluid, not fixed, positions.
 Clarify the strengths and weaknesses of both party’s positions
 Recognize the other person’s (and your own) possible need for face-saving
 Be candid and up-front; don’t hold back key information.
 Avoid arguing or using ‘yes-but’ responses; maintain control over your emotions
 Strive to understand the other person’s viewpoints, need and bottom line,
 Ask questions to elicit needed informations; probe for deeper meanings and support
 Make sure that both parties have a vested interest in making the outcome succeed
 Give the other party substantial credit when the conflict is over