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Effective Leadership and Management in Nursing
Eleanor J. Sullivan, PhD, RN, FAAN
Eighth Edition
Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto
Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo
v
Eleanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nurs- ing, past president of Sigma Theta Tau International, and previous editor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Institutes of Health council, presented papers to international audiences, been quoted in the Chicago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal.
She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.
Dr. Sullivan is known for her publications in nursing, including this award-winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, 2nd edition, from Prentice Hall. Other publica- tions include Creating Nursing’s Future: Issues, Opportunities and Challenges and Nursing Care for Clients with Sub- stance Abuse.
Today, Dr. Sullivan is a mystery writer. Her first three (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt.
Her latest book, Cover Her Body, A Singular Village Mystery, is the first in a new series of historical mysteries featur- ing a 19th-century midwife and set in the Northern Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog posts, found at www.EleanorSullivan.com, reveal the history behind her historical fiction.
Connect with Dr. Sullivan at www.EleanorSullivan.com.
This book is dedicated to my family for their continuing love and support.
Eleanor J. Sullivan
ABOUT THE AUTHOR
www.EleanorSullivan.com
www.EleanorSullivan.com
vi
Our heartfelt thanks go out to our colleagues from schools of nursing across the country who have given their time generously to help us create this exciting new edition of our book. We have reaped the benefit of your collective experi- ence as nurses and teachers and have made many improvements due to your efforts. Among those who gave us their encouragement and comments are:
THANK YOU
Reviewers Theresa Ameri Part-time/adjunct instructor, Marymount University Arlington, VA
Becky Brown, MSN, RN Full-time instructor, College of Southern Idaho Twin Falls, ID
Candace Burns, PhD, ARNP Professor, University of South Florida College of Nursing Tampa, FL
Sandra Janashak Cadena, PhD, APRN, CNE Professor, University of South Florida Tampa, FL
Margaret Decker Full-time instructor, Binghamton University Binghamton, NY
Denise Eccles, MSN/Ed, RN Professor, Miami Dade College Miami, FL
Barb Gilbert, EdD, MSN, RN, CNE Part-time/adjunct instructor, Excelsior College Albany, NY
Karen Joris, MSN, RN Assistant professor, Lorain County Community College Elyria, OH
Jean M. Klein, PhD, PMHCNS, BC Associate professor, Widener University Chester, PA
Jemimah Mitchell-Levy, MSN, ARNP Professor, Miami Dade College Miami, FL
Rorey Pritchard, EdS, MSN, RN, CNOR Full-time instructor, Chippewa Valley Technical College Eau Claire, WI
Heather Saifman, MSN, RN, CCRN Assistant professor, Nova Southeastern University
Miami Kendall, FL Linda Stone Other Cambridge, MA
Sandra Swearingen Part-time/adjunct instructor, UCF Orlando, FL
Diane Whitehead, EdD, RN, ANEF Department chair, Nova Southeastern University Fort Lauderdale, FL
vii
PREFACE
Leading and managing are essential skills for all nurses in today’s rapidly changing health care arena. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of health care providers from a variety of disciplines and educational lev- els. Declining revenues, increasing costs, demands for safe care, and health care reform legislation mandate that every organization use its resources efficiently.
Nurses today are challenged to manage effectively with fewer resources. Never has the information presented in this textbook been needed more. Effective Leadership & Management in Nursing, eighth edition, can help both stu- dent nurses and those with practice experience acquire the skills needed to ensure success in today’s dynamic health care environment.
Features of the Eighth Edition Effective Leadership & Management in Nursing has made a significant and lasting contribution to the education of nurses and nurse managers in its seven previous editions. Used worldwide, this award-winning textbook is now of- fered in an updated and revised edition to reflect changes in the current health care system and in response to sug- gestions from the book’s users. The eighth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.
This book has been a success for many reasons. It com- bines practicality with conceptual understanding; is respon- sive to the needs of faculty, nurse managers, and students; and taps the expertise of contributors from a variety of dis- ciplines, especially management professionals whose work has been adapted by nurses for current nursing practice. The expertise of management professors in schools of busi- ness and practicing nurse managers is seldom incorporated into nursing textbooks. This unique approach provides students with invaluable knowledge and skills and sets the book apart from others.
Features new or expanded in the eighth edition include:
• Information about the Patient Protection and Afford- able Care Act
• An emphasis on quality initiatives, including Six Sigma, Lean Six Sigma, and DMAIC
• The use of Magnet-certified hospitals as examples of concepts
• The addition of emotional leadership concepts • The use of social media in management • An emphasis on multicratic leadership and interprofes-
sional relationships • Updated legal and legislative content • Tips on how to deal with disruptive staff behaviors,
including bullying • Guidance on preparing for emergencies and mass
casualty incidents • Information on preventing workplace violence
Student-Friendly Learning Tools Designed with the adult learner in mind, the book focuses on the application of the content presented and offers spe- cific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:
• A chapter outline and preview • New MediaLink boxes introduce readers to resources
and activities on the Student Resources site through nursing.pearsonhighered.com.
• Key terms are defined in the glossary at the end of the book
• What You Know Now lists at the end of each chapter • A list of “tools,” or key behaviors, for using the skills
presented in the chapter • Questions to Challenge You to help students relate
concepts to their experiences • Up-to-date references and Web resources identified • Case Studies with a Manager’s Checklist to demonstrate
application of content
Organization The text is organized into four sections that address the es- sential information and key skills that nurses must learn to succeed in today’s volatile health care environment.
Part 1. Understanding Nursing Management and Organizations. Part 1 introduces the context for nursing management, with an emphasis on how organizations are designed, on ways that nursing care is delivered, on the concepts of leading and managing, on how to initiate and manage change, on
viii PREFACE
providing quality care, and on using power and politics— all necessary for nurses to succeed and prosper in today’s chaotic health care world.
Part 2. Learning Key Skills in Nursing Management. Part 2 delves into the essential skills for today’s manag- ers, including thinking critically, making decisions, solv- ing problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving con- flicts, and managing time.
Part 3. Managing Resources. Knowing how to manage resources is vital for nurses to- day. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disciplining and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, including bullying. In addition, collective bargaining and preparing for emergencies and preventing workplace violence are in- cluded in Part 3.
Part 4. Taking Care of Yourself. Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.
Resources for Teaching and Learning Student and Instructor Resources can be accessed by regis- tering or logging in at nursing.pearsonhighered.com.
Acknowledgments The success of previous editions of this book has been due to the expertise of many contributors. Nursing adminis- trators, management professors, and faculty in schools of nursing all made significant contributions to earlier edi- tions. I am enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills. Without them, this book would not exist.
At Pearson Health Science, Acquisitions Editor Pamela Fuller and Development Editor Susan Geraghty guided this revision from start to finish. Editorial Assistant Cyn- thia Gates was also especially helpful.
Because health care continues to change, reviewers who are using the book in their management practice and in their classes provided invaluable comments and sugges- tions (see list on pages xi–xii).
I am especially grateful to experienced nurse manager and graduate student Rachel Pepper for her expert research assistance, ability to generate real-life examples, and ex- pertise in creating case scenarios to exemplify the experi- ence of nurses in management roles. She lent assistance throughout with ideas and suggestions. This book and Becoming Influential: A Guide for Nurses, 2nd edition, are better for her contributions.
To everyone who has contributed to this fine book over the years, I thank you.
Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com
www.EleanorSullivan.com
ix
CONTENTS
Thank You vi Preface vii
PART 1 Understanding Nursing Management and Organizations 1
CHAPTER 1 Introducing Nursing Management 1 Learning Outcomes 1
CHANGES IN HEALTH CARE 2 PAYING FOR HEALTH CARE 2
How America Pays for Health Care 2 Pay for Performance 2
DEMAND FOR QUALITY 2 Quality Initiatives 2 The Leapfrog Group 3 Benchmarking 3 Evidence-Based Practice 3 Magnet® Certification 4
EVOLVING TECHNOLOGY 4 Electronic Health Records 5 Virtual Care 5 Robotics 5 Communication Technology 5
CULTURAL, GENDER, AND GENERATIONAL DIFFERENCES 6 VIOLENCE PREVENTION AND DISASTER PREPAREDNESS 6 CHANGES IN NURSING’S FUTURE 6
Even More Change . . . 7 Challenges Facing Nurses and Managers 7
CHAPTER 2 Designing Organizations 11 Learning Outcomes 11
TRADITIONAL ORGANIZATIONAL THEORIES 12
Classical Theory 12 Humanistic Theory 14 Systems Theory 14 Contingency Theory 14 Chaos Theory 15 Complexity Theory 15
TRADITIONAL ORGANIZATIONAL STRUCTURES 15
Functional Structure 16 Hybrid Structure 16
Matrix Structure 16 Parallel Structure 16
SERVICE-LINE STRUCTURES 17 SHARED GOVERNANCE 17 OWNERSHIP OF HEALTH CARE ORGANIZATIONS 18 HEALTH CARE SETTINGS 19
Primary Care 19 Acute Care Hospitals 20 Home Health Care 20 Long-Term Care 20
COMPLEX HEALTH CARE ARRANGEMENTS 21
Health Care Networks 21 Interorganizational Relationships 21 Diversification 22 Managed Health Care Organizations 23 Accountable Care Organizations 23
REDESIGNING HEALTH CARE 23 STRATEGIC PLANNING 24 ORGANIZATIONAL ENVIRONMENT AND CULTURE 25
CHAPTER 3 Delivering Nursing Care 29 Learning Outcomes 29
TRADITIONAL MODELS OF CARE 30 Functional Nursing 30 Team Nursing 31 Total Patient Care 32 Primary Nursing 33
INTEGRATED MODELS OF CARE 34 Practice Partnerships 34 Case Management 34 Critical Pathways 35 Differentiated Practice 36
EVOLVING MODELS OF CARE 36 Patient-Centered Care 36 Synergy Model of Care 37 Clinical Microsystems 37 Chronic Care Model 37
CHAPTER 4 Leading, Managing, Following 40 Learning Outcomes 40
LEADERS AND MANAGERS 41 LEADERSHIP 41 TRADITIONAL LEADERSHIP THEORIES 42
x CONTENTS
CONTEMPORARY THEORIES 42 Quantum Leadership 42 Transactional Leadership 42 Transformational Leadership 43 Shared Leadership 43 Servant Leadership 44 Emotional Leadership 44
TRADITIONAL MANAGEMENT FUNCTIONS 45
Planning 46 Organizing 46 Directing 47 Controlling 47
NURSE MANAGERS IN PRACTICE 47 Nurse Manager Competencies 47 Staff Nurse 48 First-Level Management 48 Charge Nurse 49 Clinical Nurse Leader 50
FOLLOWERSHIP: AN ESSENTIAL COMPONENT OF LEADERSHIP 51 WHAT MAKES A SUCCESSFUL LEADER? 51
CHAPTER 5 Initiating and Managing Change 55 Learning Outcomes 55
WHY CHANGE? 56 THE NURSE AS CHANGE AGENT 56 CHANGE THEORIES 57 THE CHANGE PROCESS 58
Assessment 58 Planning 60 Implementation 60 Evaluation 61
CHANGE STRATEGIES 61 Power-Coercive Strategies 61 Empirical–Rational Model 62 Normative–Reeducative Strategies 62
RESISTANCE TO CHANGE 62 THE NURSE’S ROLE 64
Initiating Change 64 Implementing Change 65
HANDLING CONSTANT CHANGE 66
CHAPTER 6 Managing and Improving Quality 69 Learning Outcomes 69
QUALITY MANAGEMENT 70 Total Quality Management 70 Continuous Quality Improvement 71 Components of Quality Management 72 Six Sigma 73 Lean Six Sigma 73 DMAIC Method 74
IMPROVING THE QUALITY OF CARE 74 National Initiatives 74 How Cost Affects Quality 75 Evidence-Based Practice 75 Electronic Medical Records 75 Dashboards 76 Nurse Staffing 76 Reducing Medication Errors 76 Peer Review 76
RISK MANAGEMENT 77 Nursing’s Role in Risk Management 77 Incident Reports 78 Examples of Risk 78 Root Cause Analysis 80 Role of the Nurse Manager 80 Creating a Blame-Free Environment 81
CHAPTER 7 Understanding Power and Politics 86 Learning Outcomes 86
POWER DEFINED 87 POWER AND LEADERSHIP 87 POWER: HOW MANAGERS AND LEADERS GET THINGS DONE 87 USING POWER 88
Image as Power 89 Using Power Appropriately 91
SHARED VISIONING AS A POWER TOOL 92 POWER, POLITICS, AND POLICY 92
Nursing’s Political History 93 Using Political Skills to Influence Policies 93 Influencing Public Policies 94
USING POWER AND POLITICS FOR NURSING’S FUTURE 96
PART 2 Learning Key Skills in Nursing Management 99
CHAPTER 8 Thinking Critically, Making Decisions, Solving Problems 99 Learning Outcomes 99
CRITICAL THINKING 100 Critical Thinking in Nursing 100 Using Critical Thinking 101 Creativity 101
DECISION MAKING 103 Types of Decisions 104 Decision-Making Conditions 104 The Decision-Making Process 106
CONTENTS xi
Decision-Making Techniques 107 Group Decision Making 108
PROBLEM SOLVING 109 Problem-Solving Methods 109 The Problem-Solving Process 110 Group Problem Solving 112
STUMBLING BLOCKS 114 INNOVATION 115
CHAPTER 9 Communicating Effectively 117 Learning Outcomes 117
COMMUNICATION 118 Modes of Communication 118 Distorted Communication 118 Directions of Communication 120 Effective Listening 120
EFFECTS OF DIFFERENCES IN COMMUNICATION 121
Gender Differences in Communication 121 Generational and Cultural Differences in Communication 121 Differences in Organizational Culture 122
THE ROLE OF COMMUNICATION IN LEADERSHIP 123
Employees 123 Administrators 123 Coworkers 125 Medical Staff 125 Other Health Care Personnel 126 Patients and Families 126
COLLABORATIVE COMMUNICATION 126 ENHANCING YOUR COMMUNICATION SKILLS 129
CHAPTER 10 Delegating Successfully 131 Learning Outcomes 131
DELEGATION 132 BENEFITS OF DELEGATION 132
Benefits to the Nurse 132 Benefits to the Delegate 133 Benefits to the Manager 133 Benefits to the Organization 133
THE FIVE RIGHTS OF DELEGATION 133 The Delegation Process 134
ACCEPTING DELEGATION 137 INEFFECTIVE DELEGATION 138
Organizational Culture 138 Lack of Resources 138 An Insecure Delegator 138 An Unwilling Delegate 139 Underdelegation 140
Reverse Delegation 140 Overdelegation 140
CHAPTER 11 Building and Managing Teams 143 Learning Outcomes 143
GROUPS AND TEAMS 144 GROUP AND TEAM PROCESSES 146
Norms 147 Roles 148
BUILDING TEAMS 149 Assessment 149 Team-Building Activities 150
MANAGING TEAMS 150 Task 151 Group Size and Composition 151 Productivity and Cohesiveness 151 Development and Growth 152 Shared Governance 152
THE NURSE MANAGER AS TEAM LEADER 153
Communication 153 Evaluating Team Performance 153
LEADING COMMITTEES AND TASK FORCES 154
Guidelines for Conducting Meetings 155 Managing Task Forces 156
PATIENT CARE CONFERENCES 157
CHAPTER 12 Handling Conflict 160 Learning Outcomes 160 CONFLICT 161 INTERPROFESSIONAL CONFLICT 161 CONFLICT PROCESS MODEL 162
Antecedent Conditions 163 Perceived and Felt Conflict 164 Conflict Behaviors 165 Conflict Resolved or Suppressed 165 Outcomes 165
MANAGING CONFLICT 165 Conflict Responses 166 Filley’s Strategies 168 Alternative Dispute Strategies 169
CHAPTER 13 Managing Time 172 Learning Outcomes 172
TIME WASTERS 173 Time Analysis 174 The Manager’s Time 175
SETTING GOALS 175 Determining Priorities 176 Daily Planning and Scheduling 176
xii CONTENTS
Grouping Activities and Minimizing Routine Work 177 Personal Organization and Self-Discipline 177
CONTROLLING INTERRUPTIONS 178 Phone Calls, Voice Mail, Text Messages 179 E-Mail 180 Drop-In Visitors 181 Paperwork 181
CONTROLLING TIME IN MEETINGS 182 RESPECTING TIME 182
PART 3 Managing Resources 184
CHAPTER 14 Budgeting and Managing Fiscal Resources 184 Learning Outcomes 184
THE BUDGETING PROCESS 185 APPROACHES TO BUDGETING 186
Incremental Budget 186 Zero-Based Budget 187 Fixed or Variable Budgets 187
THE OPERATING BUDGET 187 The Revenue Budget 187 The Expense Budget 188
DETERMINING THE SALARY (PERSONNEL) BUDGET 189
Benefits 189 Shift Differentials 190 Overtime 190 On-Call Hours 190 Premiums 190 Salary Increases 191 Additional Considerations 191
MANAGING THE SUPPLY AND NONSALARY EXPENSE BUDGET 191 THE CAPITAL BUDGET 192 TIMETABLE FOR THE BUDGETING PROCESS 192 MONITORING BUDGETARY PERFORMANCE DURING THE YEAR 193
Variance Analysis 193 Position Control 195
PROBLEMS AFFECTING BUDGETARY PERFORMANCE 195
Reimbursement Problems 195 Staff Impact on Budget 196
CHAPTER 15 Recruiting and Selecting Staff 199 Learning Outcomes 199
THE RECRUITMENT AND SELECTION PROCESS 200
RECRUITING APPLICANTS 200 Where to Look 201 How to Look 202 When to Look 202 How to Promote the Organization 202 Cross-Training as a Recruitment Strategy 203
SELECTING CANDIDATES 204 INTERVIEWING CANDIDATES 205
Principles for Effective Interviewing 205 Involving Staff in the Interview Process 209 Interview Reliability and Validity 209
MAKING A HIRE DECISION 210 Education, Experience, and Licensure 210 Integrating the Information 210 Making an Offer 211
LEGALITY IN HIRING 211
CHAPTER 16 Staffing and Scheduling 217 Learning Outcomes 217
STAFFING 218 Patient Classification Systems 218 Determining Nursing Care Hours 219 Determining FTEs 219 Determining Staffing Mix 220 Determining Distribution of Staff 220
SCHEDULING 221 Creative and Flexible Staffing 221 Automated Scheduling 222 Supplementing Staff 223
CHAPTER 17 Motivating and Developing Staff 227 Learning Outcomes 227 A MODEL OF JOB PERFORMANCE 228
Employee Motivation 229 Motivational Theories 229
MANAGER AS LEADER 231 STAFF DEVELOPMENT 231
Orientation 231 On-the-Job Instruction 232 Preceptors 233 Mentoring 233 Coaching 234 Nurse Residency Programs 234 Career Advancement 234 Leadership Development 235
SUCCESSION PLANNING 235
CONTENTS xiii
CHAPTER 18 Evaluating Staff Performance 239 Learning Outcomes 239
THE PERFORMANCE APPRAISAL 240 Evaluation Systems 241 Evidence of Performance 244 Evaluating Skill Competency 247 Diagnosing Performance Problems 247 The Performance Appraisal Interview 248
POTENTIAL APPRAISAL PROBLEMS 251 Leniency Error 251 Recency Error 251 Halo Error 252 Ambiguous Evaluation Standards 252 Written Comments Problem 252
IMPROVING APPRAISAL ACCURACY 253 Appraiser Ability 253 Appraiser Motivation 253
RULES OF THUMB 255
CHAPTER 19 Coaching, Disciplining, and Terminating Staff 257 Learning Outcomes 257
DAY-TO-DAY COACHING 258 POSITIVE COACHING 259 DEALING WITH A POLICY VIOLATION 259 DISCIPLINING STAFF 260 TERMINATING EMPLOYEES 262
CHAPTER 20 Managing Absenteeism, Reducing Turnover, Retaining Staff 268 Learning Outcomes 268 ABSENTEEISM 269
A Model of Employee Attendance 269 Managing Employee Absenteeism 272 Absenteeism Policies 273 Selecting Employees and Monitoring Absenteeism 274 Family and Medical Leave 274
REDUCING TURNOVER 275 Cost of Nursing Turnover 275 Causes of Turnover 276 Understanding Voluntary Turnover 276
RETAINING STAFF 277 Employee Engagement 277 Healthy Work Environment 277 Improving Salaries 277 Recognizing Staff Performance 278 Additional Retention Strategies 279
CHAPTER 21 Dealing with Disruptive Staff Problems 283 Learning Outcomes 283
HARASSING BEHAVIORS 284 Bullying 284 Lack of Civility 284 Lateral Violence 285
HOW TO HANDLE PROBLEM BEHAVIORS 286 Marginal Employees 286 Disgruntled Employees 287
THE EMPLOYEE WITH A SUBSTANCE ABUSE PROBLEM 288
State Board of Nursing 289 Strategies for Intervention 289 Reentry 290 The Americans with Disabilities Act and Substance Abuse 291
CHAPTER 22 Preparing for Emergencies 294 Learning Outcomes 294
PREPARING FOR EMERGENCIES 295 TYPES OF EMERGENCIES 295
Natural Disasters 295 Man-Made Disasters 295 Levels of Disasters 295
NATIONAL RESPONSES TO EMERGENCY PREPAREDNESS 296 HOSPITAL PREPAREDNESS FOR EMERGENCIES 296
Emergency Operations Plan 296 Disaster Triage 297 Core Competencies for Nurses 297 Continuation of Services 297 Impact on Employees 298
CHAPTER 23 Preventing Workplace Violence 302 Learning Outcomes 302
VIOLENCE IN HEALTH CARE 303 Incidence of Workplace Violence 303 Consequences of Workplace Violence 303 Factors Contributing to Violence in Health Care 303
PREVENTING VIOLENCE 304 Zero-Tolerance Policies 304 Reporting and Education 304 Environmental Controls 304
DEALING WITH VIOLENCE 305 Verbal Intervention 305 A Violent Incident 305 Other Dangerous Incidents 306 Post-Incident Follow-Up 306
xiv CONTENTS
CHAPTER 24 Handling Collective Bargaining Issues 310 Learning Outcomes 310
LAWS GOVERNING UNIONS 311 PROCESS OF UNIONIZATION 311
The Grievance Process 312 The Nurse Manager’s Role 312
STATUS OF COLLECTIVE BARGAINING FOR NURSES 313
Legal Status of Nursing Unions 313 The Future of Collective Bargaining for Nurses 314
PART 4 Taking Care of Yourself 316
CHAPTER 25 Managing Stress 316 Learning Outcomes 316
THE NATURE OF STRESS 317 CAUSES OF STRESS 318
Organizational Factors 318 Interpersonal Factors 318 Individual Factors 319
CONSEQUENCES OF STRESS 320 MANAGING STRESS 320
Personal Methods 320 Organizational Methods 321
CHAPTER 26 Advancing Your Career 325 Learning Outcomes 325
ENVISIONING YOUR FUTURE 326 MANAGING YOUR CAREER 326 ACQUIRING YOUR FIRST POSITION 326
Applying for the Position 327 The Interview 328 Accepting the Position 331 Declining the Position 331
BUILDING A RÉSUMÉ 331 Tracking Your Progress 333 Identifying Your Learning Needs 334
FINDING AND USING MENTORS 336 CONSIDERING YOUR NEXT POSITION 336
Finding Your Next Position 337 Leaving Your Present Position 337
WHEN YOUR PLANS FAIL 337 Taking the Wrong Job 337 Adapting to Change 338
Glossary 340 Index 348
CHAPTER
Changes in Health Care
Paying for Health Care HOW AMERICA PAYS FOR HEALTH CARE
PAY FOR PERFORMANCE
Demand for Quality QUALITY INITIATIVES
THE LEAPFROG GROUP
BENCHMARKING
EVIDENCE-BASED PRACTICE
MAGNET® CERTIFICATION
Evolving Technology ELECTRONIC HEALTH RECORDS
VIRTUAL CARE
ROBOTICS
COMMUNICATION TECHNOLOGY
Cultural, Gender, and Generational Differences
Violence Prevention and Disaster Preparedness
Changes in Nursing’s Future EVEN MORE CHANGE . . .
