Essentials of Nursing Leadership and Management, 5th Edition

chapter 5 | Organizations, Power, and Empowerment 61

and to avoid slipping into too much debt. This
is sometimes difficult to accomplish.
■Status.The leaders or owners of many health-
care organizations also want to be known as the
best in their field; for example, by having the
best open-heart surgeon, providing “the best
nursing care in the world” (Frusti, Niesen, &
Campion, 2003, p. 34), providing gourmet
meals, or having the most attractive birthing
rooms in town.
■Dominance.Some organizations also want to
drive others out of the health-care business or
acquire them, surpassing the goal of survival
and moving toward dominance of a particular
market by driving out the competition.
These additional goals are not discussed in public as
often as the f irst, more lofty statement of goals in the
true-or-false question. However, they still drive an
organization, especially the way an organization
handles its f inances and treats its employees.
These goals may have profound effects on every
one of the organization’s employees, nurses included.
For example, return to the story of Hazel Rivera.
Why did she receive a less favorable rating than her
friend Carla?
After comparing ratings with those of her friend
Carla, Hazel asked for a meeting with her nurse
manager to discuss her evaluation. The nurse man-
ager explained the rating: Hazel ’s care plans were
very well done, and the nurse manager genuinely
appreciated Hazel ’s efforts to make them so. The

problem was that Hazel had to be paid overtime for

this work according to the union contract, and this

reduced the amount of overtime pay the nurse man-

ager had available when the patient care load was

especially high. “The corporation is very strict about

staying within the budget,” she said. “In fact, my

rating is higher when I don’t use up all of my

budgeted overtime hours.” When Hazel asked what

she could do to improve her rating, the nurse man-

ager offered to help her streamline the care plans and

manage her time better so that the care plans could

be done during her shift.

Structure

The Traditional Approach

Almost all health-care organizations have a hier-

archical structure of some kind (Box 5-1). In a

traditional hierarchical structure, employees are

ranked from the top to the bottom, as if they were

on the steps of a ladder (Fig. 5.1). The number of

people on the bottom rungs of the ladder is

almost always much greater than the number at

the top. The president or CEO is usually at the

top of this ladder; the housekeeping and mainte-

nance crews are usually at the bottom. Nurses fall

somewhere in the middle of most health-care

organizations, higher than the cleaning people,

aides, and technicians, but lower than physicians

and administrators. The organizational structure

of a small ambulatory care center in a horizontal

form is illustrated in Figure 5.2.

box 5-1

What Is a Bureaucracy?

Although it seems as if everyone complains about “the bureaucracy,” not everyone is clear about what a bureaucracy really is.

Max Weber defined a bureaucratic organizationas having the following characteristics:

• Division of labor.Specific parts of the job to be done are assigned to different individuals or groups. For example, nurses,
  physicians, therapists, dietitians, and social workers all provide portions of the health care needed by an individual.


• Hierarchy.All employees are organized and ranked according to their level of authority within the organization. For
  example, administrators and directors are at the top of most hospital hierarchies, whereas aides and maintenance workers
  are at the bottom.


• Rules and regulations.Acceptable and unacceptable behavior and the proper way to carry out various tasks are defined,
  often in writing. For example, procedure books, policy manuals, bylaws, statements, and memos prescribe many types of
  behavior, from acceptable isolation techniques to vacation policies.


• Emphasis on technical competence.People with certain skills and knowledge are hired to carry out specific parts of the
  total work of the organization. For example, a community mental health center has psychiatrists, social workers, and nurses
  to provide different kinds of therapies and clerical staff to do the typing and filing. Some bureaucracy is characteristic of the
  formal operation of every organization, even the most deliberately informal, because it promotes smooth operations within
  a large and complex group of people.
  Adapted from Weber, M. (1969). Bureaucratic organization. In Etzioni, A. (ed.). Readings on Modern Organizations. Englewood
  Cliffs, N.J.: Prentice-Hall.