CHALLENGES FACING NURSES AND MANAGERS
Introducing Nursing Management 1
1. Describe the forces that are changing the health care system.
2. Discuss changes in paying for health care. 3. Explain how quality initiatives can reduce
medical errors. 4. Describe how evidence-based practice is
changing nursing. 5. Explain how to become a Magnet-certified
hospital.
6. Explain what emerging technologies mean for nursing.
7. Describe how cultural, gender, and genera- tional differences affect management.
8. Explain why preparation is the best defense against violence and disasters.
9. Discuss the changes and challenges that nurses face now and into the future.
Learning Outcomes After completing this chapter, you will be able to:
Key Terms Benchmarking Electronic health records
(EHRs) Evidence-based practice Leapfrog Group
Magnet Recognition Program®
Patient Protection and Affordable Care Act (PPACA)
Quality initiatives Robotics Social media Virtual care
2 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
T oday, all nurses are managers. Whether you work in a freestanding clinic, an ambula-tory surgical center, a critical unit in an acute care hospital, or in hospice care for a home care agency, you must deal with staff, including other nurses and unlicensed as- sistive personnel, who work with you and for you. At the same time, you must be vigilant about costs. To manage well, you must understand the health care system and the organizations where you work. You need to recognize what external forces affect your work and how to influence those forces. You need to know what motivates people and how you can help create an environ- ment that inspires and sustains the individuals who work in it. You must be able to collaborate with others, as a leader, a follower, and a team member, in order to become confident in your ability to be a leader and a manager.
This book is designed to provide new graduates or novice managers with the information they need to become effective managers and leaders in health care. More than ever before, today’s rapidly changing health care environment demands highly refined management skills and superb leadership.
Changes in Health Care Today’s health care system is continuing to undergo significant changes. Costly lifesaving medi- cines, robotics, virtual care, and innovations in imaging technologies, noninvasive treatments, and surgical procedures have combined to produce the most sophisticated and effective health care ever—and the most expensive. Skyrocketing costs and inaccessibility to health care are ongoing concerns for employers, health care providers, policy makers, and the public at large. A number of factors are forcing change on the health care system.
Paying for Health Care
How America Pays for Health Care The United States spends more money on health care than any other country, and health care spending continues to rise with costs of $2.5 trillion in 2009, consuming more than 17 percent of the country’s gross domestic product (GDP) (CMS, 2011). With the goal of providing access to health care to most U.S. citizens and containing costs, Congress passed a health care reform bill known as the Patient Protection and Affordable Care Act (PPACA) that was signed into law March 23, 2010. While implementation of the bill is pending court challenges, the promise of providing adequate and affordable care to more Americans is on the horizon.
Pay for Performance In 1999, the Institute of Medicine (IOM, 1999) reported that 98,000 deaths occurred each year from preventable medical mistakes, such as falls, wrong site surgeries, avoidable infections, and pressure ulcers, among others. By 2008, researchers learned that “the effects of medical mistakes continue long after the patient leaves the hospital” (Encinosa & Hellinger, 2008, p. 2067). In spite of numerous efforts to prevent mistakes, the cost of medical errors has con- tinued to climb. Recent estimates put such costs at $19.5 billion annually (Shreve et al., 2010).
In 2008, the Centers for Medicare and Medicaid Services, the agency that oversees gov- ernment payments for care, tied payment to the quality of care by changing its reimbursement policy to no longer cover costs incurred by medical mistakes (Wachter, Foster, & Dudley, 2008). If medical mistakes occur, the hospital must absorb the costs. Thus, pay for performance became the norm, and performance is now measured by the quality of care (Milstein, 2009).
Demand for Quality
Quality Initiatives In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. Quality management is a preventive approach designed to address problems before they become crises. The quality movement actually began in post–World War II Japan, when Japanese industries adopted a
CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 3
system that W. Edwards Deming designed to improve the quality of manufactured products. The philosophy of the system is that consumers’ needs should be the focus and that employees should be empowered to evaluate and improve quality. In addition to businesses in the United States and else- where, the health care industry has adopted total quality management or variations on it.
Built into the system is a mechanism for continuous improvement of products and services through constant evaluation of how well consumers’ needs are met and plans adjusted to per- fect the process. Patient satisfaction surveys are one example of how health care organizations evaluate their customers’ needs. Today, quality initiatives address all aspects of patient care and include government efforts as well as private sector endeavors.
Public reporting of heath care organizations has emerged as a strategy to improve quality (Christianson et al., 2010). To further that goal, the Agency for Healthcare Research and Quality (AHRQ)—whose mission is to improve the quality, safety, efficiency, and effectiveness of health care—funds projects that address three quality indicators: prevention, inpatient, quality, and patient safety (Dunton et al., 2011).
The Leapfrog Group Efforts by the Leapfrog Group constitute one private sector initiative to address quality. The Leapfrog Group is a consortium of public and private purchasers established to reduce prevent- able medical mistakes. The organization uses its mammoth purchasing power to leverage quality care for its consumers by rewarding health care organizations that demonstrate quality outcome measures. The quality indicators the group focuses on include ICU staffing, electronic medi- cation ordering systems, and the use of higher performing hospitals for high-risk procedures. Leapfrog estimates that if these three patient safety practices were implemented, more than 57,000 lives could be saved, more than $12 billion dollars could be saved, and more than 3 mil- lion adverse drug events could be avoided (Binder, 2010).
Benchmarking In contrast to quality management strategies that compare internal measures across comparable units, such as the Leapfrog Group, benchmarking compares an organization’s data with similar organizations. Outcome indicators are identified that can be used to compare performance across disciplines or organizations. Once the results are known, health care organizations can address areas of weakness and enhance areas of strength (Nolte, 2011). Interestingly, one study found that hospital size didn’t affect the ability of institutions to compare results (Brown et al., 2010).
Evidence-Based Practice Evidence-based practice has emerged as a strategy to improve quality by using the best avail- able knowledge integrated with clinical experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).
Similar to the nursing process, the steps in EBP are:
1. Identify the clinical question.
2. Acquire the evidence to answer the question.
3. Evaluate the evidence.
4. Apply the evidence.
5. Assess the outcome.
Research findings with conflicting results puzzle consumers daily, and nurses are no excep- tion, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:
● Anecdotal—derived from experience ● Testimonial—reported by an expert in the field
4 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
● Statistical—built from a scientific approach ● Case study—an in-depth analysis used to translate to other clinical situations ● Nonexperimental design research—gathering factors related to a clinical condition ● Quasi-experimental design research—a study limited to one group of subjects ● Randomized control trial—uses both experimental and control groups to determine the
effectiveness of an intervention
While all forms of evidence are useful for clinical decision making, a randomized control design and statistical evidence are the most rigorous (Hader, 2010).
Magnet® Certification The Magnet Recognition Program® designates organizations that “recognize health care orga- nizations that provide nursing excellence” (ANCC, 2011). To qualify for recognition as a mag- net hospital the organization must demonstrate that they are:
● Promoting quality in a setting that supports professional practice ● Identifying excellence in the delivery of nursing services to patients/residents ● Disseminating “best practices” in nursing services.
Becoming a magnet hospital requires a significant investment of time and financial resources. Research shows, however, that patient safety is improved when nurse staffing meets Magnet standards (Lake et al., 2010).
Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy. These orga- nizations retain and recruit independent, accountable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organizations are adopting consumer-sensitive cultures that require accountability and decision making from nurses.
Magnet hospitals are those institutions that have met the stringent guidelines for nurses and are credentialed by the American Nurses Credentialing Center. Characteristics common in mag-
net hospitals include:
● Higher ratios of nurses to patients ● Flexible schedules ● Decentralized administration ● Participatory management ● Autonomy in decision making ● Recognition ● Advancement opportunities
To retain the current workforce and attract other nurses, health care organizations can take from the magnet program characteristics to improve work-life conditions for nurses. Encourag- ing nurses to be full participants and to share a vested interest in the success of the organization can help alleviate the nursing shortage in those organizations and in the profession.
See Chapter 6 , Managing and Improving Quality, to learn more about improving quality in health care.
Evolving Technology Rapid changes in technology seem, at times, to overwhelm us. Hospital information systems (HIS); electronic health records (EHR); point-of-care data entry (POC); provider order entry; bar-code medication administration; dashboards to manage, report, and compare data across plat- forms; virtual care provided from a distance; and robotics—to name a few of the many evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication
CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 5
technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in health care complain that they can’t keep up! The rapidity of technological change promises, unfortunately, to continue unabated.
Electronic Health Records Electronic health records (EHRs) represent a technology destined for rapid expansion. While banks, retailers, airlines, and other industries began to rely on fully integrated systems to man- age communication and reduce redundancies, health care was still continuing to rely on volu- minous paper records duplicated in multiple locations. Keeping data safe continues to worry health care organizations, consumers, and policy makers, but the benefits of integrated systems outweigh the risks (Trossman, 2009a).
EHRs reduce redundancies, improve efficiency, decrease medical errors, and lower health care costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully integrated systems allow for collective data analysis across clinical conditions, health care organizations, or worldwide and sup- port evidence-based decision making. With the federal government funding health systems to upgrade to EHRs, the current 12 percent of hospitals with EHRs is expected to increase (Gomez, 2010).
Virtual Care Virtual care, previously known as telemedicine and now more commonly called telehealth, has evolved as technologies to assess, intervene, and monitor patients remotely improved. Both communication technology (i.e., audio and video) and improvements in mobile care technology contribute to the ability of health care professionals to provide care from a distance. Nurses, for example, can watch banks of video screens monitoring ICU patients’ vitals signs miles away from the hospital. Electronic equipment, such as a stethoscope, can be accessed by a health care provider in a distant location. Such systems are especially useful in providing expert consulta- tion for specialty care (Zapatochny-Rufo, 2010).
Robotics Another technological advance is robotics. In the hospital, supplies can be ordered electroni- cally, and then laser-guided robots can fill the order in the pharmacy or central supply and de- liver the requested supplies to nursing units via their own elevators more efficiently, accurately, and in less time than individuals can. Mobile robots can also monitor patients, report changes and conditions, and allow caregivers to communicate from a distance (Markoff, 2010) via a wireless connection to a laptop or a smart phone. Robot functionality will continue to expand, limited only by resources and ingenuity.
Communication Technology Just as rapidly as clinical and data technology are evolving, so are communication technolo- gies, changing forever the ways people keep informed and interact (Sullivan, 2013). Informa- tion (accurate or inaccurate) is disseminated with lightening speed while smartphones capture real-time events and broadcast images instantaneously.
Social media has revolutionized communication beyond the realm of possibilities from just a few years ago (Kaplan & Haenlein, 2010). Social media connects diverse populations and en- courages collaboration, the exchange of images, ideas, opinions, and preferences in networking Web sites, online forums, Web blogs, social blogs, wikis, podcasts, RSS feeds, photos, video content communities, social bookmarking, online chat rooms, microblogs, such as Twitter, and online communities, such as Facebook and LinkedIn (Sullivan, 2013).
Similar to other enterprises, most health care organizations have an online presence with a Web site and social media sites, such as Facebook, Twitter, and blogs. Units within the organiza- tion may have Facebook pages as well, with staff who post on those sites. These opportunities
6 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
for information sharing and relationship building also come with risks (Raso, 2010; Trossman, 2010b). Patient confidentiality, the organization’s reputation, and recruiting efforts can be en- hanced or put in jeopardy by posts to the site (Sullivan, 2013).
Cultural, Gender, and Generational Differences According to the U.S. Census Bureau, the minority population in the U.S. increased from 31 to 36 percent from 2000 to 2010 (U.S. Census, 2011). The largest minority population is Hispanic, and that population increased to 50 million (16 percent of the total U.S. population) in 2010. The Asian population grew to 14 million (5 percent) in the same time period, and the African American population stands at 42 million (14 percent).
The cultural diversity seen in the general population is also reflected in nursing. The Health Resources and Services Administration (HRSA, 2011) reports that 16 percent of nurses are Asian, African American, Hispanic, or other ethnic minorities, an increase from 12 percent in 2004.
The gender mix found in nursing, however, differs from the general population, with men greatly outnumbered by women. Of the population of more than 3 million nurses in the U.S., only 6 percent are men, although changes suggest the ratio is improving. The proportion of men to women has risen to 1 in 10 in the decades since 1990 (HRSA, 2011). Both cultural diversity and gender diversity challenge the nurse manager to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.
Generational differences in the nursing population is unprecedented, with four generational cohorts working together (Keepnews et al., 2010). Referred to as traditionals, baby boomers, Generation X, and Generation Y, each generational group has different expectations in the work- place. Traditionals value loyalty and respect authority. Baby boomers value professional and personal growth and expect that their work will make a difference.
Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities (Keepnews et al., 2010). Generation Y (also called milleni- als) are technically savvy and expect immediate access to information electronically.
Similar to dealing with cultural and gender differences, the challenge for managers is to avoid stereotyping within the generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Chambers, 2010).
Violence Prevention and Disaster Preparedness Sadly, violence invades workplaces, and health care is no exception. Moreover, nearly 500,000 nurses are victims of workplace violence (Trossman, 2010c). In addition, recent disasters (e. g., the earthquake and tsunami in Japan, tornadoes in the U.S.) and the threats of terrorism and pan- demics challenge health care organizations to prepare for the unthinkable.
Extensive staff training is required (AHRQ, 2011). Techniques include computer simula- tions, video demonstrations, disaster drills, and a clear understanding of communication sys- tems and the incident command center. A natural disaster, an attack of terrorism, an epidemic, or other mass casualty events may, and probably will, occur at some time. All health care organizations must be prepared to care for a surge in casualties while reducing the impact on patients and staff.
Changes in Nursing’s Future Nurses will face many changes in the future, including an increasing demand for nurses as the population ages, a worsening shortage as nurses age, and recommendations for changes to prac- tice and education. The aging population is surviving previously fatal diseases and conditions
CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 7
due to ever-evolving health care technologies. These patients often require ongoing care for chronic illnesses as well as for acute episodes of illness.
Just as the population is aging and requiring more and more care, nurses too are growing older. The average age of the registered nurse is 46 years, although the number of RNs under age 30 is increasing at a faster pace than before (HRSA, 2011).
Slightly more than 3 million nurses are currently licensed as registered nurses in the U.S., and 85 percent of them practice full- or part-time in the profession (HRSA, 2011). Jobs for nurses, however, are expected to grow to 3.2 million by 2018, much faster than the average for all occupations (U.S. Department of Labor, 2011). Also, with implementation of health care reform, increases in the demand for nurses in primary care and acute care settings are expected.
The Institute of Medicine’s report on the future of nursing makes sweeping recommenda- tions for nursing’s future, including that “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (IOM, 2010, p. 3). In addition, IOM posits that today’s health care environment necessitates better-educated nurses and recommends that 80 percent of nurses be prepared at the baccaluareate or higher level by 2020.
At the same time, the Carnegie Foundation recommends radically transforming nursing education (Benner et al., 2009). Its recommendations include:
1. Focus on how to apply knowledge, not only acquire it.
2. Integrate clinical and classroom teaching, rather than separately.
3. Emphasize clinical reasoning, not only critical thinking.
4. Emphasize formation, rather than socialization and role taking (Benner et al., 2009).
Even More Change . . . What does the future hold for health care? Change is the one constant. Quality of care will continue to be monitored and reported with accompanying demands to tie pay to performance. Technology of care, communication, and data management will become more and more com- plex as computer processing power and storage capacity expand (Clancy, 2010) and equipment becomes smaller and more mobile. Access to care and how to pay for it will continue to drive policy and funding decisions. Everyone in health care must learn to live with ambiguity and be flexible enough to adapt to the changes it brings.
Challenges Facing Nurses and Managers Every nurse must be prepared to manage. Specific training in management skills is needed in nursing school as well as in the work setting. Most important, however, is that nurses be able to transfer their newly acquired skills to the job itself. Thus, nurse managers must be experienced in management themselves and be able to assist their staff in developing adequate management skills. Management training for nurses at all levels is essential for any organization to be effi- cient and effective in today’s cost-conscious and competitive environment.
The challenge for nurse managers and administrators is how to manage in a constantly changing system. Working with teams of administrators and providers to deliver quality health care in the most cost-effective manner offers opportunity as well. Nurses’ unique skills in communication, negotiation, and collaboration position them well for the system of today and for the future.
Nurse managers today are challenged to monitor and improve quality care, manage with limited resources, help design new systems of care, supervise teams of professionals and nonprofessionals from a variety of cultures, and, finally, teach personnel how to function well in
8 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
the new system. This is no small task. It requires that nurses and their managers be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. Because the nurse manager of today is responsible for others’ work, the nurse manager must also be a coach, a teacher, and a facilitator. The manager works through others to meet the goals of individuals, of the unit, and of the organization. Most of all, the man- ager must be a leader who can motivate and inspire.
Nurse managers must address the interests of administrators, colleagues in other disciplines, and employees. All want the same result—quality care. Administrators, however, must focus on cost and efficiency in order for the organization to compete and survive. Colleagues want col- laborative and efficient systems of care. Employees want to be supported in their work with ad- equate staffing, supplies, equipment, and, most of all, time. Therein lies the conflict. Between all of them is the nurse manager, who must balance the needs of all. Being a nurse manager today is the most challenging opportunity in health care. This book is designed to prepare you to meet these challenges.
What You Know Now • Health care is radically changing and is expected to continue to change in the foreseeable future. • The tension between providing adequate nursing care and paying for that care will continue to dominate
health policy decisions. • Reducing medical errors is the goal of quality initiatives. • Cultural, gender, and generational diversity will continue to shape the nursing workforce. • Evidence-based practice will guide nursing decisions into the future. • Electronic health records, robotics, and virtual care are just a few of the many technologies continuing to
evolve. • Expansion in communication technologies will continue to offer opportunities and challenges to health
care organizations. • Threats of natural disasters, terrorism, and pandemics require all health care organizations to plan and
prepare for mass casualties. • The nurse manager is challenged to manage in a constantly changing environment.
Questions to Challenge You 1. Name three changes that you would suggest to reduce the cost of health care without compromising
patients’ health and safety. Talk about how you could help make these changes. 2. What mechanisms could you suggest to improve and ensure the quality of care? (Don’t just suggest
adding nursing staff!) 3. How could you help reduce medical errors? What can you suggest that a health care organization
could do? 4. Do your clinical decisions rely on evidence-based practice? If you answer no, why not? 5. What are some ways that nurses could take advantage of emerging technologies in health care and
information systems? Think big. 6. Have you participated in a disaster drill? Did you notice ways to improve the organization’s readi-
ness for mass casualties? Name at least one. 7. What steps can you take to transfer the knowledge and skills you learn in this book into your work
setting?
CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 9
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
Agency for Healthcare Research and Quality. (2011). AHRQ disaster response tools and resources. Retrieved May 25, 2011 from http://www.ahrq. gov/research/altstand
American Nurses Credential- ing Center (2011). Magnet Recognition Program. Retrieved April 27, 2011 from http://www. nursecredentialing.org/ Magnet.aspx
Benner, P., Sutphen, M., Leonard, V., and Day, L. (2009). Educating nurses: A call for radical trans- formation. San Francisco: Jossey-Bass.
Binder, L. (2010). Leapfrog: Unique and salient mea- sures of hospital quality and safety. Prescriptions for Excellence in Health Care, 8, 1–2.
Brown, D. S., Aydin, C. E., Donaldson, N., Fridman, M., & Sandhu, M. (2010). Benchmarking for small hospitals: Size didn’t mat- ter! Journal of Healthcare Quality, 32(4), 50–60.
Centers for Medicare and Medic- aid Services (CMS) (2011). National health expenditure data. Retrieved April 25, 2011 from https://www. cms.gov/NationalHealth- ExpendData/25_NHE_Fact_ Sheet.asp
Chambers, P. D. (2010). Tap the unique strengths of the mil- lennial generation. Nursing
Management, 41(3), 37–39.
Christianson, J. B., Volmar, K. M., Alexander, J., & Scanlon, D. P. (2010). A report card on provider report cards: Current status of the health care transpar- ency movement. Journal of General Internal Medicine, 25(11), 1235–1241.
Clancy, T. R. (2010). Technology and complexity: Trouble brewing? Journal of Nurs- ing Administration, 40(6), 247–249.
Dunton, N., Gonnerman, D., Montalvo, I., & Schumann, M. J. (2011). Incorporating nursing quality indicators in public reporting and value- based purchasing initiatives. American Nurse Today, 6(1), 14–18.
Encinosa, W. E., & Hellinger, F. J. (2008). The impact of medical errors on ninety- day costs and outcomes: An examination of sur- gical patients. Health Services Research, 43(6), 2067–2085.
Hader, R. (2010). The evident that isn’t . . . interpreting research. Nursing Manage- ment, 41(9), 23–26.
Health Resources and Services Administration (HRSA) (2011). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved April 26, 2011
from http://bhpr.hrsa.gov/ healthworkforce/ rnsurvey2008.html
Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementa- tion guide for healthcare organizations. Sudbury, MA: Jones & Bartlett.
Gomez, R. (2010). Automation: HER upgrade consider- ations. Nursing Manage- ment, 41(2), 35–37.
Institute of Medicine (1999). To err is human: Build- ing a safer health system. Washington, DC: National Academy Press.
Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved April 26, 2011 from http://www. thefutureofnursing.org/ IOM-Report
Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.
Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin, J. H. (2010). Genera- tional differences among newly licensed registered nurses. Nursing Outlook, 58(3), 155–163.
Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010). Patient falls: Association with hospi- tal magnet status and nursing unit staffing. Research in
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10 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
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CHAPTER
Traditional Organizational Theories
CLASSICAL THEORY
HUMANISTIC THEORY
SYSTEMS THEORY
CONTINGENCY THEORY
CHAOS THEORY
COMPLEXITY THEORY
Traditional Organizational Structures
FUNCTIONAL STRUCTURE
HYBRID STRUCTURE
MATRIX STRUCTURE
PARALLEL STRUCTURE
Service-Line Structures
Shared Governance
Ownership of Health Care Organizations
Health Care Settings PRIMARY CARE
ACUTE CARE HOSPITALS
HOME HEALTH CARE
LONG-TERM CARE
Complex Health Care Arrangements HEALTH CARE NETWORKS
INTERORGANIZATIONAL RELATIONSHIPS
DIVERSIFICATION
MANAGED HEALTH CARE ORGANIZATIONS
ACCOUNTABLE CARE ORGANIZATIONS
Redesigning Health Care
Strategic Planning
Organizational Environment and Culture
Designing Organizations 2
1. Discuss how organizational theories differ.
2. Describe the different types of health care organizations.
3. Explain how health care organizations are structured.
4. Discuss various ways that health care is provided.
5. Demonstrate how strategic planning guides the organization’s future.
6. Discuss how the organizational environment and culture affect workplace conditions.
Learning Outcomes After completing this chapter, you will be able to:
Key Terms Accountable care organization Bureaucracy Capitation Chain of command Diversification Goals Hawthorne effect Horizontal integration Integrated health care networks Line authority
Logic model Medical home Mission Objectives Organization Organizational culture Organizational environment Philosophy Redesign Retail medicine
Service-line structures Shared governance Span of control Staff authority Strategic planning Strategies Throughput Values Vertical integration Vision statement
12 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
A n organization is a collection of people working together under a defined structure to achieve predetermined outcomes using financial, human, and material resources. The justification for developing organizations is both rational and economic. Coordinated efforts capture more information and knowledge, purchase more technology, and produce more goods, services, opportunities, and securities than individual efforts. This chapter discusses or- ganizational theory, structures, and functions.
Traditional Organizational Theories The earliest recorded example of organizational thinking comes from the ancient Sumerian civi- lization, around 5000 b.c. The early Egyptians, Babylonians, Greeks, and Romans also gave thought to how groups were organized. Later, Machiavelli in the 1500s and Adam Smith in 1776 established the management principles we know as specialization and division of labor. Never- theless, organizational theory remained largely unexplored until the Industrial Revolution during the late 1800s and early 1900s, when a number of approaches to the structure and management of organizations developed. The early philosophies are traditionally labeled classical theory and humanistic theory while later approaches include systems theory, contingency theory, chaos theory, and complexity theory.
Classical Theory The classical approach to organizations focuses almost exclusively on the structure of the formal organization. The main premise is efficiency through design. People are seen as operating most productively within a rational and well-defined task or organizational design. Therefore, one designs an organization by subdividing work, specifying tasks to be done, and only then fitting people into the plan. Classical theory is built around four elements: division and specialization of labor, organizational structure, chain of command, and span of control.
Division and Specialization of Labor Dividing the work reduces the number of tasks that each employee must carry out, thereby increasing efficiency and improving the organization’s product. This concept lends itself to proficiency and specialization. Therefore, division of work and specialization are seen as economically beneficial. In addition, managers can standardize the work to be done, which in turn provides greater control.
Organizational Structure Organizational structure describes the arrangement of the work group. It is a rational approach for designing an effective organization. Classical theorists developed the concept of departmentaliza- tion as a means to maintain command, reinforce authority, and provide a formal system for commu- nication. The design of the organization is intended to foster the organization’s survival and success.
Characteristically, the structure takes shape as a set of differentiated but interrelated func- tions. Max Weber (1958) proposed the term bureaucracy to define the ideal, intentionally ratio- nal, most efficient form of organization. Today this word has a negative connotation, suggesting long waits, inefficiency, and red tape.
Chain of Command The chain of command is the hierarchy of authority and responsibility within the organization. Authority is the right or power to direct activity, whereas responsibility is the obligation to attain objectives or perform certain functions. Both are derived from one’s position within the organi- zation and define accountability. The line of authority is such that higher levels of management delegate work to those below them in the organization.
One type of authority is line authority, the linear hierarchy through which activity is directed. Another type is staff authority, an advisory relationship; recommendations and advice
CHAPTER 2 • DESIGNING ORGANIZATIONS 13
are offered, but responsibility for the work is assigned to others. In Figure 2-1, the relationships among the chief nurse executive, nurse manager, and staff nurse are examples of line authority. The relationship between the acute care nurse practitioner and the nurse manager illustrates staff authority. Neither the acute care nurse practitioner nor the nurse manager is responsible for the work of the other; instead, they collaborate to improve the efficiency and productivity of the unit for which the nurse manager is responsible.
Span of Control Span of control addresses the pragmatic concern of how many employees a manager can effec- tively supervise. Complex organizations usually have numerous departments that are highly spe- cialized and differentiated; authority is centralized, resulting in a tall organizational structure with many small work groups. Less complex organizations have flat structures; authority is decentral- ized, with several managers supervising large work groups. Figure 2-2 depicts the differences.
In the professional bureaucracy, the operating core of professionals is the dominant feature. Decision making is usually decentralized, and the technostructure is underdeveloped. The sup- port staff, however, is well developed. Most hospitals are professional bureaucracies.
Chief nurse executive
Staff nurse Staff nurse Staff nurse
Acute care nurse practitioner
Nurse manager
Nurse manager
Nurse manager
Figure 2-1 • Chain of authority.
Tall
Flat
Figure 2-2 • Contrasting spans of control. From Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health services organizations and systems (4th ed.). Baltimore: Health Professions Press, p. 124. Reprinted by permission.
14 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Organizational theories suggest organizational structures. Traditional structures (described later in the chapter) operationalize the tenets of classical theory.
Humanistic Theory Criticism of classical theory led to the development of humanistic theory, an approach identified with the human relations movement of the 1930s. A major assumption of this theory is that peo- ple desire social relationships, respond to group pressures, and search for personal fulfillment. This theory was developed as the result of a series of studies conducted by the Western Electric Company at its Hawthorne plant in Chicago. The first study was conducted to examine the effect of illumination on productivity. However, this study failed to find any relationship between the two. In most groups, productivity varied at random, and in one study productivity actually rose as illumination levels declined. The researchers concluded that unforeseen psychological factors were responsible for the findings.
Further studies of working conditions, such as rest breaks and the length of the workweek, still failed to reveal a relationship to productivity. The researchers concluded that the social set- ting created by the research itself—that is, the special attention given to workers as part of the research—enhanced productivity. This tendency for people to perform as expected because of special attention became known as the Hawthorne effect.
Although the findings are controversial, they led organizational theorists to focus on the so- cial aspects of work and organizational design. (See Chapter 17 for a description of motivational theories.) One important assertion of this school of thought was that individuals cannot be co- erced or bribed to do things they consider unreasonable; formal authority does not work without willing participants.
Systems Theory Organizational theorists who maintain a systems perspective view productivity as a function of the interplay among structure, people, technology, and environment. Like nursing theories based on systems theory (such as those of Roy and Neuman), organizational theory defines system as a set of interrelated parts arranged in a unified whole. Systems can be closed or open. Closed systems are self-contained and usually can be found only in the physical sciences. An open sys- tem, in contrast, interacts both internally and with its environment, much like a living organism.
An organization is a complex, sociotechnical, open system. This theory provides a frame- work by which the interrelated parts of the system and their functions can be studied. Resources, or input, such as employees, patients, materials, money, and equipment, are imported from the environment. Within the organization, energy and resources are utilized and transformed; work, a process called throughput, is performed to produce a product. The product, or output, is then exported to the environment. An organization, then, is a recurrent cycle of input, throughput, and output. Each health care organization—whether a hospital, ambulatory surgical center, or a home care agency, and so on—requires human, financial, and material resources. Each also provides a variety of services to treat illness, restore function, provide rehabilitation, and protect or promote wellness.
Throughput today is commonly associated with moving patients into and out of the sys- tem. Hospitals everywhere are focused on throughput of patients, such as if emergency depart- ments are on diversion, how long a patient has to wait for a bed, and the number of readmissions (Handel et al., 2010). Using information technology, bed management systems have emerged as a strategy to identify bed availability in real time (Gamble, 2009). Joint Commission accreditation standards now require hospitals to show data “throughput” statistics (Joint Commission, 2011).
Contingency Theory Contingency theory posits that organizational performance can be enhanced by matching an organization’s structure to its environment. The environment is defined as the people, objects,
CHAPTER 2 • DESIGNING ORGANIZATIONS 15
and ideas outside the organization that influence the organization. The environment of a health care organization includes patients and potential patients; third-party payers, including the gov- ernment; regulators; competitors; and suppliers of physical facilities, personnel (such as schools of nursing and medicine), equipment, and pharmaceuticals.
Health care organizations are unique with respect to the kinds of products and services they offer. However, like all other organizations, health care organizations are shaped by external and internal forces. These forces stem from the economic and social environment, the technologies used in patient care, organizational size, and the abilities and limitations of the personnel involved in the delivery of health care, including nurses, physicians, technicians, administrators, and, of course, patients.
Given the variety of health care services and patients served today, it should come as no sur- prise that organizations differ with respect to the environments they face, the levels of training and skills of their caregivers, and the emotional and physical needs of patients. It is naive to think that the form of organization best for one type of patient in one type of environment is appropriate for another type of patient in a completely different environment. Think about the differences in the environment of a substance abuse treatment center compared to a women’s health clinic. Thus, the optimal form of the organization is contingent on the circumstances faced by that organization.
Chaos Theory Chaos theory, which was inspired by the finding of quantum mechanics, challenges us to look at organizations and the nature of relationships and proposes that nature’s work does not follow a straight line. The elements of nature often move in a circular, ebbing fashion; a stream destined for the ocean, for example, never takes a straight path. In fact, very little in life operates as a straight line; people’s relationships to each other and to their work certainly do not. This notion challenges traditional thinking regarding the design of organizations. Organizations are living, self-organizing systems that are complex and self-adaptive.
The life cycle of an organization is fully dependent on its adaptability and response to changes in its environment. The tendency is for the organization to grow. When it becomes a large entity, it tends to stabilize and develop more formal standards. From that point, however, the organization tends to lose its adaptability and responsiveness to its environment.
Chaos theory suggests that the drive to create permanent organizational structures is doomed to fail. The set of rules that guided the industrial notions of organizational function and integrity must be discarded, and newer principles that ensure flexibility, fluidity, speed of adaptability, and cultural sensitivity must emerge. The role of leadership in these changing organizations is to build resilience in the midst of change and to maintain a balance between tension and order, which promotes creativity and prevents instability. This theory requires us to abandon our at- tachment to any particular model of design and to reflect instead on creative and flexible formats that can be quickly adjusted and changed as the organization’s realities shift.
Complexity Theory Complexity theory originated in the computational sciences when scientists noted that random events interfered with expectations. The theory is useful in health care because the environment is rife with randomness and complex tasks. Patients’ conditions change in an instant; necessary staff are not available; or equipment fails, all without warning. Tasks involve intricate interactions between and among staff, patients, and the environment. Managing in such ambiguous circumstances requires considering every aspect of the system as it interacts and adapts to changes. Complexity theory ex- plains why health care organizations, in spite of concerted efforts, struggle with patient safety.
Traditional Organizational Structures The optimal organizational structure integrates organizational goals, size, technology, and envi- ronment. Various organizational structures have been utilized over time. Examples include func- tional structures, hybrid structures, matrix structures, and parallel structures.
16 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Functional Structure In functional structures, employees are grouped in departments by specialty, with similar tasks being performed by the same group, similar groups operating out of the same depart- ment, and similar departments reporting to the same manager. In a functional structure, all nursing tasks fall under nursing service; the same is true of other functional areas. Functional structures tend to centralize decision making because the functions converge at the top of the organization.
Functional structures have several weaknesses. Coordination across functions is poor. Decision-making responsibilities can pile up at the top and overload senior managers, who may be uninformed regarding day-to-day operations. Responses to the external environment that re- quire coordination across functions are slow. General management training is limited because most employees move up the organization within functional departments. Functional structures are uncommon in today’s rapidly changing health care environment.
Hybrid Structure When an organization grows, it typically organizes both self-contained units and functional units; the result is a hybrid organization. The hybrid structure can provide simultaneous coordi- nation within product divisions, can improve alignment between corporate and service or prod- uct goals, and foster adaptation to the environment while still maintaining efficiency.
The weakness of hybrid structures is conflict between top administration and managers. Managers often resent administrators’ intrusions into what they see as their own area of respon- sibility. Over time, organizations tend to accumulate large corporate staffs to oversee divisions in an attempt to provide functional coordination across service or product structures.
Matrix Structure The matrix structure is unique and complex; it integrates both product and functional structures into one overlapping structure. In a matrix structure, different managers are responsible for func- tion and product. For example, the nurse manager for the oncology clinic may report to the vice president for nursing as well as the vice president for outpatient services.
Matrices tend to develop where there are strong outside pressures for a dual organizational focus on product and function. The matrix is appropriate in a highly uncertain environment that changes frequently but also requires organizational expertise.
A major weakness of the matrix structure is its dual authority, which can be frustrating and confusing for departmental managers and employees. Excellent interpersonal skills are required from the managers involved. A matrix organization is time-consuming because frequent meetings are required to resolve problems and conflicts; the structure will not work unless participants can see beyond their own functional area to the big organizational picture. Finally, if one side of the matrix is more closely aligned with organizational objectives, that side may become dominant.
Parallel Structure Parallel structure is a structure unique to health care. It is the result of complex relationships that exist between the formal authority of the health care organization and the authority of its medi- cal staff. In a parallel structure, the medical staff is separate and autonomous from the organiza- tion. The result is an organizational dilemma: two lines of authority. One line extends from the governing body to the chief executive officer and then to the managerial structure; the other line extends from the governing body to the medical staff. These two intersect in departments such as nursing because decision making involves both managerial and clinical elements.
Parallel structures are found in health care institutions with a functional structure and sepa- rate medical governance structure. Parallel structures are becoming less successful as health care organizations integrate into newer models that incorporate physician practice under the organi- zational umbrella.
CHAPTER 2 • DESIGNING ORGANIZATIONS 17
Service-Line Structures More common in health care organizations today are service-line structures (Nugent et al., 2008). Service-line structures also are called product-line or service-integrated structures. In a service-line structure, clinical services are organized around patients with specific conditions (Figure 2-3).
Integrated structures are preferred in large and complex organizations because the same ac- tivity (for example, hiring) is assigned to several self-contained units, which can respond rapidly to the unit’s immediate needs. This is appropriate when environmental uncertainty is high and the organization requires frequent adaptation and innovation.
One of the strengths of the service-line structure is its potential for rapid change in a chang- ing environment. Because each division is specialized and its outputs can be tailored to the situa- tion, client satisfaction is high. Coordination across function (nursing, dietary, pharmacy, and so on) occurs easily; work partners identify with their own service and can compromise or collabo- rate with other service functions to meet service goals and reduce conflict. Service goals receive priority under this organizational structure because employees see the service outcomes as the primary purpose of their organization.
The major weaknesses of service-integrated structures include possible duplication of resources (such as ads for new positions) and lack of in-depth technical training and specialization. Coordination across service categories (oncology, cardiology, and the burn unit, for example) is difficult; services operate independently and often compete. Each service category, which is independent and autono- mous, has separate and often duplicate staff and competes with other service areas for resources. In addition, some service lines (e. g., pediatrics, obstetrics, bariatric surgery, and transplant centers) pres- ent special challenges due to low usage or the need for specialized personnel (Page, 2010).
Service-line structures are the most common structures found in Magnet-certified organiza- tions (Kaplow & Reed, 2008). Such structures, however, present a challenge to nursing adminis- trators and managers to maintain nursing standards across service lines (Hill, 2009). Armstrong, Laschinger, and Wong (2009) found improved patient safety in Magnet hospitals was related to nurses’ perception of empowerment. This can be explained, possibly, by Magnet standards that encourage staff participation in decision making.
Shared Governance Shared governance is a process for empowering nurses in the practice setting. It is based on a philosophy that nursing practice is best determined by nurses. Participative decision making is the hallmark of shared governance and a standard for Magnet certification. Interdependence and
Nursing Dietary
Oncology
CEO
Pharmacy Storeroom
Nursing Dietary Pharmacy Storeroom
Cardiology
Nursing Dietary
Burn unit
Pharmacy Storeroom
Figure 2-3 • Service line structure.
18 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
accountability are the basis for constructing a network of making nursing practice decisions in a decentralized environment. As a result, nurses gain significant control over their practice, ef- ficiency and accountability are improved, and feelings of powerlessness are mitigated.
The ultimate outcome of shared governance is that nurses participate in an accountable fo- rum to control their own practice within the health care organization. The assumption is that nursing staffs, like medical staffs, will predetermine the clinical skills of staff nurses and moni- tor the work of each through peer review while deciding on other practice issues through ac- countable forums or councils.
Shared governance allows staff nurses significant control over major decisions about nurs- ing practice. Most shared governance systems are similar to and reflect the principles often found in academic or medical governance models. As shown in the example in Figure 2-4, nurses par- ticipate in unit-based councils that interface with divisional councils, specialty councils, and a leadership council, consisting of nurse managers and administrators.
Decisions are made by consensus, rather than by the manager’s order or majority rule, a process that allows staff nurses an active voice in the decision. In the example in Figure 2-4, unit councils make decisions that directly affect the unit, divisional councils address issues that affect more than one unit, and a hospital-wide council determines overall issues.
The hospital-wide council consists of specific councils that address particular issues. The practice council, for example, is responsible for patient care standards. The professional development council maintains educational standards and competency assessments. The quality council monitors patient care quality. The research council assists in implementing evidence- based practice.
Although nursing practice councils have been operational for several decades, changes in health care and in organizational structures often require restructuring the councils, a process not without difficulty (Moore & Wells, 2010). Staffing shortages, patient demands and unfamiliarity with the process or its benefits may discourage participation.
Furthermore, not all shared governance models are successful (Ballard, 2010). Human fac- tors, such as lack of leadership, lack of staff or manager understanding of shared governance, or the absence of knowledgeable mentors, can impede the implementation of the model. Structural factors, such as a known structure for decision making, time available for meetings, and staffing support for attendance also can affect the success of shared governance.
With shared governance a Magnet standard, efforts to implement, refine and restructure the model in health care organizations is expected to continue (McDowell et al., 2010).
Ownership of Health Care Organizations Today’s health care organizations differ in ownership, role, activity, and size. Ownership can be either private or government, voluntary (not for profit) or investor-owned (for profit), and sectarian or non- sectarian (Figure 2-5). Private organizations are usually owned by corporations or religious entities,
Unit-based councils
Divisional council
Leadership council
Practice council
Professional development
council
Quality council
Research council
Figure 2-4 • Shared governance model. Adapted from McDowell, J. B., Williams, R. L., Kautz, D. D., Madden, P., Heilig, A., & Thompson, A. (2010). Shared governance: 10 years later. Nursing Management, 41(7), 32–37.
CHAPTER 2 • DESIGNING ORGANIZATIONS 19
whereas government organizations are operated by city, county, state, or federal entities, such as the Indian Health Service. Voluntary organizations are usually not for profit, meaning that surplus mon- ies are reinvested into the organization. Investor-owned, or for-profit corporations, distribute surplus monies back to the investors, who expect a profit. Sectarian agencies have religious affiliations.
Health Care Settings Organizations are further divided by the setting in which they deliver care. These include pri- mary care, acute care hospitals, home health care, and long-term care organizations.
Primary Care Primary care is considered the patient’s first encounter with the health care system. Primary care is deliv- ered in physician’s offices, emergency rooms, public health clinics, and in sites known as retail medicine.
PRIVATE (NONGOVERNMENT) OWNERSHIP
Voluntary (not for profit)
Roman Catholic, Salvation Army, Lutheran, Methodist, Baptist, Presbyterian, Latter-day Saints, Jewish
Community
Industrial (railroad, lumber, union) Kaiser-Permanente Plan Shriners hospitals
Investor- owned (for profit)
Individual owner partnership corporation
Single hospital (Investor-owned hospitals)
Sectarian
Nonsectarian
GOVERNMENT OWNERSHIP
Federal
State Long-term psychiatric, chronic, and other State university medical centers
Army Navy Air Force
Public Health Service Indian Health Service Other
Local
Hospital district or authority County City-county City
Department of Defense
Department of Veterans Affairs
Department of Health and Human Services
Department of Justice—prisons
Figure 2-5 • Types of ownership in health care organizations. From Longest, B. S., Rakich, J. S., & Darr, K. (2000). Managing Health Services Organizations and Systems (4th ed.). Baltimore: Health Professions Press, p. 173. Reprinted by permission.
20 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Retail medicine describes walk-in clinics that provide convenient services for low-acuity illnesses without scheduled appointments. Staffed by nurse practitioners with physician backup, these clinics seem a natural expectation of today’s fast food, 24/7 public mindset. The Ameri- can Medical Association, however, has questioned the quality of care provided in these clinics (Costello, 2008).
Rohrer, Angstman, and Furst (2009) addressed quality of care in their study. They com- pared the reutilization rates of patients seen in a retail clinic with those in a large group physician practice. They surmised that if clinic patients had no higher return visits or emer- gency room visits for the same condition than physician office patients, then the quality of care could be assumed to be comparable in both settings. That is exactly what they found. So, according to this study, patients not only benefitted from the convenience of a walk-in clinic, but the quality of care they received was comparable to a private physician’s office visit. In addition, the cost of care was much lower than either physician offices or emer- gency rooms.
Another model of primary care is the logic model. The logic model is a practice-based re- search network (PBRN) that provides a framework for planning and evaluation of primary care (Hayes, Parchman, & Howard, 2011). The goal of this model is to improve the health outcomes of patients. Primary care outcomes are seldom evaluated. The logic model offers one way to determine if efforts and resources are used in the most productive way and if subjective outcomes, such as pa- tient satisfaction and easy access are achieved.
Acute Care Hospitals Hospitals are frequently classified by length of stay and type of service. Most hospitals are acute (short-term or episodic) care facilities, and they may be classified as general or special care fa- cilities, such as pediatric, rehabilitative, and psychiatric facilities. Many hospitals also serve as teaching institutions for nurses, physicians, and other health care professionals.
The term “teaching hospital” commonly designates a hospital associated with a medical school that maintains a house staff of residents on call 24 hours a day. Nonteaching hospitals, in contrast, have only private physicians on staff. Because private physicians are less accessible than house staff, the medical supervision of patient care differs, as may the role of the nurse. This designation is changing dramatically as new forms of physician groups and allied practices emerge in partnerships with hospitals and medical schools. Some organizations hire hospitalists, physicians who provide care only to hospital inpatients; those who care for patients in intensive care are known as intensivists.
Home Health Care Home health care is the intermittent, temporary delivery of health care in the home by skilled or unskilled providers. With shortened lengths of hospital stay, more acutely ill patients are dis- charged to recuperate at home. Furthermore, more people are surviving life-threatening illnesses or trauma and require extended care. The primary service provided by home care agencies is nursing care; however, larger home care agencies also offer other professional services, such as physical or occupational therapy, and durable medical equipment, such as ventilators, hospital beds, home oxygen equipment, and other medical supplies. Hospice care for the final days of a patient’s terminal illness may be provided by a home care agency or a hospital.
An outgrowth of the home health care industry is the temporary service agency. These agencies provide nurses and other health care workers to hospitals that are temporarily short- staffed; they also provide private duty nurses to individual patients either at home or in the hospital.
Long-Term Care Long-term care facilities provide professional nursing care and rehabilitative services. They may be freestanding, part of a hospital, or affiliated with a health care organization. Usually, length of
CHAPTER 2 • DESIGNING ORGANIZATIONS 21
stay is limited. Residential care facilities, also known as nursing homes, are sheltered environ- ments in which long-term care is provided by nursing assistants with supervision from licensed professional or registered nurses.
As the population ages and the frail elderly account for more and more of the nation’s citi- zens, care in long-term care facilities is growing (Weaver et al., 2008). These organizations pose different problems for staff. Ageism and infantilism permeate many settings (Ryvicker, 2009). In addition, patients often transition between the nursing home and the hospital, and that care may be fragmented and lead to poor outcomes (Naylor, Kurtzman, & Pauly, 2009). Challenges in providing care to the elderly include addressing the tendency to stigmatize older, frail adults and to provide continuity of care across settings.
Complex Health Care Arrangements Health Care Networks Integrated health care networks emerged as organizations struggled to find ways to survive in today’s cost-conscious environment. Integrated systems encompass a variety of model organiza- tional structures, but certain characteristics are common. Network systems
● Deliver a continuum of care; ● Provide geographic coverage for the buyers of health care services; and ● Accept the risk inherent in taking a fixed payment in return for providing health care for
all persons in the selected group, such as all employees of one company.
To provide such services, networks of providers evolved to encompass hospitals and physi- cian practices. Most importantly, the focal point for care is primary care rather than the hospital. The goal is to keep patients healthy by treating them in the setting that incurs the lowest cost and thereby reducing expensive hospital treatments. The former goal—to keep hospital beds filled— has been replaced with a new goal: to keep patients out of them!
A variety of other arrangements have emerged, varying from loose affiliations between hos- pitals to complete mergers of hospitals, clinics, and physician practices. These arrangements continue to move and shift as alliances fail, return to separate entities, and form new affiliations. Changes in health care payments offer possibilities for nurses to practice in expanding primary care networks are anticipated.
Interorganizational Relationships With increased competition for resources and public and governmental pressures for better efficiency and effectiveness, organizations have been forced to establish relationships with one another for their continued survival. Multihospital systems and multiorganizational ar- rangements, both formal and informal, are mechanisms by which these relationships have formed.
Arrangements between or among organizations that provide the same or similar services are examples of horizontal integration. For instance, all hospitals in the network provide compa- rable services, as shown in Figure 2-6.
Vertical integration, in contrast, is an arrangement between or among dissimilar but re- lated organizations to provide a continuum of services. An affiliation of a health maintenance organization with a hospital, pharmacy, and nursing facility represents vertical integration (see Figure 2-7).
Numerous arrangements using horizontal and vertical integration can be found, and these models likely will become the common structure for delivery of health care. Examples of such arrangements include affiliations, consortia, alliances, mergers, and consolidations. An assort- ment of health care agencies under the umbrella of a corporate network is shown in the example in Figure 2-8.
22 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Hospital A
Hospital B
Hospital C
Hospital D
Hospital E
Hospital F
Hospital G
Figure 2-6 • Horizontal integration.
Acute care hospital
Long-term care facility
Home health agency
Ambulatory care clinic
Sports medicine clinic
Hospice care
Figure 2-7 • Vertical integration.
Hospital Imaging center
Home care services
Medical group
practice
Skilled nursing facility
Ambulatory surgical center
Long-term care
Corporate board
Figure 2-8 • Corporate health care network.
Diversification Diversification provides another strategy for survival in today’s economy. Diversification is the expansion of an organization into new arenas. Two types of diversification are common: concen- tric and conglomerate.
Concentric diversification occurs when an organization complements its existing services by expanding into new markets or broadening the types of services it currently has available. For example, a children’s hospital might open a day-care center for developmentally delayed children or offer drop-in facilities for sick child care.
Conglomerate diversification is the expansion into areas that differ from the original product or service. The purpose of conglomerate diversification is to obtain a source of income that will support the organization’s product or service. For example, a long-term care facility might develop real estate or purchase a company that produces durable medical equipment.
Another type of diversification common to health care is the joint venture. A joint venture is a partnership in which each partner contributes different areas of expertise, resources, or services to create a new product or service. In one type of joint venture, one partner (general partner) finances and manages the venture, whereas the other partner (limited partner) pro- vides a needed service. Joint ventures between health care organizations and physicians are becoming increasingly common. Integrated health care organizations, hospitals, and clinics seek physician and/or practitioner groups they can bond (capture) in order to obtain more referrals. The health care organization as financier and manager is the general partner, and physicians are limited partners.
CHAPTER 2 • DESIGNING ORGANIZATIONS 23
Managed Health Care Organizations The managed health care organization is a system in which a group of providers is responsible for delivering services (that is, managing health care) through an organized arrangement with a group of individuals (for example, all employees of one company, all Medicaid patients in the state). Different types of managed-care organizations exist: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service plans (POS).
An HMO is a geographically organized system that provides an agreed-on package of health maintenance and treatment services provided to enrollees at a fixed monthly fee per enrollee, called capitation. Patients are required to choose providers within the network.
In a PPO, the managed-care organization contracts with independent practitioners to pro- vide enrollees with established discounted rates. If an enrollee obtains services from a nonpar- ticipating provider, significant copayments are usually required.
Point-of-service (POS) is considered to be an HMO–PPO hybrid. In a POS, enrollees may use the network of managed-care providers to go outside the network as they wish. However, use of a pro- vider outside the network usually results in additional costs in copayments, deductibles, or premiums.
Accountable Care Organizations Effective January 2012, accountable care organizations have been able to contract with Medicare to provide care to a group of Medicare recipients (Ansel & Miller, 2010). Strong incentives to reduce cost, share information across networks and improve quality are included in the provisions for reimbursement.
An accountable care organization consists of a group of health care providers that provide care to a specified group of patients. Various structures can be used in accountable care organiza- tions from loosely affiliated groups of providers to integrated delivery systems. An accountable care organization is more flexible than a HMO because consumers are free to choose providers from outside the network. Cognizant of the potential for Medicare contracts and, later, reim- bursement by other third-party payers, health care providers and organizations are scrambling to establish collaborative arrangements and networks.
Redesigning Health Care Health care is a dynamic environment with multiple factors impinging on continuity and stability. Implementation of accountable care organizations, demands for safe, quality care, Magnet standards that promote decentralized organizational structures and an aging population with multiple chronic conditions are just two of the factors that make redesigning health care a reality today.
Redesign includes strategies to better provide safe, efficient, quality health care. Some ex- amples of redesign strategies include adopting a patient-centered care model, focusing on spe- cific service lines, applying lean thinking to the system, and establishing a flat, decentralized organizational structure.
The Institute of Medicine’s 2001 report, Crossing the Quality Chasm, recommended ways to improve health care. One of those was to adopt a patient-centered care model (IOM, 2001). Success in implementing a patient- and family-centered care model has been reported in the lit- erature (Zarubi, Reiley & McCarter, 2008).
Another patient-centered model is the medical home (Berenson et al., 2008). Centered by a primary care provider (primary care physician or nurse practitioner), a medical home links all care providers in the “home.” The goal is to provide continuous, accessible, and comprehen- sive care. Challenges for coordinating care in a medical home include communication (e.g., ab- sence of electronic medical records for all providers), the multiple needs of patients with chronic health problems, discomfort of patients and providers to use electronic communication of data and information, and compensation for primary care. To offset some of these challenges are sev- eral suggestions (Berenson et al., 2008). These include implementing electronic medical records
24 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
using nurse practitioners to manage patients with chronic conditions, encouraging patients to self-manage chronic conditions, and persuading providers to use electronic communication with patients.
To meet both quality and cost-effective goals, the health care organization may decide to concentrate on specific service lines. Called big-dot focus areas, an organization selects a few major initiatives. They might, for example, put resources into building cardiology, cancer, and neuroscience while maintaining other services as is.
Another strategy is to adopt the quality concepts of lean thinking to redesign (Joosten, Bongers, & Janssen, 2009). Lean thinking focuses on the system rather than on individuals, concentrates on interventions that improve outcomes and disregards those that have little or no effect. A flat, decentralized organizational structure centers decision making closest to the problem. It promotes unit-based decision making and empowers staff to implement process improvements in a timely manner (Kramer, Schmalenberg, & Maguire, 2010). Furthermore, a decentralized structure encourages communication and collaboration and provides a quality im- provement infrastructure.
Redesigning an organization presents numerous challenges. Staff may be concerned that their jobs will change or may disappear. Administrators may complain that loss of authority will result in poor performance. Everyone may worry that cost effective measures may diminish the quality of care. Significant stress is to be expected (Lavoie-Tremblay et al., 2010).
Nurse managers are key players in the redesign efforts. They are expected not only to initi- ate change while reducing costs, maintaining or improving quality of care, coaching and men- toring, and team building, but also to do so in an ever-changing environment full of ambiguities while their own responsibilities are expanded.
Strategic Planning Successful organizations know that they must focus their resources on their unique strengths, and health care is no exception. Organizations that focus on a few strategic initiatives, as dis- cussed previously, do so after an intensive planning process. The competitive health care en- vironment and limited resources require organizations to respond to public demands for safe, accessible quality health care.
This is a time-consuming and demanding process and should not be undertaken hurriedly. Put in use, however, a well-thought-out strategic plan guides the organization toward its goals, helps all the staff stay directed, and prevents the organization from responding to inappropriate requests.
A strategic plan projects the organization’s goals and activities into the future, usually two to five years ahead (Schaffner, 2009). Based on the organization’s philosophy and leaders’ as- sessment of their organization and the environment, strategic planning guides the direction the organization is to take.
The philosophy is a written statement that reflects the organizational values, vision, and mission (Conway-Morana, 2009). Values are the beliefs or attitudes one has about people, ideas, objects, or actions that form a basis for behavior. Organizations use value statements to identify those beliefs or attitudes esteemed by the organizational leaders.
A vision statement describes the goal to which the organization aspires. The vision state- ment is designed to inspire and motivate employees to achieve a desired state of affairs. “Our vision is to be a regional integrated health care delivery system providing premier health care services, professional and community education, and health care research” is an example of a vision statement for a health care system.
The mission of an organization is a broad, general statement of the organization’s reason for existence. Developing the mission is the necessary first step to designing a strategic plan. “Our mission is to improve the health of the people and communities we serve” is an example of a mission statement that guides decision making for the organization. Purchasing a medical equipment company, for example, might not be considered because it fails to meet the mission of improving the community’s health.
CHAPTER 2 • DESIGNING ORGANIZATIONS 25
The strategic plan is based on the organization’s philosophy, vision, and mission. The first steps in strategic planning are:
● Appoint a strategic planning committee ● Interview key stakeholders ● Conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis ● Develop the plan ● Communicate the plan
People who are enthusiastic, experienced, and committed to the organization are the best representatives to serve on the planning committee. Naysayers can be included once some parts of the plan are formulated. Everyone in the organization must be involved even peripherally. “Buy-in” is critical to the plan’s success.
Stakeholders include physicians, administrators, nurses, ancillary and support staff, and community representatives. They will have differing opinions about what the organization can and should do and provide valuable information unavailable elsewhere.
The SWOT analysis includes assessment of the external and internal environment (Kalisch & Curley, 2008). Data is collected from multiple sources, including stakeholder information.
To develop the plan:
● Determine goals, objectives and strategies ● Assess the projected costs ● Assign responsible units or individuals ● Identify outcome measures and expected dates of completion
Goals are specific statements of what outcome is to be achieved. Goals describe outcomes that are measurable and precise. “Every patient will be satisfied with his or her care” is an example of a goal.
Goals apply to the entire organization, whereas objectives are specific to an individual unit. A nursing objective to meet the above goal might be “Provide appropriate information and ed- ucation to patients from preadmission to discharge.” Strategies follow objectives and specify what actions will be taken. “Implement patient education classes for prenatal patients” is an example of a strategy to meet the patient satisfaction objective.
Other categories in a strategic plan include identifying the personnel responsible for each activity, determining the projected cost, establishing criteria to recognize that the goal has been met, and deciding the expected date of completion.
Strategic planning is an ongoing process, not an end in itself. It requires meticulous atten- tion to how the organization is meeting its goals and, if goals are not met, what the reasons are for the variance. Maybe the goal needs to change, or possibly other personnel should be assigned to the task. Perhaps a change in the environment (reimbursement) or within the organization (shortage of key personnel) requires the goal to be abandoned. Continual evaluation will help the organization target its resources best.
Organizational Environment and Culture The terms organizational environment and organizational culture both describe internal con- ditions in the work setting. Organizational environment is the systemwide conditions that con- tribute to a positive or negative work setting. In 2005, the American Association of Critical-Care Nurses identified six characteristics of a healthy work environment, characteristics that the orga- nization continues to promote (AACN, 2011 ). The characteristics are:
● Skilled communication ● True collaboration ● Effective decision making ● Appropriate staffing ● Meaningful recognition ● Authentic leadership.
26 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
One way to assess the organizational environment is to evaluate the qualities of those hired for key positions in the organization. An organization in which nursing leaders are in- novative, creative, and energetic will tend to operate in a fast-moving, goal-oriented fashion. If humanistic, interpersonal skills are sought in candidates for leadership positions, the or- ganization will focus on human resources, employees, and patient advocacy (Hersey, 2011).
Organizational culture, on the other hand, are the basic assumptions and values held by members of the organization (Sullivan, 2013). These are often known as the unstated “rules of the game.” For example, who wears a lab coat? When is report given? To whom? Is tardiness tolerated? How late is acceptable?
Like environment, organizational culture varies from one institution to the next and subcul- tures and even countercultures, groups whose values and goals differ significantly from those of the dominant organization, may exist. A subculture is a group that has shared experiences or like interests and values. Nurses form a subculture within health care environments. They share a common language, rules, rituals, dress, and have their own unstated rules. Individual units also can become subcultures.
Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy (Kramer, Schmalenberg, & Maguire, 2010). These organizations retain and recruit independent, ac- countable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organi- zations are adopting consumer-sensitive cultures that require accountability and decision mak- ing from nurses.
What You Know Now • The schools of organizational theory include classical theory, humanistic theory, systems theory, contin-
gency theory, chaos theory, and complexity theory. • Organizations can be viewed as social systems consisting of people working in a predetermined pattern of
relationships who strive toward a goal. The goal of health care organizations is to provide a particular mix of health services.
• Traditional organizational structures include functional, hybrid, matrix, and parallel structures. • Service-line structures organize clinical services around specific patient conditions. • Shared governance provides the framework for empowerment and partnership within the health care
organization. • Accountable care organizations are recent additions to health care design. They can contract with a payer
to provide care to a specific group of patients. • The medical home is one of the patient-centered models where all services are provided by a group of
health care professionals. • Strategic planning is a process used by organizations to focus their resources on a limited number of
activities. • Organizational environment and culture affect the internal conditions of the work setting.
Questions to Challenge You 1. Secure a copy of the organizational chart from your employment or clinical site. Would you describe
the organization the same way the chart depicts it? If not, redraw a chart to illustrate how you see the organization.
2. What organizational structure would you prefer? Think about how you might go about finding an organization that meets your criteria.
3. Organizational theories explain how organizations function. Which theory or theories describes your organization’s functioning? Do you think it is the same theory your organization’s administrators would use to describe it? Explain.
CHAPTER 2 • DESIGNING ORGANIZATIONS 27
4. Have you been involved in strategic planning? If so, explain what happened and how well it worked in directing the organization’s activities.
5. Using the six characteristics of a healthy work environment in the chapter, evaluate the organiza- tion where you work or have clinicals. How well does it rate? What changes would improve the environment?
American Association of Criti- cal Care Nurses (AACN). (2011). AACN standards for establishing and sustaining healthy work environments. Retrieved May 5, 2011 from http://www.aacn. org/WD/HWE/Docs/ HWEStandards.pdf
Ansel, T. C., & Miller, D. W. (2010). Reviewing the land- scape and defining the core competencies needed for a successful accountable care organization. Louisville, KY: Healthcare Strategy Group.
Armstrong, K., Laschinger, H., & Wong, C. (2009). Work- place empowerment and Magnet hospital characteris- tics as predictors of patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62.
Ballard, N. (2010). Factors as- sociated with success and breakdown of shared gov- ernance. Journal of Nursing Administration, 40(10), 411–416.
Berenson, R. A., Hammons, T., Gans, D. H., Zuckerman, S., Merrell, K., Underwood, W. S., & Williams, A. F. (2008). A house is not a home: Keeping patients at the center of practice
redesign. Health Affairs, 27(5), 1219–1230.
Conway-Morana, P. L. (2009). Nursing strategy: What’s your plan? Nursing Man- agement, 40(3), 25–29.
Costello, D. (2008). Report from the field: A checkup for retail medicine. Health Af- fairs, 27(5), 1299–1303.
Gamble, K. H. (2009). Con- necting the dots: Patient flow systems are being leveraged to increase throughput, improve com- munication, and provide a more complete view of care. Healthcare Informat- ics, 25(13), 27–29.
Handel, D. A., Hilton, J. A., Ward, M. J., Rabin, E., Zwemer, F. L., & Pines, J. M. (2010). Emergency department throughput, crowding, and financial outcomes for hospitals. Academic Emergency Medicine, 17(8), 840–847.
Hayes, H., Parchman, M. L., & Howard, R. (2011). A logic model framework for evaluation and planning in a primary care practice-based research network (PBRN). Journal of the American Board of Family Medicine, 24(5), 576–582.
Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.
Hill, K. S. (2009). Service line structures: Where does this leave nursing? Journal of Nursing Administration, 39(4), 147–148.
Institute of Medicine (2001). Crossing the quality chasm: A new health sys- tem for the 21st century. Retrieved October 24, 2011 from http://www. iom.edu/Reports/2001/ Crossing-the-Quality- Chasm-A-New-Health- System-for-the-21st- Century.aspx
Joint Commission (2011). Edition standards. Retrieved May 12, 2011 from http:// www.jcrinc.com/ E-dition-Home/Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: Issues and observations. International Journal of Quality in Health Care, 21(5), 341–347.
Kalisch, B. J., and Curley, M. (2008). Transforming a nursing organization. Jour- nal of Nursing Administra- tion, 38(2), 76–83.
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
References
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28 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
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http://www.hfma.org/Templates/InteriorMaster.aspx?id=1523
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www.beckershospitalreview.com/news-analysis/challenges-facing-10-hospital-service-lines.html
CHAPTER
Traditional Models of Care FUNCTIONAL NURSING
TEAM NURSING
TOTAL PATIENT CARE
PRIMARY NURSING
Integrated Models of Care PRACTICE PARTNERSHIPS
CASE MANAGEMENT
CRITICAL PATHWAYS
DIFFERENTIATED PRACTICE
Evolving Models of Care PATIENT-CENTERED CARE
SYNERGY MODEL OF CARE
CLINICAL MICROSYSTEMS
CHRONIC CARE MODEL
Delivering Nursing Care 3
Chronic care model Clinical microsystems
Critical pathways Patient-centered care
Practice partnership Synergy model of care
Key Terms
1. Describe how the delivery system structures nursing care.
2. Describe what types of nursing care delivery systems exist.
3. Discuss the positive and negative aspects of different systems.
4. Describe evolving types of delivery systems that have emerged.
5. Explain characteristics of effective delivery systems.
Learning Outcomes After completing this chapter, you will be able to:
30 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
T he core business of a health care organization is providing nursing care to patients. The purpose of a nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to a specified group of patients. The delivery of care
includes assessing care needs, formulating a plan of care, implementing the plan, and evaluating the patient’s responses to interventions. This chapter describes how nursing care is organized to ensure quality care in an era of cost containment.
Since World War II, nursing care delivery systems have undergone continuous and significant changes (Box 3-1). Over the years, various nursing care delivery systems have been tried and critiqued. Debates regarding the pros and cons of each method have focused on identifying the perfect delivery system for providing nursing care to patients with varying degrees of need.
In addition, a delivery system must utilize specific nurses and groups of nurses, optimizing their knowledge and skills while at the same time ensuring that patients receive appropriate care. It’s no small challenge. In fact, researchers have found that a better hospital environment for nurses is associ- ated with lower mortality rates (Aiken et al., 2008) and nurse satisfaction (Spence-Laschinger, 2008).
Traditional Models of Care Functional Nursing Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to a national nursing shortage (see Figure 3-1). The number of registered nurses (RNs) serving in the armed forces during World War II depleted the supply of nurses at home. As a result of this loss of RNs, the composition of nursing staffs in hospitals changed. Staff that had been composed almost entirely of RNs gave way to the widespread use of licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs) to deliver nursing care.
In functional nursing, the needs of a group of patients are broken down into tasks that are assigned to RNs, LPNs, or UAPs so that the skill and licensure of each caregiver is used to his or her best advantage. Under this model an RN assesses patients whereas others give baths, make beds, take vital signs, administer treatments, and so forth. As a result, the staff become very efficient and effective at performing their regular assigned tasks.
BOX 3-1 Job Description of a Floor Nurse (1887)
Developed in 1887 and published in a magazine of Cleveland Lutheran Hospital.
In addition to caring for your 50 patients, each nurse will follow these regulations:
1. Daily sweep and mop the floors of your ward, dust the patients’ furniture and window sills.
2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business.
3. Light is important to observe the patient’s condi- tion. Therefore, each day fill kerosene lamps, clean chimneys, and trim wicks. Wash windows once a week.
4. The nurse’s notes are important to aiding the phy- sician’s work. Make your pens carefully. You may whittle nibs to your individual taste.
5. Each nurse on day duty will report every day at 7 A.M. and leave at 8 P.M., except on the Sabbath, on which you will be off from 12 noon to 2 P.M.
6. Graduate nurses in good standing with the Direc- tor of Nurses will be given an evening off each week for courting purposes, or two evenings a week if you go regularly to church.
7. Each nurse should lay aside from each pay a goodly sum of her earnings for her benefits during her declining years, so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.
8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the Director of Nurses good reason to suspect her worth, intentions, and integrity.
9. The nurse who performs her labor, serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents a day providing there are no hospital debts that are outstanding.
CHAPTER 3 • DELIVERING NURSING CARE 31
Disadvantages of functional nursing include:
● Uneven continuity ● Lack of holistic understanding of the patient ● Problems with follow-up
Because of these problems, functional nursing care is used infrequently in acute care facilities and only occasionally in long-term care facilities.
Team Nursing Team nursing (Figure 3-2) evolved from functional nursing and has remained popular since the middle to late 1940s. Under this system, a team of nursing personnel provides total patient care to a group of patients. In some instances, a team may be assigned a certain number of patients; in others, the assigned patients may be grouped by diagnoses or provider services.
The size of the team varies according to physical layout of the unit, patient acuity, and nurs- ing skill mix. The team is led by an RN and may include other RNs, LPNs, and UAPs. Team members provide patient care under the direction of the team leader. The team, acting as a uni- fied whole, has a holistic perspective of the needs of each patient. The team speaks for each patient through the team leader.
Typically, the team leader’s time is spent in indirect patient care activities, such as:
● Developing or updating nursing care plans ● Resolving problems encountered by team members ● Conducting nursing care conferences ● Communicating with physicians and other health care personnel
With team nursing, the unit nurse manager consults with team leaders, supervises patient care teams, and may make rounds with all physicians. To be effective, team nursing requires that all team members have good communication skills. A key aspect of team nursing is the nursing care conference, where the team leader reviews with all team members each patient’s plan of care and progress.
Charge nurse
UAP responsible for transportation
UAP responsible for vital signs
UAP with bath duty
Treatment nurse
Medication nurse
Patients
Figure 3-1 • Functional nursing.
Charge nurse
Team/module leaderTeam/module leaderTeam/module leader
RN, LPN, UAP RN, LPN, UAP RN, LPN, UAP
Patients Patients Patients
Figure 3-2 • Team/modular nursing.
32 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Advantages of team nursing are:
● It allows the use of LPNs and UAPs to carry out some functions (e.g., making beds, trans- porting patients, collecting some data) that do not require the expertise of an RN.
● It allows patient care needs requiring more than one staff member, such as patient trans- fers from bed to chair, to be easily coordinated.
● The geographical boundaries of team nursing help save steps and time.
Disadvantages of team nursing are:
● A great deal of time is needed for the team leader to communicate, supervise, and coordi- nate team members.
● Continuity of care may suffer due to changes in team members, leaders, and patient assignments.
● No one person considers the total patient. ● There may be role confusion and resentment against the team leader, who staff may
view as more focused on paperwork and less directed at the physical or real needs of the patient.
● Nurses have less control over their assignments due to the geographical boundaries of the unit.
● Assignments may not be equal if they are based on patient acuity or may be monotonous if nurses continuously care for patients with similar conditions (e.g., all patients with hip replacements).
Skills in delegating, communicating, and problem solving are essential for a team leader to be effective. Open communication between team leaders and the nurse manager is also im- portant to avoid duplication of effort, overriding of delegated assignments, or competition for control or power. Problems in delegation and communication are the most common reasons why team nursing is less effective than it theoretically could be.
Total Patient Care The original model of nursing care delivery was total patient care, also called case method (Figure 3-3), in which a registered nurse was responsible for all aspects of the care of one or more patients. During the 1920s, total patient care was the typical nursing care delivery system. Student nurses often staffed hospitals, whereas RNs provided total care to the patient at home. In total patient care, RNs work directly with the patient, family, physician, and other health care staff in implementing a plan of care.
The goal of this delivery system is to have one nurse give all care to the same patient(s) for the entire shift. Total patient care delivery systems are typically used in areas requiring a high level of nursing expertise, such as in critical care units or postanesthesia recovery areas.
The advantages of a total patient care system include:
● Continuous, holistic, expert nursing care ● Total accountability for the nursing care of the assigned patient(s) for that shift ● Continuity of communication with the patient, family, physician(s), and staff from other
departments
Charge nurse
RNRNRN
Patients Patients Patients
Figure 3-3 • Total patient care.
CHAPTER 3 • DELIVERING NURSING CARE 33
The disadvantage of this system is that RNs spend some time doing tasks that could be done more cost-effectively by less skilled persons. This inefficiency adds to the expense of using a total patient care delivery system.
Primary Nursing Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team nursing, primary nursing (Figure 3-4) was designed to place the registered nurse back at the patient’s bedside (Manthey, 1980). Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility and authority for nursing care allocated to staff nurses at the bedside. Primary nursing recognized that nursing was a knowledge-based profes- sional practice, not just a task-focused activity.
In primary nursing, the RN maintains a patient load of primary patients. A primary nurse designs, implements, and is accountable for the nursing care of patients in the patient load for the duration of the patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses (other RNs).
Primary nursing advanced the professional practice of nursing significantly because it provided:
● A knowledge-based practice model ● Decentralization of nursing care decisions, authority, and responsibility to the staff nurse ● 24-hour accountability for nursing care activities by one nurse ● Improved continuity and coordination of care ● Increased nurse, patient, and physician satisfaction.
Primary nursing also has some disadvantages, including:
● It requires excellent communication between the primary nurse and associate nurses. ● Primary nurses must be able to hold associate nurses accountable for implementing the
nursing care as prescribed. ● Because of transfers to different units, critically ill patients may have several primary care
nurses, disrupting the continuity of care inherent in the model. ● Staff nurses are neither compensated nor legally responsible for patient care outside their
hours of work. ● Associates may be unwilling to take direction from the primary nurse.
Although the concept of 24-hour accountability is worthwhile, it is a fallacy. When primary nursing was first implemented, many organizations perceived that it required an all–RN staff. This practice was viewed as not only expensive but also ineffective because many tasks could be done by less skilled persons. As a result, many hospitals discontinued the use of primary nurs- ing. Other hospitals successfully implemented primary nursing by identifying one nurse who was assigned to coordinate care and with whom the family and physician could communicate, and other nurses or unlicensed assistive personnel assisted this nurse in providing care.
Patient
Other health care providers
Primary nurse Charge nurse
Associate nurse Associate nurse
Figure 3-4 • Primary nursing.
34 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Integrated Models of Care Practice Partnerships The practice partnership (Figure 3-5) was introduced by Marie Manthey in 1989 (Manthey, 1989). In the practice partnership model, an RN and an assistant—UAP, LPN, or less experi- enced RN—agree to be practice partners. The partners work together with the same schedule and the same group of patients. The senior RN partner directs the work of the junior partner within the limits of each partner’s abilities and within limits of the state’s nurse practice act.
The relationship between the senior and junior partner is designed to create synergistic en- ergy as the two work in concert with patients. The senior partner performs selected patient care activities but delegates less specialized activities to the junior partner. When compared to team nursing, practice partnerships offer more continuity of care and accountability for patient care. When compared to total patient care or primary nursing, partnerships are less expensive for the organization and more satisfying professionally for the partners.
Disadvantages of this model are:
● Organizations tend to increase the number of UAPs and decrease the ratio of professional nurses to nonprofessional staff. If, for example, one UAP is assigned to more than one RN, the UAP must follow the instructions of several people, making a synergistic relation- ship with any one of them difficult.
● Another problem is the potential for the junior member of the team to assume more responsibility than appropriate. Senior partners must be careful not to delegate inappropriate tasks to junior partners.
Practice partnerships can be applied to primary nursing and used in other nursing care delivery systems, such as team nursing, modular nursing, and total patient care. As organizations restructured, practice partnerships offered an efficient way of using the skills of a mix of professional and nonprofessional staff with differing levels of expertise.
Case Management Following the introduction and impact of prospective payments, nursing case management, used for decades in community and psychiatric settings, was adopted for acute inpatient care. Nursing case management (Figure 3-6) is a model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired patient care outcomes within a specified period of time. Nursing case management organizes patient care by major diagnoses or diagnosis-related groups (DRGs) and focuses on attaining predetermined patient outcomes within specific time frames and resources.
Nursing case management requires:
● Collaboration of all members of the health care team ● Identification of expected patient outcomes within specific time frames ● Use of principles of continuous quality improvement (CQI) and variance analysis ● Promotion of professional practice.
Case manager
Patient caseload
Caregivers CaregiversCaregivers
Figure 3-6 • Case management.
RN
Patients
Partner
Figure 3-5 • Practice partnerships.
CHAPTER 3 • DELIVERING NURSING CARE 35
In an acute care setting, the case manager has a caseload of 10 to 15 patients and follows patients’ progress through the system from admission to discharge, accounting for variances from expected progress. One or more nursing case managers on a patient care unit may coordi- nate, communicate, collaborate, problem solve, and facilitate patient care for a group of patients. Ideally, nursing case managers have advanced degrees and considerable experience in nursing.
After a specific patient population is selected to be “case managed,” a collaborative prac- tice team is established. The team, which includes clinical experts from appropriate disciplines (e.g., nursing, medicine, physical therapy) needed for the selected patient population, defines the expected outcomes of care for the patient population. Based on expected patient outcomes, each member of the team, using his or her discipline’s contribution, helps determine appropriate interventions within a specified time frame.
To initiate case management, specific patient diagnoses that represent high-volume, high- cost, and high-risk cases are selected. High-volume cases are those that occur frequently, such as total hip replacements on an orthopedic floor. High-risk cases include patients or case types who have complications, stay in a critical care unit longer than two days, or require ventilatory support. Patients also may be selected because they are treated by one particular physician who supports case management.
Whatever patient population is selected, baseline data must be collected and analyzed first. These data provide the information necessary to measure the effectiveness of case management. Essential baseline data include length of stay, cost of care, and complication information.
Five elements are essential to successful implementation of case management:
● Support by key members of the organization (administrators, physicians, nurses) ● A qualified nurse case manager ● Collaborative practice teams ● A quality management system ● Established critical pathways (see next section)
In case management, all professionals are equal members of the team; thus, one group does not determine interventions for other disciplines. All members of the collaborative practice team agree on the final draft of the critical pathways, take ownership of patient outcomes, and accept responsibility and accountability for the interventions and patient outcomes associated with their discipline. The emphasis must be on managing interdisciplinary outcomes and building consensus with physicians. In addition, outcomes must be specified in measurable terms.
Critical Pathways Successful case management relies on critical pathways to guide care. The term critical path, also called a care map, refers to the expected outcomes and care strategies developed by the col- laborative practice team. Again, interdisciplinary consensus must be reached and specific, and measurable outcomes determined.
Critical paths provide direction for managing the care of a specific patient during a specified time period. Critical paths are useful because they accommodate the unique characteristics of the patient and the patient’s condition. Critical paths use resources appropriate to the care needed and, thus, reduce cost and length of stay. Critical paths are used in every setting where health care is delivered.
A critical path quickly orients the staff to the outcomes that should be achieved for the patient for that day. Nursing diagnoses identify the outcomes needed. If patient outcomes are not achieved, the case manager is notified and the situation analyzed to determine how to modify the critical path.
Altering time frames or interventions is categorized as a variance, and the case manager tracks all variances. After a time, the appropriate collaborative practice teams analyze the vari- ances, note trends, and decide how to manage them. The critical pathway may need to be revised or additional data may be needed before changes are made.
36 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Some features are included on all critical paths, such as specific medical diagnosis, the expected length of stay, patient identification data, appropriate time frames (in days, hours, minutes, or visits) for interventions, and patient outcomes. Interventions are presented in modality groups (medications, nursing activity, and so on). The critical path must include a means to identify variances easily and to determine whether the outcome has been met.
Differentiated Practice Differentiated practice is a method that maximizes nursing resources by focusing on the struc- ture of roles and functions of nurses according to their education, experience, and competence. Differentiated practice is designed to identify distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions.
In differentiated practice, the responsibilities of RNs (mainly those with bachelor’s and as- sociate degrees) differ according to the competence and training associated with the two edu- cation levels as well as the nurses’ experience and preferences. The scope of nursing practice and level of responsibility are specifically defined for each level. Some organizations differenti- ate roles, responsibilities, and tasks for professional nurses, licensed practical nurses, and unli- censed assistive personnel, which are incorporated into their respective job descriptions.
Evolving Models of Care Recognizing the need for improving patient care, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement established a program titled Transforming Care at the Bedside (IHI, 2009). The goal was, and continues to be, to help hospitals achieve affordable and lasting improvements to care (Lavizzo-Mourey & Berwick, 2009). One of its premises is the use of a patient-centered care model.
Patient-Centered Care Patient-centered care is a model of nursing care delivery in which the role of the nurse is broadened to coordinate a team of multifunctional unit-based caregivers. In patient-centered care, all patient care services are unit-based, including admission and discharge, diagnostic and treatment services, and support services, such as environmental and nutrition services and medical records. The focus of patient-centered care is decentralization, the promotion of efficiency and quality, and cost control.
In this model of care, the number of caregivers at the bedside is reduced, but their responsibilities are increased so that service time and waiting time are decreased. A typical team in a unit providing patient-centered care consists of:
● Patient care coordinators (RNs) ● Patient care associates or technicians who are able to perform delegated patient care tasks ● Unit support assistants who provide environmental services and can assist with hygiene
and ambulation needs ● Administrative support personnel who maintain patient records, transcribe orders,
coordinate admission and discharge, and assist with general office duties
Success using a patient-centered care model continues to be reported in the literature (Miles & Vallish, 2010; Schneider & Fake, 2010). Furthermore, lower mortality in patients with acute myocardial infarctions has been found (Meterko et al., 2010). Patients with chronic conditions are appropriate candidates for patient-centered care approaches, including the use of complementary and alternative medicine therapies (Maizes, Rakel, & Niemiec, 2009).
The nurse manager’s role in patient-centered care requires considerable time. No longer is the manager doing rounds and assisting with patient care. Instead, being responsible for a staff that is more diverse with fewer professional RN staff demands a strong leader proficient to
CHAPTER 3 • DELIVERING NURSING CARE 37
interview, hire, train, and motivate staff. Some organizations share assistive staff between units, also increasing the need for more communication and coordination with other managers.
Synergy Model of Care Developed by the American Association of Critical Nurses, the American Association of Critical Care Nurses conceptualizes nursing practice based on the needs and characteristics of patients (AACN, 2011). These characteristics drive nurse competencies. Patient characteristics include:
● Resiliency ● Vulnerability ● Stability ● Complexity ● Resource availability ● Participation in care ● Participation in decision making ● Predictability
These characteristics are then matched with nurse competencies, including:
● Clinical judgment ● Advocacy and moral agency ● Caring practices ● Collaboration ● Systems thinking ● Response to diversity ● Facilitation of learning ● Clinical inquiry (AACN, 2011)
When patients’ characteristics and nurses’ competencies match, synergy is the outcome. The model is useful to nurses by delineating job descriptions, evaluation formats, and advancement criteria. Furthermore, a synergy model helps meet the standards for Magnet certification (Kaplow & Reed, 2008).
Clinical Microsystems Clinical microsystems are a recent addition to care delivery structures. Clinical microsystems evolved from the belief that decision making is best given to those involved in the smallest unit of care. Thus, a clinical microsystem is a small unit of care that maintains itself over time.
Clinical microsystems include the following elements:
● Core team of caregivers ● Defined population to receive care ● Informational system for both patients and caregivers ● Support staff, equipment and facilitative environment
The clinical microsystem model has been shown to be effective in neonatal intensive care units (Reis, Scott, & Rempel, 2009) and to increase quality improvement projects among medical residents (Tess et al., 2009). Additionally, using a clinical nurse leader improved quality outcomes in a hospital using a clinical microsystem model (Hix, McKeon, & Walters, 2009).
Chronic Care Model So far our discussion of delivery systems has focused on hospital nursing care. Increasingly, however, care is being delivered in ambulatory care environments. Additionally, most of the patients cared for in those environments suffer from chronic health conditions. The chronic care model addresses these concerns.
38 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
The goal of the chronic care model is not to manage a disease but to change how daily care is delivered by clinical teams (Coleman et al., 2009). Instead of reacting to changes in the patient’s condition, the team provides proactive interventions. The model is systematic and re- quires six components. They are:
● Self-management support ● Decision support ● Delivery system design ● Clinical information systems ● Health care organization ● Community resources
Given that the population is aging and chronic conditions are expected to rise, the chronic care model is an appropriate one to consider for providing care to patients with chronic illnesses.
No delivery system is perfect. Or permanent. As health care adapts to changes in reimbursement, demands for quality, and technological advances, models for delivering care will continue to evolve.
What You Know Now • Nursing care delivery systems provide a structure for nursing care. Most organizations use a combina-
tion of nursing care delivery systems or modify one or more systems to meet their own needs. • Traditional care models include functional nursing, team nursing, total patient care, and primary nursing. • Integrated models of care include practice partnerships, case management, critical pathways, and differen-
tiated practice. • Evolving models of care include patient-centered care, a synergy model of care, clinical microsystems,
and a chronic care model. • Commonly used by Magnet-certified hospitals, the patient-centered care model provides care from admit-
ting to discharge on the unit. • The synergy model, developed by the American Association of Critical Care Nurses, matches patients’
characteristics with nurses’ competencies. • Clinical microsystems use a structure that puts decision making in small units of those who provide the care. • The chronic care model is a systemwide, proactive model designed to provide daily care to patients by
clinical teams. • As health care adapts to changes in reimbursement, demands for quality, and technological advances,
models for delivering care will continue to evolve.
Questions to Challenge You 1. Describe the patient care delivery system(s) at your place of work or clinical placement site. How
well does it work? Can you suggest a better system? 2. Pretend that you are designing a new nursing care delivery system. Select the system or combination
of systems you would use. Explain your rationale. 3. Why have different systems been used in earlier times? Would any of them be useful today? Explain what
characteristics of the health care system today would make them appropriate or inappropriate to use. 4. As a manager, which system would you prefer? Why? 5. If you were a patient, which system do you think would provide you with the best care?
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
www.nursing.pearsonhighered.com
CHAPTER 3 • DELIVERING NURSING CARE 39
References Aiken, L. H., Clarke, S. P.,
Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse out- comes. Journal of Nursing Administration, 38(5), 223–229.
American Association of Critical Care Nurses (AACN) (2011). The AACN synergy model for patient care. Retrieved May 9, 2011 from http://www.aacn.org/ WD/Certifications/Docs/ SynergyModelforPatient- Care.pdf
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75–85.
Hix, C., McKeon, L., and Walters, S. (2009). Clini- cal nurse leader impact on clinical microsystems outcomes. Journal of Nurs- ing Administration, 39(2), 71–76.
Institute for Healthcare Improvement (IHI) (2009). IHI Collaborative: Trans- forming care at the bedside. Retrieved May 9, 2011 from http://www.ihi.org/IHI/ Programs/Collaboratives/ TransformingCareatthe Bedside.htm.
Kaplow, R., & Reed, K. D. (2008). The AACN synergy model for patient care: A nursing model as a force of magnetism. Nursing Economics, 26(1), 17–25.
Lavisso-Mourey, R., & Berwick, D. M. (2009). Nurses trans- forming care. American Journal of Nursing, 109(11), 3.
Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered care. Explore: The Journal of Science & Healing, 5(5), 277–289.
Manthey, M. (1980). The prac- tice of primary nursing. St. Louis: Mosby.
Manthey, M. (1989). Practice partnerships: The newest concept in care delivery. Journal of Nursing Associa- tion, 19(2), 33–35.
Meterko, M., Wright, S., Lin, H., Lowy, E., & Cleary, P. D. (2010). Mortality among patients with acute myocardial infarction: The influences of patient- centered care and evidence- based medicine. Health Services Research, 45(5), 1188–1204.
Miles, K. S., & Vallish, R. (2010). Creating a personal- ized professional practice framework for nursing.
Nursing Economics, 28(3), 171–189.
Reis, M. D., Scott, S. D., & Rempel, G. R. (2009). Including parents in the evaluation of clinical microsystems in the neonatal intensive care unit. Advances in Neonatal Care, 9(4), 174–179.
Schneider, M. A., & Fake, P. (2010). Implementing a relationship-based care model on a large orthopaedic/neurosurgical hospital unit. Orthopaedic Nursing, 29(6), 374–378.
Spence-Laschinger, H. K. (2008). Effect of empow- erment on professional practice environment, work satisfaction, and patient care quality: Further testing the nursing work life model. Journal of Nursing Care Quality, 23(4), 322–330.
Tess, A. V., Yang, J. J., Smith, C., Fawcett, C. M., Bates, C. K., & Reynolds, E. E. (2009). Combining clinical microsystems and an experiential quality im- provement curriculum to improve residency educa- tion in internal medicine. Academic Medicine, 84(3), 326–334.
http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf
http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf
http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf
http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm
http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm
http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm
http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf
http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm
Charge nurse Clinical nurse leader Controlling Directing Emotional intelligence First-level manager
Followership Formal [leadership] Informal [leadership] Leader Manager Organizing
Planning Quantum leadership Servant leadership Shared leadership Transactional leadership Transformational leadership
Key Terms
1. Explain why every nurse is a manager and can be a leader.
2. Differentiate between leaders and managers.
3. Discuss how different theories explain leadership and management.
4. Describe what management roles nurses fill in practice.
5. Discuss how followership is essential to leadership.
6. Describe what makes a leader successful.
Learning Outcomes After completing this chapter, you will be able to:
Leaders and Managers
Leadership
Traditional Leadership Theories Contemporary Theories
QUANTUM LEADERSHIP
TRANSACTIONAL LEADERSHIP
TRANSFORMATIONAL LEADERSHIP
SHARED LEADERSHIP
SERVANT LEADERSHIP
EMOTIONAL LEADERSHIP
Traditional Management Functions
PLANNING
ORGANIZING
DIRECTING
CONTROLLING
Nurse Managers in Practice NURSE MANAGER
COMPETENCIES
STAFF NURSE
FIRST-LEVEL MANAGEMENT
CHARGE NURSE
CLINICAL NURSE LEADER
Followership: An Essential Component of Leadership
What Makes a Successful Leader?
Leading, Managing, Following4
CHAPTER
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 41
M anagers are essential to any organization. A manager’s functions are vital, com-plex, and frequently difficult. They must be directed toward balancing the needs of patients, the health care organization, employees, physicians, and self. Nurse managers need a body of knowledge and skills distinctly different from those needed for nurs- ing practice, yet few nurses have the education or training necessary to be managers. Frequently, managers depend on experiences with former supervisors, who also learned supervisory tech- niques on the job. Often a gap exists between what managers know and what they need to know.
Today, all nurses are managers, not in the formal organizational sense but in practice. They direct the work of nonprofessionals and professionals in order to achieve desired outcomes in patient care. Acquiring the skills to be both a leader and a manager will help the nurse become more effective and successful in any position.
Leaders and Managers Manager, leader, supervisor, and administrator are often used interchangeably, yet they are not the same. A leader is anyone who uses interpersonal skills to influence others to accomplish a specific goal. The leader exerts influence by using a flexible repertoire of personal behaviors and strategies. The leader is important in forging links—creating connections—among an organiza- tion’s members to promote high levels of performance and quality outcomes.
The functions of a leader are to achieve a consensus within the group about its goals, main- tain a structure that facilitates accomplishing the goals, supply necessary information that helps provide direction and clarification, and maintain group satisfaction, cohesion, and performance.
A manager, in contrast, is an individual employed by an organization who is responsible and accountable for efficiently accomplishing the goals of the organization. Managers focus on coordinating and integrating resources, using the functions of planning, organizing, supervising, staffing, evaluating, negotiating, and representing. Interpersonal skill is important, but a man- ager also has authority, responsibility, accountability, and power defined by the organization. The manager’s job is to:
● Clarify the organizational structure ● Choose the means by which to achieve goals ● Assign and coordinate tasks, developing and motivating as needed ● Evaluate outcomes and provide feedback
All good managers are also good leaders—the two go hand in hand. However, one may be a good manager of resources and not be much of a leader of people. Likewise, a person who is a good leader may not manage well. Both roles can be learned; skills gained can enhance either role.
Leadership Leadership may be formal or informal. Leadership is formal when practiced by a nurse with legitimate authority conferred by the organization and described in a job description (e.g., nurse manager, supervisor, coordinator, case manager). Formal leadership also depends on personal skills, but it may be reinforced by organizational authority and position. Insightful formal lead- ers recognize the importance of their own informal leadership activities and the informal leader- ship of others who affect the work in their areas of responsibility.
Leadership is informal when exercised by a staff member who does not have a speci- fied management role. A nurse whose thoughtful and convincing ideas substantially influ- ence the efficiency of work flow is exercising leadership skills. Informal leadership depends primarily on one’s knowledge, status (e.g., advanced practice nurse, quality improvement coordinator, education specialist, medical director), and personal skills in persuading and guiding others.
42 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Traditional Leadership Theories Research on leadership has a long history, but the focus has shifted over time from personal traits to behavior and style, to the leadership situation, to change agency (the capacity to trans- form), and to other aspects of leadership. Each phase and focus of research has contributed to managers’ insights and understandings about leadership and its development. Traditional leader- ship theories include trait theories, behavioral theories, and contingency theories.
In the earliest studies researchers sought to identify inborn traits of successful leaders. Although inconclusive, these early attempts to specify unique leadership traits provided bench- marks by which most leaders continue to be judged.
Research on leadership in the early 1930s focused on what leaders do. In the behavioral view of leadership, personal traits provide only a foundation for leadership; real leaders are made through education, training, and life experiences.
Contingency approaches suggest that managers adapt their leadership styles in relation to changing situations. According to contingency theory, leadership behaviors range from au- thoritarian to permissive and vary in relation to current needs and future probabilities. A nurse manager may use an authoritarian style when responding to an emergency situation such as a cardiac arrest but use a participative style to encourage development of a team strategy to care for patients with multiple system failure.
The most effective leadership style for a nurse manager is the one that best complements the organizational environment, the tasks to be accomplished, and the personal characteristics of the people involved in each situation.
Contemporary Theories Leaders in today’s health care environment place increasing value on collaboration and team- work in all aspects of the organization. They recognize that as health systems become more complex and require integration, personnel who perform the managerial and clinical work must cooperate, coordinate their efforts, and produce joint results. Leaders must use additional skills, especially group and political leadership skills, to create collegial work environments.
Quantum Leadership Quantum leadership is based on the concepts of chaos theory (see Chapter 2). Reality is constantly shifting, and levels of complexity are constantly changing. Movement in one part of the system reverberates throughout the system. Roles are fluid and outcome oriented. It matters little what you did; it only matters what outcome you produced. Within this framework, employees become di- rectly involved in decision making as equitable and accountable partners, and managers assume more of an influential facilitative role, rather than one of control (Porter-O’Grady & Malloch, 2010).
Quantum leadership demands a different way of thinking about work and leadership. Change is expected. Informational power, previously the purview of the leader, is now available to all. Patients and staff alike can access untold amounts of information. The challenge, however, is to assist patients, uneducated about health care, how to evaluate and use the information they have. Because staff have access to information only the leader had in the past, leadership be- comes a shared activity, requiring the leader to possess excellent interpersonal skills.
Transactional Leadership Transactional leadership is based on the principles of social exchange theory. The primary premise of social exchange theory is that individuals engage in social interactions expecting to give and receive social, political, and psychological benefits or rewards. The exchange process between leaders and followers is viewed as essentially economic. Once initiated, a sequence of exchange behavior continues until one or both parties finds that the exchange of performance and rewards is no longer valuable.
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 43
The nature of these transactions is determined by the participating parties’ assessments of what is in their best interests; for example, staff respond affirmatively to a nurse manager’s re- quest to work overtime in exchange for granting special requests for time off. Leaders are suc- cessful to the extent that they understand and meet the needs of followers and use incentives to enhance employee loyalty and performance. Transactional leadership is aimed at maintaining equilibrium, or the status quo, by performing work according to policy and procedures, maxi- mizing self-interests and personal rewards, emphasizing interpersonal dependence, and routin- izing performance (Weston, 2008).
Transformational Leadership Transformational leadership goes beyond transactional leadership to inspire and motivate fol- lowers (Marshall, 2010). Transformational leadership emphasizes the importance of interper- sonal relationships. Transformational leadership is not concerned with the status quo, but with effecting revolutionary change in organizations and human service. Whereas traditional views of leadership emphasize the differences between employees and managers, transformational lead- ership focuses on merging the motives, desires, values, and goals of leaders and followers into a common cause. The goal of the transformational leader is to generate employees’ commitment to the vision or ideal rather than to themselves.
Transformational leaders appeal to individuals’ better selves rather than these individuals’ self-interests. They foster followers’ inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes. Transformational leaders also encourage others to exercise leader- ship. The transformational leader inspires followers and uses power to instill a belief that follow- ers also have the ability to do exceptional things.
Transformational leadership may be a natural model for nursing managers, because nurs- ing has traditionally been driven by its social mandate and its ethic of human service. In fact, Weberg (2010) found that transformational leadership reduced burnout among employees, and Grant et al., (2010) reports transformational leadership positively affected the practice environ- ment in one medical center. Transformational leadership can be used effectively by nurses with clients or coworkers at the bedside, in the home, in the community health center, and in the health care organization.
Shared Leadership Reorganization, decentralization, and the increasing complexity of problem solving in health care have forced administrators to recognize the value of shared leadership, which is based on the empowerment principles of participative and transformational leadership (Everett & Sitterding, 2011). Essential elements of shared leadership are relationships, dialogues, partnerships, and understanding boundaries. The application of shared leadership assumes that a well-educated, highly professional, dedicated workforce is comprised of many leaders. It also assumes that the notion of a single nurse as the wise and heroic leader is unrealistic and that many individuals at various levels in the organization must be responsible for the organization’s fate and performance.
Different issues call for different leaders, or experts, to guide the problem-solving process. A single leader is not expected always to have knowledge and ability beyond that of other mem- bers of the work group. Appropriate leadership emerges in relation to the current challenges of the work unit or the organization. Individuals in formal leadership positions and their colleagues are expected to participate in a pattern of reciprocal influence processes. Kramer, Schmalenberg, and Maguire (2010) and Watters (2009) found shared leadership common in Magnet-certified hospitals.
Examples of shared leadership in nursing include:
● Self-directed work teams. Work groups manage their own planning, organizing, schedul- ing, and day-to-day work activities.
● Shared governance. The nursing staff are formally organized at the service area and orga- nizational levels to make key decisions about clinical practice standards, quality assurance
44 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
and improvement, staff development, professional development, aspects of unit opera- tions, and research. Decision making is conducted by representatives of the nursing staff who have been authorized by the administrative hierarchy and their colleagues to make decisions about important matters.
● Co-leadership. Two people work together to execute a leadership role. This kind of lead- ership has become more common in service-line management, where the skills of both a clinical and an administrative leader are needed to successfully direct the operations of a multidisciplinary service. For example, a nurse manager provides administrative leader- ship in collaboration with a clinical nurse specialist, who provides clinical leadership. The development of co-leadership roles depends on the flexibility and maturity of both indi- viduals, and such arrangements usually require a third party to provide ongoing consulta- tion and guidance to the pair.
Servant Leadership Founded by Robert Greenleaf (Greenleaf, 1991), servant leadership is based on the premise that leadership originates from a desire to serve and that in the course of serving, one may be called to lead (Keith, 2008; The Greenleaf Center for Servant Leadership, 2011). Servant leaders embody three characteristics:
● Empathy ● Awareness ● Persuasion (Neill & Saunders, 2008)
Servant leadership appeals to nurses for two reasons. First, our profession is founded on principles of caring, service, and the growth and health of others (Anderson et al., 2010). Sec- ond, nurses serve many constituencies, often quite selflessly, and consequently bring about change in individuals, systems, and organizations.
Emotional Leadership Social intelligence (Goleman, 2007), including emotional intelligence (Bradberry & Greaves, 2009; Goleman, 2006), has gained acceptance in the business world and more recently in health care (Veronsesi, 2009). Emotional intelligence involves personal competence, which includes self-awareness and self-management, and social competence, which includes social awareness and relationship management that begins with authenticity. (See Table 4-1.)
Goleman (2007) asserts that attachment to others is an innate trait of human beings. Thus, emotions are “catching.” Consider a person having a pleasant day. Then an otherwise innocuous event turns into a negative experience that spills over into future interactions. Or the reverse. A positive experience lightens the mood and affects the next encounter. When people feel good, they work more effectively.
Emotional intelligence has been linked with leadership (Antonakis, Ashkanasy, & Dasbor- ough, 2009; Cote et al., 2010; Lucas, Spence-Laschinger, & Wong, 2008). One study, however, found no relationship between emotional intelligence and transformational leadership (Linde- baum & Cartwright, 2010).
Nurses, with their well-honed skills as compassionate caregivers, are aptly suited to this direction in leadership that emphasizes emotions and relationships with others as a primary at- tribute for success. These skills fit better with the more contemporary relationship-oriented theo- ries as well. Thus, the workplace is a more complex and intricate environment than previously suggested. The following chapters show you how to put these skills to work.
Health care environments require innovations in care delivery and therefore innovative lead- ership approaches. Quantum, transactional, transformational, shared, servant, and emotional leadership make up a new generation of leadership styles that have emerged in response to the need to humanize working environments and improve organizational performance. In practice, leaders tap a variety of styles culled from diverse leadership theories.
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 45
TABLE 4-1 AONE Five Areas of Competency
AONE BELIEVES THAT MANAGERS AT ALL LEVELS MUST BE COMPETENT IN THE FOLLOWING:
COMMUNICATION AND RELATIONSHIPS-BUILDING COMPETENCIES INCLUDE: ● Effective communication ● Relationship management ● Influence of behaviors ● Ability to work with diversity ● Shared decision making ● Community involvement ● Medical staff relationships ● Academic relationships
KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT INCLUDES: ● Clinical practice knowledge ● Patient care delivery models and work design knowledge ● Health care economics knowledge ● Health care policy knowledge ● Understanding of governance ● Understanding of evidence-based practice ● Outcome measurement ● Knowledge of and dedication to patient safety ● Understanding of utilization/case management ● Knowledge of quality improvement and metrics ● Knowledge of risk management
LEADERSHIP SKILLS INCLUDE: ● Foundational thinking skills ● Personal journey disciplines ● The ability to use systems thinking ● Succession planning ● Change management
PROFESSIONALISM INCLUDES: ● Personal and professional accountability ● Career planning ● Ethics ● Evidence-based clinical and management practice ● Advocacy for the clinical enterprise and for nursing practice ● Active membership in professional organizations
BUSINESS SKILLS INCLUDE: ● Understanding of health care financing ● Human resource management and development ● Strategic management ● Marketing ● Information management and technology
Copyright © 2005 by the American Organization of Nurse Executives. Address reprint permission requests to [email protected].
Traditional Management Functions In 1916, French industrialist Henri Fayol first described the functions of management as planning, organizing, directing, and controlling. These are still relevant today, however, the complexity of today’s health care systems make these functions more difficult and less certain (Clancy, 2008).
46 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Planning Planning is a four-stage process to:
● Establish objectives (goals) ● Evaluate the present situation and predict future trends and events ● Formulate a planning statement (means) ● Convert the plan into an action statement
Planning is important on both an organizational and a personal level and may be an in- dividual or group process that addresses the questions of what, why, where, when, how, and by whom. Decision making and problem solving are inherent in planning. Numerous computer software programs and databases are available to help facilitate planning.
Organization-level plans, such as determining organizational structure and staffing or operational budgets, evolve from the mission, philosophy, and goals of the organization. The nurse manager plans and develops specific goals and objectives for her or his area of responsibility.
Antonio, the nurse manager of a home care agency, plans to establish an in-home photo- therapy program, knowing that part of the agency’s mission is to meet the health care needs of the child-rearing family. To effectively implement this program, he would need to address:
• How the program supports the organization’s mission
• Why the service would benefit the community and the organization
• Who would be candidates for the program
• Who would provide the service
• How staffing would be accomplished
• How charges would be generated
• What those charges should be
Planning can be contingent or strategic. Using contingency planning, the manager identifies and manages the many problems that interfere with getting work done. Contingency planning may be re- active, in response to a crisis, or proactive, in anticipation of problems or in response to opportunities.
What would you do if two registered nurses called in sick for the 12-hour night shift? What if you were a manager for a specialty unit and received a call for an admission, but had no more beds? Or what if you were a pediatric oncology clinic manager and a patient’s sibling exposed a number of immunocompromised patients to chickenpox? Planning for crises such as these are examples of contingency planning.
Strategic planning refers to the process of continual assessment, planning, and evaluation to guide the future (Fairholm & Card, 2009). Its purpose is to create an image of the desired future and design ways to make those plans a reality. A nurse manager might be charged, for example, with developing a business plan to add a time-saving device to commonly used equipment, pre- senting the plan persuasively, and developing operational plans for implementation, such as ac- quiring devices and training staff.
Organizing Organizing is the process of coordinating the work to be done. Formally, it involves identifying the work of the organization, dividing the labor, developing the chain of command, and assign- ing authority. It is an ongoing process that systematically reviews the use of human and material resources. In health care, the mission, formal organizational structure, delivery systems, job de- scriptions, skill mix, and staffing patterns form the basis for the organization.
In organizing the home phototherapy project, Antonio develops job descriptions and pro- tocols, determines how many positions are required, selects a vendor, and orders supplies.
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 47
Directing Directing is the process of getting the organization’s work done. Power, authority, and leader- ship style are intimately related to a manager’s ability to direct. Communication abilities, moti- vational techniques, and delegation skills also are important. In today’s health care organization, professional staff are autonomous, requiring guidance rather than direction. The manager is more likely to sell the idea, proposal, or new project to staff rather than tell them what to do. The manager coaches and counsels to achieve the organization’s objectives. In fact, it may be the nurse who assumes the traditional directing role when working with unlicensed personnel.
In directing the home phototherapy project, Antonio assembles the team of nurses to provide the service, explains the purpose and constraints of the program, and allows the team to decide how they will staff the project, giving guidance and direction when needed.
Controlling Controlling involves comparing actual results with projected results. This includes establishing standards of performance, determining the means to be used in measuring performance, evaluat- ing performance, and providing feedback. The efficient manager constantly attempts to improve productivity by incorporating techniques of quality management, evaluating outcomes and per- formance, and instituting change as necessary.
Today, managers share many of the control functions with the staff. In organizations us- ing a formal quality improvement process, such as continuous quality improvement (CQI), staff participate in and lead the teams. Some organizations use peer review to control quality of care.
When Antonio introduces the home phototherapy program, the team of nurses involved in the program identify standards regarding phototherapy and their individual performances. A subgroup of the team routinely reviews monitors designed for the program and identifies ways to improve the program.
Planning, organizing, directing, and controlling reflect a systematic, proactive approach to management. This approach is used widely in all types of organizations, health care included, but Clancy (2008) asserts that today’s rapidly changing health care environment makes it more difficult to control events and predict outcomes.
Nurse Managers in Practice Putting nursing management into practice in the dynamic health care system of today is a chal- lenge. Organizations are in flux, structures are changing, and roles and functions of nurse man- agers become moving targets.
Titles for nurse managers vary as widely as do their responsibilities. The first level manager may be titled first-line manager or unit manager. A middle manager might be deemed a depart- ment manager. The top-level nursing administrator could be named executive manager, chief nursing officer, or vice president of patient care. In addition, clinical titles might include profes- sional practice leaders who are clinical nurse specialists or nurse practitioners. Regardless of their titles, all nurse managers must hold certain competencies.
Nurse Manager Competencies The American Organization of Nurse Executives (AONE), an organization for the top nursing administrators in health care, identified five areas of competency necessary for nurses at all lev- els of management (AONE, 2005). Nurse managers must be skilled communicators and rela- tionship builders, have a knowledge of the health care environment, exhibit leadership skills, display professionalism, and demonstrate business skills (see Table 4-2). These characteristics intersect to provide a common core of leadership competencies (see Figure 4-1).
48 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
TABLE 4-2 Emotional Intelligence Domains and Associated Competencies
PERSONAL COMPETENCE: These capabilities determine how we manage ourselves.
Self-Awareness • Emotional self-awareness: Reading one’s own emotions and recogniz- ing their impact; using “gut sense” to guide decisions
• Accurate self-assessment: Knowing one’s strengths and limits • Self-confidence: A sound sense of one’s self-worth and capabilities
Self-Management • Emotional self-control: Keeping disruptive emotions and impulses under control
• Transparency: Displaying honesty and integrity; trustworthiness • Adaptability: Flexibility in adapting to changing situations or over-
coming obstacles • Achievement: The drive to improve performance to meet inner stan-
dards of excellence • Initiative: Readiness to act and seize opportunities • Optimism: Seeing the upside in events
SOCIAL COMPETENCE: These capabilities determine how we manage relationships.
Social Awareness • Empathy: Sensing others’ emotions, understanding their perspective, and taking active interest in their concerns
• Organizational awareness: Reading the currents, decision networks, and politics at the organizational level
• Service: Recognizing and meeting follower, client, or customer needs
Relationship Management
• Inspirational leadership: Guiding and motivating with a compelling vision
• Influence: Wielding a range of tactics for persuasion • Developing others: Bolstering others’ abilities through feedback and
guidance • Change catalyst: Initiating, managing, and leading in a new direction • Conflict management: Resolving disagreements • Building bonds: Cultivating and maintaining a web of relationships • Teamwork and collaboration: Cooperation and team building
From Goleman, D., Boyatsis, R., & McKee, A. Primal Leadership (2002). Boston: Harvard Business School Press, 39. Copyright © 2002 by the Harvard Business School Publishing Corporation; all rights reserved.
Staff Nurse Although not formally a manager, the staff nurse supervises LPNs, other professionals, and assistive personnel and so is also a manager who needs management and leadership skills. Com- munication, delegation, and motivation skills are indispensable.
In some organizations, shared governance has been implemented and traditional manage- ment responsibilities are allocated to the work team. In this case, staff nurses have considerable involvement in managing the unit. More information about shared governance and other innova- tive management methods is provided in Chapter 2.
First-Level Management The first-level manager is responsible for supervising the work of nonmanagerial personnel and the day-to-day activities of a specific work unit or units. With primary responsibility for motivat- ing the staff to achieve the organization’s goals, the first-level manager represents staff to upper administration, and vice versa. Nurse managers have 24-hour accountability for the management of a unit(s) or area(s) within a health care organization. In the hospital setting, the first-level
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 49
manager is usually the head nurse, nurse manager, or an assistant. In other settings, such as an ambulatory care clinic or a home health care agency, a first-level manager may be referred to as a coordinator. Box 4-1 describes a first-level manager’s day.
Charge Nurse Another role that does not fit the traditional levels of management is the charge nurse. The charge nurse position is an expanded staff nurse role with increased responsibility. The charge nurse functions as a liaison to the nurse manager, assisting in shift-by-shift coordination and promotion of quality patient care as well as efficient use of resources. The charge nurse of- ten troubleshoots problems and assists other staff members in decision making. Role modeling, mentoring, and educating are additional roles that the charge nurse often assumes. Therefore, the charge nurse usually has extensive experience, skills, and knowledge in clinical practice and is familiar with the organization’s standards and practices.
The charge nurse’s job differs, though, from that of the first-level manager. The charge nurse’s responsibilities are confined to a specific shift or task, whereas the first-level manager has 24-hour responsibility and accountability for all unit activities. Also the charge nurse has limited authority; the charge nurse functions as an agent of the manager and is accountable to the manager for any actions taken or decisions made.
Although often involved in planning and organizing the work to be done, the charge nurse has a limited scope of responsibility, usually restricted to the unit for a specific time period. In the past, the charge nurse had limited involvement in the formal evaluation of performance, but in today’s climate of efficiency, the charge nurse may be involved in evaluations as well. With the trend toward participative management, charge nurses are assuming more of the roles and functions traditionally reserved for the first-level manager.
In some organizations, the position may be permanent and assigned and thus a part of the formal management team; in other organizations, the job may be rotated among experienced staff. The charge nurse, who switches from serving as a manager one day and a staff nurse the next, is especially challenged to balance the rotating roles (Leary & Allen, 2005). In some orga- nizations, a differential amount of compensation is paid to the person performing charge duties; in others, no differential is paid because the position is shared equally among staff or represents a higher rung of a career ladder (possibly the first rung of a management ladder).
The charge nurse is often key to a unit’s successful functioning (Leary & Allen, 2005). A charge nurse usually has considerable influence with the staff and may actually have more infor- mal power than the manager. Therefore, the charge nurse is an important leader and can benefit by developing the skills considered necessary for a manager. Acting as charge nurse is often the first step toward a formal management position.
Professionalism Communication & relationship management
Business skills and principles
Knowledge of health care environment
Leadership
Figure 4-1 • Core of leadership competencies. Source: Copyright © 2005 by the American Organization of Nurse Executives. Address reprint permission requests to [email protected].
50 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Clinical Nurse Leader The clinical nurse leader is not a manager, per se, but instead is a lateral integrator of care re- sponsible for a specified group of clients within a microsystem of the health care setting (AACN, 2007). The CNL role is designed to respond more effectively to challenges in today’s rapidly changing, complex technological environment (Harris & Roussel, 2009). Prepared at the mas- ter’s level, the CNL coordinates care at the bedside and supervises the health care team, among other duties (Sherman, 2010).
Use of the clinical nurse leader positions in health care organizations has improved patient outcomes and reduced costs and is expected to expand as the demand for quality continues (Hix, McKeon, & Walters, 2009; Stanley et al., 2008). Problems have emerged, however, as CNLs transition into organizations. These include being drawn into direct patient care, explaining the role to other nurses and health care providers, and acceptance by the staff (Sherman, 2010).
BOX 4-1 A Day in the Life of a First-Level Manager
As the manager for a surgical intensive care unit (SICU), Jamal Johnson is routinely responsible for supervising patient care, trouble shooting, maintain- ing compliance with standards, and giving guidance and direction as needed. In addition, he has fiscal and committee responsibilities and is accountable to the organization for maintaining its philosophies and ob- jectives. The following exemplifies a typical day.
As Jamal came on duty, he learned that there had been a multiple vehicle accident and that three of the victims were currently in the operating room and destined for the unit. The assistant manager for nights had secured more staff for days: two part-time SICU nurses and a staff nurse from the surgical floor. However, she had not had time to arrange for two more patients to be moved out of the unit. From their assigned nurses, Jamal obtained an update on the pa- tients who were candidates for transfer from the SICU to another floor and, in consultation with his assistant, made the appropriate arrangements for the transfers.
Other staffing problems were at hand: in addition to the nurse who had been pulled from the surgical floor, there were two orientees, and the staff needed to attend a safety in-service. As soon as the charge nurse came in, Jamal apprised her of the situation. Together, they reviewed the operating room schedule and identified staffing arrangements. Fortunately, Jamal had only one meeting today and would be avail- able for backup staffing. In the meantime, he would work on evaluations.
After his discussions with the charge nurse, Jamal met with each of the night nurses to get an update on the status of the other patients. Then he went to his office to review his messages and plan his day. Tamera, an RN, had just learned she was pregnant but stated that she planned to work until delivery. Jamal learned that his budget hearing had been scheduled for the following Monday at 10 A.M. A pharmaceutical
representative wanted to provide an in-service for the unit. Fortunately, there were no immediate crises.
Jamal called his supervisor to inform her of the status of affairs on the unit and learned that two other individuals in the accident had been transported to another hospital; one had since died. They discussed the ethical and legal ramifications. Jamal would need to review the policies on relations with the press and law enforcement and update his staff.
As the first patient returned from surgery, Jamal went to help admit the patient and receive a report. Learning that the patient was stable, he informed Lu- cinda, the charge nurse, that the patient they had just received was likely to be charged with manslaughter and reviewed media and legal policies with her. They also discussed how the staff were doing. There were some equipment problems in room 2110; Lucinda had temporarily placed the patient in that room on a transport monitor and was waiting for a biomedi- cal technology staff member to check the monitor. Could Jamal follow up? Jamal agreed and commended Lucinda for her problem solving. She reminded Jamal they would need backup for lunch and in-services.
As Jamal returned to his office, he noted that the alarms were turned off on one of the patients. He pulled aside the nurse assigned to the patient and re- minded her of the necessity to keep the alarms on at all times. Finally, back in his office, he called biomedical technology to ascertain their plans to check the monitor and made notes regarding the charge nurse’s problem- solving abilities and the staff nurse’s negligence.
He reviewed staffing for the next 24 hours and noted that an extra nurse was needed for both the evening and night shifts because of the increased workload. After finding staff, he was able to finish one evaluation before covering for the in-services and lunch and then attending the policy and procedure team meeting.
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 51
Questions about the differences between a clinical nurse specialist and the CNL are also raised. While the CNS is assigned hospital-wide, the CNL is unit based. Ignatius (2010) sug- gests that hospitals are designed for the 19th century with little accommodation for the coordina- tion of care needed in this century. CNLs can help bridge that gap.
Followership: An Essential Component of Leadership Leaders cannot lead without followers in much the same way that instructors need students to teach. Nor is anyone a leader all the time; everyone is a follower as well. Even the hospital CEO follows the board of directors’ instructions.
Followership is interactive and complementary to leadership, and the follower is an active participant in the relationship with the leader. A skilled, self-directed, energetic staff member is an invaluable complement to the leader and to the group. Most leaders welcome active follow- ers; they help leaders accomplish their goals and the team succeed.
Followers are powerful contributors to the relationship with their leaders. Followers can in- fluence leaders in negative ways, as government cover-ups, Medicare fraud, and corporate law- breaking attest. The reverse is also true. Poor managers can undermine good followers by direct and indirect ways, such as criticizing, belittling, or ignoring positive contributions to the team (Arnold & Pulich, 2008). To counter such behaviors, you should note incidents that you experi- ence, enlist others to help, and remain in control of yourself. (See Chapter 21 for more about handling difficult problems, such as bullying.)
Miller (2007) describes followership along two continuums: participative and thinking. Par- ticipation can vary from passive (ineffective follower) to active (successful follower). Thinking can fluctuate between dependent and uncritical to independent and critical. Courage to be active contributors to the team and to the leader characterizes the effective follower.
Followership is fluid in another way. The nurse may be a leader at one moment and become a follower soon afterward. In fact, the ability to move along the continuum of degrees of fol- lowership is a must for successful teamwork. The nurse is a leader with subordinate staff and a follower of the nurse manager, possibly at the same time.
A constructive follower has several positive characteristics:
● Self-directed ● Proactive ● Supportive ● Commitment ● Initiative
Many of these qualities are the same ones that make an excellent leader, discussed next.
What Makes a Successful Leader? Leadership success is an elusive quality. Some people seem to be natural leaders, and others struggle to attain leadership skills.
See how one nurse leader described her work:
I believe that the most important role of a nurse leader is to live the life and exemplify at all times the qualities that every professional nurse leader should. I also believe the nurse leader/manager must be the person to set the bar high and perform at the highest levels in order to inspire their staff to achieve the same.
As a nurse manager, I at all times work to be an excellent communicator, compassionate, caring, vested in my job, willing to go above and beyond, and assist people with any task or issue they just need a little extra support on. I feel that by doing this, there is never a question what I expect from them and those around me. I verbally set expectations, but by living them as a role model.
52 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
For example, at shift change two nights ago, a physician wanted to do a bedside proce- dure. I was actually planning on leaving soon after a long day. I knew it was shift change, and didn’t want the staff to be interrupted, so I volunteered to stay and do the procedure so they could continue with report and the physician and patient were not kept waiting. The staff were very appreciative, but more importantly, I think it set the right example of teamwork, being flexible, being patient focused, etc.
I think it is important for the nurse leader to provide feedback at times other than evalu- ations. The nurse leader should schedule time into the workweek to have informal conver- sations with staff on the floor about comments a patient or coworker has shared or to send an e-mail to a staff member about feedback the leader has received. I think constructive feedback needs to be timely and supportive and the need for improvement discussed long before an evaluation.
I find having conversations about “What are your goals?” or “What can I help you explore or do that you’ve been dreaming about to enhance your nursing career?” People need to feel comfortable having these conversations with their trusted nurse leader. Build- ing relationships with those you lead is important.
Leaders are skilled in empowering others, creating meaning and facilitating learning, developing knowledge, thinking reflectively, communicating, solving problems, making deci- sions, and working with others. Leaders generate excitement; they clearly define their purpose and mission. Leaders understand people and their needs; they recognize and appreciate differ- ences in people, individualizing their approach as needed.
What You Know Now • A leader employs specific behaviors and strategies to influence individuals and groups to attain goals. • Managers are responsible for efficiently accomplishing the goals of the organization. • Leadership approaches are not static; they can be adapted for different situations, tasks, individuals, and
future expectations. • Contemporary theorists assert that reality is fluid, complex, and interrelated and that interpersonal
relationships are core to successful leadership. • Traditional management functions include planning, organizing, directing, and controlling. • Both leaders and followers contribute to the effectiveness of their relationship. • Successful leaders inspire and empower others, generate excitement, and individualize their approach to
differences in people.
Tools for Leading, Managing, and Following 1. Pay attention to the context: Are you leading, managing, or following in this situation? 2. Recognize that each situation requires a specific skill set. Each is described in the chapter. 3. Notice others whose leadership style you admire and try to incorporate their behaviors in your own
leadership if the situation is appropriate. 4. Evaluate yourself at regular opportunities in order to find ways to improve your abilities to lead,
manage, and follow.
Questions to Challenge You 1. Think about people you know in management positions. Are any of them leaders as well?
Describe the characteristics that make them leaders. 2. Consider people you know who are not in management positions but are leaders nonetheless.
What characteristics do they have that make them leaders?
CHAPTER 4 • LEADING, MANAGING, FOLLOWING 53
References
3. Describe the manager to whom you report. (If you are not employed, use the first-level manager on a clinical placement site.) Evaluate this person using the management functions described in the chapter.
4. Imagine yourself as a manager whether you are in a management position or not. What skills do you possess that help you? What skills would you like to improve?
5. Evaluate yourself as a follower. Find at least one characteristic listed in the chapter that you would like to develop or improve. During the next week, try to find opportunities to practice that skill.
6. Assess yourself as a leader. How would you like to improve?
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
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54 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
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CHAPTER
Why Change?
The Nurse as Change Agent
Change Theories
The Change Process ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Change Strategies POWER-COERCIVE STRATEGIES
EMPIRICAL–RATIONAL MODEL
NORMATIVE–REEDUCATIVE STRATEGIES
Resistance to Change
The Nurse’s Role INITIATING CHANGE
IMPLEMENTING CHANGE
Handling Constant Change
Initiating and Managing Change 5
Key Terms Change Change agent Driving forces
1. Explain why nurses have the opportunity to be change agents.
2. Describe how different theorists explain change.
3. Discuss how the change process is similar to the nursing process.
4. Differentiate among change strategies. 5. Discuss how to handle resistance to
change. 6. Describe the nurse’s role in change.
Learning Outcomes After completing this chapter, you will be able to:
Empirical–rational model Normative–reeducative
strategies
Power-coercive strategies Restraining forces Transitions
56 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Why Change? Change is inevitable, if not always welcome. Organizational change is essential for adaptation; creative change is mandatory for growth (Heath & Heath, 2010). Change, though, is a continu- ally unfolding process rather than an either/or event. The process begins with the present state, is disrupted, moves through a transition period, and ultimately comes to a desired state. Once the desired state has been reached, however, the process begins again.
Leading change is never needed more in today’s rapidly evolving system of health care. Those who initiate and manage change often encounter resistance. Even when planned, it can be threatening and a source of conflict because change is the process of making something different from what it was. There is a sense of loss of the familiar, the status quo. This is particu- larly true when change is unplanned or beyond human control. Even when change is expected and valued, a grief reaction still may occur.
Although nurses should understand and anticipate these reactions to change, they need to develop and exude a different approach. They can view change as a challenge and encourage their colleagues to participate. They can become uncomfortable with the status quo and be willing to take risks.
This is a particular fortuitous time for the nursing profession (Nickitas, 2010). The Institute of Medicine’s report on the future of nursing proposes radical change for the profession (IOM, 2010). Specifically, they propose:
● Nurses should practice to the full extent of their education and training. ● Nurses should achieve higher levels of education and training through an improved
education system that promotes seamless academic progression. ● Nurses should be full partners with physicians and other health care professionals in
redesigning health care in the United States. ● Effective workforce planning and policymaking require better data collection and an
improved information infrastructure.
Furthermore, the IOM makes eight recommendations:
● Remove scope-of-practice barriers. ● Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. ● Implement nurse residency programs. ● Increase the proportion of nurses with baccalaureate degrees to 80 percent by 2020. ● Ensure nurses engage in lifelong learning. ● Prepare and enable nurses to lead change to advance health. ● Build an infrastructure for the collection and analysis of interprofessional health care
workforce data (IOM, 2010).
The Nurse as Change Agent A change agent is one who works to bring about a change. Being a change agent, however, is not easy. Although the end result of change may benefit nurses and patients alike, initially it requires time, effort, and energy, all in short supply in the high-stress environment of health care.
Several recent reports document nurses’ roles in facilitating change. Holtrop et al. (2008) found that nurse consultants improved healthy behaviors in patients served by 10 primary care practices in two health care systems. Also, MacDavitt, Cieplincki, and Walker (2011) report that small changes in communication resulted in improved patient satisfaction on a pediatric inpatient unit. Finally, McMurray et al. (2010) found that nurse managers played a key role in implementing successful change in bedside handover in two hospitals.
Changes will continue at a rapid pace with or without nursing’s expert guidance. Nurses, like organizations, cannot afford merely to survive changes. If they are to exist as a distinct pro- fession that has expertise in helping individuals respond to actual or potential health problems,
CHAPTER 5 • INITIATING AND MANAGING CHANGE 57
they must be proactive in shaping the future. Opportunities exist now for nurses, especially those in management positions, to change the system about which they so often complain.
Change Theories Because change occurs within the context of human behavior, understanding how change does (or doesn’t) occur is helpful in learning how to initiate or manage change. Five theories explain the change process from a social–psychological viewpoint. See Table 5-1 for a comparison.
Lewin (1951) proposes a force-field model, shown in Figure 5-1. He sees behavior as a dynamic balance of forces working in opposing directions within a field (such as an organiza- tion). Driving forces facilitate change because they push participants in the desired direction. Restraining forces impede change because they push participants in the opposite direction.
To plan change, one must analyze these forces and shift the balance in the direction of change through a three-step process: unfreezing, moving, and refreezing. Change occurs by add- ing a new force, changing the direction of a force, or changing the magnitude of any one force. Basically, strategies for change are aimed at increasing driving forces, decreasing restraining forces, or both. The image of people’s attitudes thawing and then refreezing is conceptually use- ful. This symbolism helps to keep theory and reality in mind simultaneously.
Lippitt and colleagues (1958) extended Lewin’s theory to a seven-step process and focused more on what the change agent must do than on the evolution of change itself. (See Table 5-1.) They emphasized participation of key members of the target system throughout the change pro- cess, particularly during planning. Communication skills, rapport building, and problem-solving strategies underlie their phases.
Havelock (1973) described a six-step process, also a modification of Lewin’s model. Have- lock describes an active change agent as one who uses a participative approach.
Rogers (2003) takes a broader approach than Lewin, Lippitt, or Havelock (see Table 5-1). His five-step innovation–decision process details how an individual or decision-making unit
Figure 5-1 • Lewin’s force-field model of change. Adapted from Resolving Social Conflicts and Field Theory in Social Science by K. Lewin. Copyright © 1997, by the American Psychological Association. Adapted with permission.
Restraining forces
Driving forces
Example:
Fear of job loss
Nurse manager lacks change agent skills
Entrenched director of
nurses
Present (status quo)
Force will be toward change
Budget in red (financial incentive
to change)
Administration mandates the
change
Interested vice-president
Need new solution (old one doesn’t work)
Some long-term employees
resist change
Almost complete turnover of staff
(many new nurses)
Restraining forces
Driving forces
(unfreezing) (Refreezing)
New equilibrium
MovingPresent equilibrium (status quo)
Restraining forces
Driving forces
58 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
passes from first knowledge of an innovation to confirmation of the decision to adopt or reject a new idea. His framework emphasizes the reversible nature of change: participants may initially adopt a proposal but later discontinue it, or the reverse—they may initially reject it but adopt it at a later time. This is a useful distinction. If the change agent is unsuccessful in achieving full implementation of a proposal, it should not be assumed the issue is dead. It can be resurrected, perhaps in an altered form or at a more opportune time.
Rogers stresses two important aspects of successful planned change: key people and policy makers must be interested in the innovation and committed to making it happen. Erwin (2009) found that organizational change in hospitals could only be successful and sustained if senior administrators were fully committed to the change.
Used primarily as a tool for patient teaching, Prochaska and DiClemente (2005) proposed a transtheoretical model of behavior change. Five stages characterize their model. The stages occur in sequence, and the person must be ready for change to occur, according to this model.
The Change Process Steps in the change process follow the same path as the nursing process: assessment, planning, implementation, and evaluation (see Table 5-2).
Assessment Emphasis is placed on the assessment phase of change for two reasons. Without data collection and analysis, planned change will not proceed past the “wouldn’t it be a good idea if” stage.
Identify the Problem or the Opportunity Change is often planned to close a discrepancy between the desired and actual state of affairs. Discrepancies may arise because of problems in reaching performance goals or because new goals have been created.
Opportunities demand change as much as (or more than) problems do, but they are often overlooked. Be it a problem or an opportunity, it must be identified clearly. If the issue is perceived differently by key individuals, the search for solutions becomes confused.
TABLE 5-1 Comparison of Change Models
Lewin Lippitt Havelock Rogers Prochaska & DiClemente
1. Unfreezing 1. Diagnose problem 1. Building a relationship 1. Knowledge 1. Precontemplation
2. Moving 2. Assess motivation 2. Diagnosing the problem 2. Persuasion 2. Contemplation
3. Refreezing 3. Assess change agent’s motivations and resources
3. Acquiring resources
4. Choosing the solution
3. Decision
4. Implementation
3. Preparation
4. Action 4. Select progressive change
objects
5. Choose change agent role
5. Gaining acceptance
6. Stabilization and self- renewal
5. Confirmation 5. Maintenance
6. Maintain change
7. Terminate helping relationships
CHAPTER 5 • INITIATING AND MANAGING CHANGE 59
Start by asking the right questions, such as:
1. Where are we now? What is unique about us? What should our business be?
2. What can we do that is different from and better than what our competitors do?
3. What is the driving stimulus in our organization? What determines how we make our final decisions?
4. What prevents us from moving in the direction we wish to go?
5. What kind of change is required?
This last question generates integrative thinking on the potential effect of change on the system. Organizational change involves modifications in the system’s interacting components: technology, structure, and people.
Introducing new technology changes the structure of the organization. The physical plant may be altered if new services are added and then relationships among the people who work in the system change when the structure is changed. Surveillance cameras, cell phones, mag- netic entry cards, bar codes, and communication technology, including social media, have al- tered the care environment as much as they’ve changed our personal world. New rules and regulations, new authority structures, and new budgeting methods may emerge. They, in turn, change staffing needs, requiring people with different skills, knowledge bases, attitudes, and motivations.
Collect Data Once the problem or opportunity has been clearly defined, the change agent collects data external and internal to the system. This step is crucial to the eventual success of the planned change. All driving and restraining forces are identified so the driving forces can be emphasized and the restraining forces reduced. It is imperative to assess the political pulse. Who will gain from this change? Who will lose? Who has more power and why? Can those power bases be altered? How?
Assess the political climate by examining the reasons for the present situation. Who in control may be benefiting now? Egos, commitment of the involved people, and personal likes and dislikes are as important to assess as the formal organizational structures and processes. The innovator has to gauge the potential for resistance.
The costs and benefits of the proposed change are obvious focal points. Also assess resources—especially those the manager can control. A manager who has the respect and support of an excellent nursing staff has access to a powerful resource in today’s climate.
TABLE 5-2 Steps in the Change Process
1. Identify the problem or opportunity.
2. Collect necessary data and information.
3. Select and analyze data.
4. Develop a plan for change, including time frame and resources.
5. Identify supporters or opposers.
6. Build a coalition of supporters.
7. Help people prepare for change.
8. Prepare to handle resistance.
9. Provide a feedback mechanism to keep everyone informed of the progress of change.
10. Evaluate effectiveness of the change and, if successful, stabilize the change.
60 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Analyze Data The kinds, amounts, and sources of data collected are important, but they are useless unless they are analyzed. The change agent should focus more energy on analyzing and summarizing the data than on just collecting it. The point is to flush out resistance, identify potential solutions and strategies, begin to identify areas of consensus, and build a case for whichever option is selected.
At a not-for-profit hospital in the process of seeking Magnet status, each service line is looking for opportunities to improve standards of care, efficiency, and patient safety. In the ambulatory surgery center, the process of providing preoperative services was often slow and inefficient. The surgery center nurses were charged with finding ways to improve efficiency.
Planning Planning the who, how, and when of the change is a key step. What will be the target system for the change? Members from this system should be active participants in the planning stage. The more involved they are at this point, the less resistance there will be later. Lewin’s unfreezing imagery is relevant here. Present attitudes, habits, and ways of thinking have to soften so mem- bers of the target system will be ready for new ways of thinking and behaving. Boundaries must melt before the system can shift and restructure.
This is the time to make people uncomfortable with the status quo. Plant the seeds of dis- content by introducing information that may make people feel dissatisfied with the present and interested in something new. This information comes from the data collected (e.g., research findings, quantitative data, and patient satisfaction questionnaires or staff surveys). Couch the proposed change in comfortable terms as far as possible, and minimize anxiety about the new change.
Managers need to plan the resources required to make the change and establish feedback mechanisms to evaluate its progress and success. Establish control points with people who will provide the feedback and work with these people to set specific goals with time frames. Develop operational indicators that signal success or failure in terms of performance and satisfaction.
Three surgery center nurses designed a flow chart of how the process could be improved. They took it to their administration and were put in charge of its implementation.
Implementation The plans are put into motion (Lewin’s moving stage). Interventions are designed to gain the nec- essary compliance. The change agent creates a supportive climate, acts as an energizer, obtains and provides feedback, and overcomes resistance. Managers are the key change-process actors. Some methods are directed toward changing individuals in an organization, whereas others are directed toward changing the group.
Methods to Change Individuals The most common method used to change individuals’ perceptions, attitudes, and values is information giving. Providing information is prerequisite to change implementation, but it is inadequate unless a lack of information is the only obstacle to effecting change. Providing infor- mation does not address the motivation to change.
Training is often considered a method to change individuals. Training combines information-giving with skill practice. Training typically shows people how they are to perform in a system, not how to change it. Therefore, it is a strategy to help make the transition to a planned change rather than a mechanism to initiate change.
Selecting and placing personnel or terminating key people often is used to alter the forces for or against change. When key supporters of the planned change are given the authority and
CHAPTER 5 • INITIATING AND MANAGING CHANGE 61
accountability to make the change, their enthusiasm and legitimacy can be effective in leading others to support the change. Conversely, if those opposed to the change are transferred or leave the organization, the change is more likely to succeed.
Methods to Change Groups Some implementation tactics use groups rather than individuals to attain compliance to change. The power of an organizational group to influence its members depends on its authority to act on an issue and the significance of the issue itself. The greatest influence is achieved when group members discuss issues that are perceived as important and make relevant, binding de- cisions based on those discussions. Effectiveness in implementing organizational change is most likely when groups are composed of members who occupy closely related positions in the organization.
Individual and group implementation tactics can be combined. Whatever methods are used, participants should feel their input is valued and should be rewarded for their efforts. Some people are not always persuaded before a beneficial change is implemented. Sometimes behav- ior changes first, and attitudes are modified later to fit the behavior. In this case, the change agent should be aware of participants’ conflicts and reward the desired behaviors. It may take some time for attitudes to catch up.
The surgery center nurses worked with physician offices, insurance companies, and other hospital departments to implement the new process for preoperative services.
Evaluation Evaluate Effectiveness At each control point, the operational indicators established are monitored. The change agent determines whether presumed benefits were achieved from a financial as well as a qualitative perspective, explaining the extent of success or failure. Unintended consequences and undesir- able outcomes may have occurred.
Stabilize the Change The change is extended past the pilot stage, and the target system is refrozen. The change agent terminates the helping relationship by delegating responsibilities to target system members. The energizer role is still needed to reinforce new behaviors through positive feedback.
Over the next three months, the preoperative services department was able to show a 90 percent decrease in duplicate test orders, a 50 percent decrease in patient waiting time, and an 80 percent increase in physician satisfaction with the process.
Change Strategies Regardless of the setting or proposed change, the four-step change process should be followed. However, specific strategies can be used, depending on the amount of resistance anticipated and the degree of power the change agent possesses.
Power-Coercive Strategies Power-coercive strategies are based on the application of power by legitimate authority, economic sanctions, or political clout. Changes are made through law, policy, or financial appropriations. Those in control enforce changes by restricting budgets or creating policies. Those who are not in power may not even be aware of what is happening. Even if they are aware, they have little power to stop it. Health care reform legislation, is an example of power-coercive strategy by the federal government.
62 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Power-coercive strategies are useful when a consensus is unlikely despite efforts to stimulate participation by those involved. When much resistance is anticipated, time is short, and the change is critical for organizational survival, power-coercive strategies may be necessary.
Empirical–Rational Model In the empirical–rational model of change strategies, the power ingredient is knowledge. The assumption is that people are rational and will follow their rational self-interest if that self- interest is made clear to them. It is also assumed that the change agent who has knowledge has the expert power to persuade people to accept a rationally justified change that will benefit them.
The flow of influence moves from those who know to those who do not know. New ideas are invented and communicated or diffused to all participants. Once enlightened, rational people will either accept or reject the idea based on its merits and consequences. Empirical–rational strategies are often effective when little resistance to the proposed change is expected and the change is perceived as reasonable.
Well-researched, cost-effective technology can be implemented using these strategies. In- troducing a new technology that is easy to use, cuts nursing time, and improves quality of care might be accepted readily after in-service education and a trial use. Using bar codes to match medications to patients is another example.
The change agent can direct the change. There is little need for staff participation in the early steps of the change process, although input is useful for the evaluation and stabilization stages. The benefits of change for the staff and research documenting improved patient out- comes are the major driving forces.
Normative–Reeducative Strategies In contrast to the rational-empirical model, normative–reeducative strategies of change rest on the assumption that people act in accordance with social norms and values. Information and rational arguments are insufficient strategies to change people’s patterns of actions; the change agent must focus on noncognitive determinants of behavior as well. People’s roles and relationships, perceptual orientations, attitudes, and feelings will influence their acceptance of change.
In this mode, the power ingredient is not authority or knowledge, but skill in interpersonal relationships. The change agent does not use coercion or nonreciprocal influence, but col- laboration. Members of the target system are involved throughout the change process. Value conflicts from all parts of the system are brought into the open and worked through so change can progress.
Normative–reeducative strategies are well suited to the creative problem solving needed in nursing and health care today. With their firm grasp of the behavioral sciences and communica- tion skills, nurses are comfortable with this model. Changing from a traditional nursing system to self-governance or initiating a home follow-up service for hospitalized patients are examples of changes amenable to the normative–reeducative approach.
In most cases, the normative–reeducative approach to change will be effective in reduc- ing resistance and stimulating personal and organizational creativity. The obvious drawback is the time required for group participation and conflict resolution throughout the change process. When there is adequate time or when group consensus is fundamental to successful adoption of the change, the manager is well advised to adopt this framework.
Resistance to Change Resistance to change is to be expected for a number of reasons: lack of trust, vested interest in the status quo, fear of failure, loss of status or income, misunderstanding, and belief that change
CHAPTER 5 • INITIATING AND MANAGING CHANGE 63
is unnecessary or that it will not improve the situation (Yukl, 2009; Hellriegel, Jackson, & Slocum, 2007). In fact, if resistance does not surface, the change may not be significant enough.
Employees may resist change because they dislike or disapprove of the person responsible for implementing the change or they may distrust the change process. Regardless, managers continually deal with change—both the change that they themselves initiate and change initiated by the larger organization.
Resistance varies from ready acceptance to full-blown resistance. Rogers (2003) identified six responses to change:
● Innovators love change and thrive on it. ● Less radical, early adopters are still receptive to change. ● The early majority prefer the status quo, but eventually accept the change. ● The late majority are resistive, accepting change after most others have. ● Laggards dislike change and are openly antagonistic. ● Rejecters actively oppose and may even sabotage change.
The change agent should anticipate and look for resistance to change. It will be lurking somewhere, perhaps where least expected. It can be recognized in such statements as:
● We tried that before. ● It won’t work. ● No one else does it like that. ● We’ve always done it this way. ● We can’t afford it. ● We don’t have the time. ● It will cause too much commotion. ● You’ll never get it past the board. ● Let’s wait awhile. ● Every new boss wants to do something different. ● Let’s start a task force to look at it; put it on the agenda.
Expect resistance and listen carefully to who says what, when, and in what circumstances. Open resisters are easier to deal with than closet resisters. Look for nonverbal signs of resis- tance, such as poor work habits and lack of interest in the change.
Resistance prevents the unexpected. It forces the change agent to clarify information, keep in- terest level high, and establish why change is necessary. It draws attention to potential problems and encourages ideas to solve them. Resistance is a stimulant as much as it is a force to be overcome. It may even motivate the group to do better what it is doing now, so that it does not have to change.
On the other hand, resistance is not always beneficial, especially if it persists beyond the planning stage and well into the implementation phase. It can wear down supporters and redirect system energy from implementing the change to dealing with resisters. Morale can suffer.
To manage resistance, use the following guidelines:
1. Talk to those who oppose the change. Get to the root of their reasons for opposition.
2. Clarify information, and provide accurate feedback.
3. Be open to revisions but clear about what must remain.
4. Present the negative consequences of resistance (e.g., threats to organizational survival, compromised patient care).
5. Emphasize the positive consequences of the change and how the individual or group will benefit. However, do not spend too much energy on rational analysis of why the change is good and why the arguments against it do not hold up. People’s resistance frequently flows from feelings that are not rational.
64 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
6. Keep resisters involved in face-to-face contact with supporters. Encourage proponents to empathize with opponents, recognize valid objections, and relieve unnecessary fears.
7. Maintain a climate of trust, support, and confidence.
8. Divert attention by creating a different disturbance. Energy can shift to a more important problem inside the system, thereby redirecting resistance. Alternatively, attention can be brought to an external threat to create a bully phenomenon. When members perceive a greater environmental threat (such as competition or restrictive governmental policies), they tend to unify internally.
The Nurse’s Role Initiating Change Contrary to popular opinion, change often is not initiated by top-level management (Yukl, 2009), but rather emerges as new initiatives or problems are identified. Furthermore, Weiner, Amick, and Lee (2008) posit that organizational readiness is the key to initiating change.
Staff nurses often think that they are unable to initiate and create change, but that is not so.
Home health nurses were often frustrated by not having appropriate supplies with them when seeing a patient for the first time. A team of nurses completed a chart audit to iden- tify commonly used supplies and equipment that nurses were using on their home visits. Each nurse was then supplied with a small plastic container to keep in his or her car with these items. Frustration decreased and efficient use of nursing time was improved.
The manager, as well, may resist leading change. Afraid of “rocking the boat,” fearful that no one will join our efforts, recalling that past efforts at change had failed, or even the reluctance to become involved may prevent the nurse from initiating change.
Making change is not easy, but it is a mandatory skill for managers. Successful change agents demonstrate certain characteristics that can be cultivated and mastered with practice. These characteristics include:
● The ability to combine ideas from unconnected sources ● The ability to energize others by keeping the interest level up and demonstrating a high
personal energy level ● Skill in human relations: well-developed interpersonal communication, group manage-
ment, and problem-solving skills ● Integrative thinking: the ability to retain a big picture focus while dealing with each part
of the system ● Sufficient flexibility to modify ideas when modifications will improve the change, but
enough persistence to resist nonproductive tampering with the planned change ● Confidence and the tendency not to be easily discouraged ● Realistic thinking ● Trustworthiness: a track record of integrity and success with other changes ● The ability to articulate a vision through insights and versatile thinking ● The ability to handle resistance
Energy is needed to change a system. Power is the main source of that energy. Informational power, expertise, and possibly positional power can be used to persuade others.
To access optimum power, use the following strategies:
1. Analyze the organizational chart. Know the formal lines of authority. Identify informal lines as well.
2. Identify key persons who will be affected by the change. Pay attention to those immedi- ately above and below the point of change.
CHAPTER 5 • INITIATING AND MANAGING CHANGE 65
3. Find out as much as possible about these key people. What are their “tickle points”? What interests them, gets them excited, turns them off? What is on their personal and organiza- tional agendas? Who typically aligns with whom on important decisions?
4. Begin to build a coalition of support before you start the change process. Identify the key people who will be affected by the change. Talk informally with them to flush out possible objections to your idea and potential opponents. What will the costs and benefits be to them—especially in political terms? Can your idea be modified in ways that retain your objectives but appeals to more key people?
5. Follow the organizational chain of command in communicating with administrators. Don’t bypass anyone to avoid having an excellent proposal undermined.
This information helps you develop the most sellable idea or at least pinpoint probable resistance. It is a broad beginning to the data-collection step of the change process and has to be fine-tuned once the idea is better defined. The astute manager keeps alert at all times to monitor power struggles.
Although a cardinal rule of change is, “Don’t try to change too much too fast,” the savvy manager develops a sense of exquisite timing by pacing the change process according to the political pulse. For example, the manager unfreezes the system during a period of coalition building and high interest, while resistance is low or at least unorganized.
You may decide to stall the project beyond a pilot stage if resistance solidifies or gains a powerful ally. In this case, do whatever you can to reduce resistance. If resistance continues, two options should be considered:
● The change is not workable and should be modified to meet the strongest objections (compromise).
● The change is fine-tuned sufficiently, but change must proceed now and resistance must be overcome.
Implementing Change In addition to initiating change, nurses and nurse managers are called on to assist with change in other ways. They may be involved in the planning stage, charged with sharing information with coworkers, or they may be asked to help manage the transition to planned change.
Planning Change One Magnet-recognized hospital engaged all its nurses in planning for the desired future of clinical nursing in its organization (Capuano et al., 2007). It held a series of group events to so- licit ideas and opinions. Every nurse—executive, manager, or staff nurse—had an equal vote to approve or veto a proposed change. This process illustrates the normative–reeducative process of change.
Managing Transitions to Change Transitions are those periods of time between the current situation and the time when change is implemented (Bridges, 2009). They are the times ripe for a change agent to act. Just as initiating change is not easy, neither is transitioning to changed circumstances.
Letting go of long-term, comfortable activities is difficult. The tendency is to:
● Add new work to the old ● Make individual decisions about what to add and what to let go ● Toss out everything done before (Bridges, 2009)
Accepting loss and honoring the past with respect is essential. Passion for the work is based on results, not activities, regardless of their necessity or effectiveness.
A large national for-profit health care system purchased a new hospital clinical informa- tion system. Because all paper charting would be eliminated, nurses would be directly
66 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
affected. Their participation could spell success or failure for the new system. To help the transition occur smoothly, nurses from each department met together for a demonstration of the new clinical information system and provided feedback to the IT department about nursing process and integrating patient care with the new system. Then a few nurses on each unit were selected to be trained as experts in the new technology, and they in turn trained other staff members, communicating with the IT department when concerns arose.
A nurse manager in a home health care agency used change management strategies to over- come resistance, as shown in Case Study 5-1.
Handling Constant Change Change has always occurred; what’s different today is both the pace of change and that an initial change causes a chain reaction of more and more change (Bridges, 2009). Change, rather than an occasional event, has become the norm.
Regardless of their position in an organization, nurses find themselves constantly dealing with change. Whether they thrive in such an atmosphere is a function of both their own personal resources and the environment in which change occurs.
ENCOURAGING CHANGE Peter Beasley is the nurse manager of pediatric home care for a private home health care agency. Last year, the agency completed a pilot of wireless devices for use in documenting home visits. As nurses complete the documentation, charges for supplies and medical equip- ment are generated. The agency director informed the nurse managers that all nurses will be required to use the wireless devices within the next three months.
Charlene Ramirez has been a pediatric nurse for 18 years, working for the home health care agency for the past 5 years. Charlene has been active in updating the pediatric documentation and training staff when new paper-based documentation was implemented in the past. Although she was part of the pilot, Charlene is very opposed to using the new wireless devices. She complains that she can barely see the text. At a recent staff meeting, Charlene stated she would rather quit than learn to use the new wireless devices.
Peter empathizes with Charlene’s reluctance to use the new technology. He also recognizes how much Char- lene contributes in expertise and leadership to the de- partment. However, he knows that the new performance standards require all employees to use the wireless de- vices. After three mandatory training sessions, Charlene repeatedly tells coworkers “We’ve tried things like this before, it never works. We’ll be back on paper within six months, so why waste my time learning this stuff?” The program trainer reports that Charlene was disruptive dur- ing the class and failed her competency exam.
Peter meets privately with Charlene to discuss her resistance to the new technology. Charlene again states that she fails to see the need for wireless devices in delivering quality patient care. Peter reviews the new performance standards with Charlene, emphasizing the technology requirements. He asks Charlene if she has difficulty understanding the application or just in using the device. Charlene admits she cannot read the text on the screen and therefore cannot determine what exact- ly she is documenting. Peter informs Charlene that the agency’s health benefits include vision exams and par- tial payment for corrective lenses. He suggests that she talk with an optometrist to see if special glasses would help her see the screen. Peter also makes a note to speak with the technology specialist to see if there are aids to help staff view data on the device.
Manager’s Checklist The nurse manager is responsible for:
● Communicating openly and honestly with employees who oppose change.
● Understanding resistance to change. ● Maintaining support and confidence in staff even if
they are resistive to change. ● Emphasizing the positive outcomes from initiating
change. ● Finding solutions to problems that are obstacles to
change.
CASE STUDY 5-1
CHAPTER 5 • INITIATING AND MANAGING CHANGE 67
If you don’t like the current situation, you may look forward to change. As Midwestern- ers are fond of saying when asked about the weather: “If you don’t like it today, just wait until tomorrow. It will change.”
What You Know Now • In today’s health care system, change is inevitable, necessary, and constant. • With changes proposed for the nursing profession, nurses are in a pivotal position to initiate and
participate in change. • For change to be positive for nurses, they must develop change agent skills. • Critical evaluation of change theories provides guidance and direction for initiating and managing change. • The change process is similar to the nursing process and includes assessment, planning, implementation,
and evaluation. • Resistance to change is to be expected, and it can be a stimulant as well as a force to be overcome. • The nurse may be involved in change by initiating it or participating in implementing change. • Handling constant change is a challenge in today’s health care environment.
Tools for Initiating and Managing Change 1. Communicate openly and honestly with employees who oppose change. 2. Maintain support and confidence in staff even if they are resistive to change. 3. Emphasize the positive outcomes from the change. 4. Find solutions to problems that are obstacles to change. 5. Accept the constancy of change.
Questions to Challenge You 1. Identify a needed change in the organization where you practice. Using the change process, outline
the steps you would take to initiate change. 2. Consider your school or college. What change do you think is needed? Explain how you would
change it to become a better place for learning. 3. Have you had an experience with change occurring in your organization? What was your initial
reaction? Did that change? How well did the change process work? Was the change successful? 4. Do you have a behavior you would like to change? Using the steps in the change process, describe
how you might effect that change. 5. How do you normally react to change? Choose from the following: a. I love new ideas, and I’m ready to try new things. b. I like to know that something will work out before I try it. c. I try to avoid change as much as possible. 6. Did your response to the above question alter how you would like to view change? Think about this
the next time change is presented to you. 7. Think back to your first time on a clinical unit. How did you feel? Overwhelmed? Afraid of failing?
That’s the feeling that people have when facing change. Try to remember how you felt when you encounter resistance to change.
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
www.nursing.pearsonhighered.com
68 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Bridges, W. (2009). Managing transitions: Making the most of change. Cambridge, MA: Da Capo Press.
Capuano, T., Durishin, L. D., Millard, J. L., & Hitchings, K. S. (2007). The desired future of nursing doesn’t just happen—engaged nurses create it. Journal of Nursing Administration, 37(2), 61–63.
Erwin, D. (2009). Changing or- ganizational performance: Examining the change pro- cess. Hospital Topics: Re- search and Perspectives on Healthcare, 87(3), 28–40.
Havelock, R. (1973). The change agent’s guide to innovation in education. Englewood Liffs, NJ: Educational Tech- nology Publications.
Heath, C., & Heath, D. (2010). Switch: How to change things when change is hard. New York: Crown.
Hellriegel, D., Jackson, S. E., & Slocum, J. W. (2007). Man- agement: A competency- based approach (11th ed.). Eagan, MN: South-Western.
Holtrop, J. S., Baumann, J., Arnold, A. K., & Torres, T. (2008). Nurses as practice
change facilitators for healthy behaviors. Journal of Nursing Care Quality, 23(2), 123–131.
Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved May 24, 2011 from http://www.iom. edu/Reports/2010/The- Future-of-Nursing-Leading- Change-Advancing- Health.aspx
Lewin, K. (1951). Field theory in social science. New York: Harper & Row.
Lippitt, R., Watson, J., & West- ley, B. (1958). The dynam- ics of planned change. New York: Harcourt & Brace.
MacDavitt, K., Cieplinski, J. A., & Walker, V. (2011). Implementing small tests of change to improve pa- tient satisfaction. Journal of Nursing Administration, 41(1), 5–9.
McMurray, A., Chaboyer, W., Wallis, M., & Fetherston, C. (2010). Implementing bedside handover: Strate- gies for change manage- ment. Journal of Clinical Nursing, 19(17–18), 2580–2589.
Nickitas, D. M. (2010). A vi- sion for future health care: Where nurses lead the change. Nursing Econom- ics, 28(6), 361, 385.
Prochaska, J. O. & DiClemente, C. C. (2005). The transtheo- retical approach. In: Nor- cross, J. C., & Goldfried, M. R. (Eds.), Handbook of psychotherapy integration (2nd ed.). New York: Ox- ford University Press.
Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.
Sare, M. V., & Ogilvie, L. (2009). Strategic planning for nurses: Change man- agement in health care. Sudbury, MA: Jones and Bartlett.
Weiner, B. J., Amick, H., & Lee, S. D. (2008). Conceptual- ization and measurement of organizational readiness for change: A review of the literature in health services research and other fields. Medical Care Research and Review, 65(4), 379–436.
Yukl, G. A. (2009). Leadership in organizations (7th ed.). Upper Saddle River, NJ: Prentice Hall.
Web Resources Agency for Healthcare Research and Quality. http://www.ahrq.gov/ Institute of Medicine. http://www.iom.edu/
References
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
http://www.ahrq.gov/
http://www.iom.edu/
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
CHAPTER
Quality Management TOTAL QUALITY
MANAGEMENT
CONTINUOUS QUALITY IMPROVEMENT
COMPONENTS OF QUALITY MANAGEMENT
SIX SIGMA
LEAN SIX SIGMA
DMAIC METHOD
Improving the Quality of Care NATIONAL INITIATIVES
HOW COST AFFECTS QUALITY
EVIDENCE-BASED PRACTICE
ELECTRONIC MEDICAL RECORDS
DASHBOARDS
NURSE STAFFING
REDUCING MEDICATION ERRORS
PEER REVIEW
Risk Management NURSING’S ROLE IN RISK
MANAGEMENT
INCIDENT REPORTS
EXAMPLES OF RISK
ROOT CAUSE ANALYSIS
ROLE OF THE NURSE MANAGER
CREATING A BLAME-FREE ENVIRONMENT
Managing and Improving Quality 6
Key Terms Continuous quality
improvement (CQI) Dashboards DMAIC Incident reports Indicator Just culture
1. Describe how total quality management, continuous quality management, Six Sigma, Lean Six Sigma, and DMAIC address quality.
2. Describe national efforts to improve the quality of health care.
3. Explain how evidence-based practice, electronic medical records, and dashboards can improve quality.
4. Point out how nurses are involved in reducing risks.
5. Discuss how to create a blame-free environment.
Learning Outcomes After completing this chapter, you will be able to:
Outcome standards Lean Six Sigma Peer review Process standards Quality management Reportable incident Risk management
Root cause analysis Six Sigma Standards Structure standards Total quality management
(TQM)
70 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
I n today’s highly competitive health care environment, each member of the health care organization must be accountable for the quality and cost of health care. Concern about quality gained national attention after publication of the Institute of Medicine’s (IOM) reports on medical errors in 1999 (IOM, 1999) and their later recommendations for health pro- fessionals’ education (IOM, 2003). Additionally, concern about cost continues unabated. Both quality and cost containment are found in the concept of total quality management, which has evolved into a model of continuous quality improvement designed to improve system and process performance. Risk management is integrated within a quality management program.
Quality Management Quality management moved health care from a mode of identifying failed standards, problems, and problem people to a proactive organization in which problems are prevented and ways to improve care and quality of care are sought. This paradigm shift involves all in the organization and promotes problem solving and experimentation.
A quality management program is based on an integrated system of information and accountability. Clinical information systems can provide the data needed to enable organizations to track activities and outcomes. For example, data from clinical information systems can be used to track patient wait times from admitting to outpatient testing to admission in an inpatient care unit. Delays in the process can be identified so appropriate staff and resources are available at the right time to decrease delays and increase efficiency and patient satisfaction. Methods can be devised to discover problems in the system without blaming the “sharp end,” the last individual in the chain to act (e.g., the nurse gives a wrong medication). The system must be accepted and used by the entire staff.
Total Quality Management Total quality management (TQM) is a management philosophy that emphasizes a commitment to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was adopted by the Japanese after World War II and helped transform their industrial development. Dr. Deming based his system on principles of quality management that were originally applied to improve quality and performance in the manufacturing industry. They are now widely used to improve quality and customer satisfaction in a number of service industries, including health care.
TQM Characteristics Four core characteristics of total quality management are:
● Customer/client focus ● Total organizational involvement ● Use of quality tools and statistics for measurement ● Key processes for improvement identified
Customer/Client Focus. An important theme of quality management is to address the needs of both internal and external customers. Internal customers include employees and departments within the organization, such as the laboratory, admitting office, and environmental services. External customers of a health care organization include patients, visitors, physicians, managed- care organizations, insurance companies, and regulatory agencies, such as the Joint Commission, which accredits health care organizations, and public health departments.
Under the principles of TQM, nurses must know who the customers are and endeavor to meet their needs. Providing flexible schedules for employees, adjusting routines for a.m. care to meet the needs of patients, extending clinic hours beyond 5 p.m., and putting infant changing tables in restrooms are some examples. Putting the customer first requires creative and innova- tive methods to meet the ever-changing needs of internal and external customers.
Total Organizational Involvement. The goal of total quality management is to involve all employees and empower them with the responsibility to make a difference in the quality of
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service they provide. This means all employees must have knowledge of the TQM philosophy as it relates to their job and the overall goals and mission of the organization. Knowledge of the TQM process breaks down barriers between departments. The phrase “That’s not my job” is eliminated. Departments work together as a team. On occasion, nursing personnel might clean a bed for a new admission from the emergency room or an administrator might transport a patient to the radiology department. Sharing processes across departments and patient care functions increases teamwork, productivity, and patient positive outcomes.
Use of Quality Tools and Statistics for Measurement. A common management adage is, “You can’t manage what you can’t (or don’t) measure.” There are many tools, formats, and designs that can be used to build knowledge, make decisions, and improve quality. Tools for data analysis and display can be used to identify areas for process and quality improvement, and then to benchmark the progress of improvements. Deming applied the scientific method to the concept of TQM to develop a model he called the PDCA cycle (Plan, Do, Check, Act) depicted in Figure 6-1.
Identification of Key Processes for Improvement. All activities performed in an organization can be described in terms of processes. Processes within a health care setting can be:
● Systems related (e.g., admitting, discharging, and transferring patients) ● Clinical (e.g., administering medications, managing pain) ● Managerial (e.g., risk management and performance evaluations).
Processes can be very complex and involve multidisciplinary or interdepartmental actions. Processes involving multiple departments must be investigated in detail by members from each department involved in the activity so that they can proactively seek opportunities to reduce waste and inefficiencies and develop ways to improve performance and promote positive outcomes.
Continuous Quality Improvement TQM is the overall philosophy, whereas continuous quality improvement (CQI) is used to im- prove quality and performance. TQM and CQI often are used synonymously. In health care orga- nizations, CQI is the process used to investigate systematically ways to improve patient care. As the name implies, continuous quality improvement is a never-ending endeavor (Hedges, 2006).
CQI means more than just meeting standards and thresholds or solving problems. It involves evaluation, actions, and a mind-set to strive constantly for excellence. This concept is sometimes difficult to grasp because patient care involves the synchronization of activities in multiple de- partments. Therefore, the importance of developing and implementing a well-thought-out pro- cess is key to a successful CQI implementation.
There are four major players in the CQI process:
● Resource group ● Coordinator
PlanPlan
DoAct
Check
Figure 6-1 • PDCA cycle.
72 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
● Team leader ● Team
The resource group is made up of senior management (e.g., CEO, vice presidents). It estab- lishes overall CQI policy, vision, and values for the organization and actively involves the board of directors in this process, thereby ensuring that the CQI program has sufficient emphasis and is provided with the resources needed. The CQI coordinator is often appointed by the CEO to pro- vide day-to-day management of the CQI process and related activities (e.g., training programs).
CQI teams are designated to evaluate and improve select processes. They are formally established and supported by the resource group. CQI teams range in size from 5 to 10 people, representing all major functions of the process being evaluated.
Each CQI team is headed by a team leader who is familiar with the process being evaluated. The leader organizes team meetings, sets the agenda, and guides the group through the discussion, evaluation, and implementation process.
Components of Quality Management A comprehensive quality management program includes:
● A comprehensive quality management plan. A quality management plan is a systematic method to design, measure, assess, and improve organizational performance. Using a multidisciplinary approach, this plan identifies processes and systems that represent the goals and mission of the organization, identifies customers, and specifies opportunities for improvement. Critical paths, which are described in Chapter 3, are an example of a quality management plan. Critical paths identify expected outcomes within a specific time frame. Then variances are tracked and accounted for.
● Set standards for benchmarking. Standards are written statements that define a level of performance or a set of conditions determined to be acceptable by some authorities. Standards relate to three major dimensions of quality care:
a. Structure b. Process c. Outcome
Structure standards relate to the physical environment, organization, and management of an organization. Process standards are those connected with the actual delivery of care. Outcome standards involve the end results of care that has been given.
An indicator is a tool used to measure the performance of structure, process, and outcome standards. It is measurable, objective, and based on current knowledge. Once indicators are identified, benchmarking, or comparing performance using identified quality indicators across institutions or disciplines, is the key to quality improvement.
In nursing, both generic and specific standards are available from the American Nurses Association and specialty organizations; however, each organization and each patient care area must designate standards specific to the patient population being served. These standards are the foundation on which all other measures of quality are based.
An example of a standard is, “Every patient will have a written care plan within 12 hours of admission.”
● Performance appraisals. Based on requirements of the job, employees are evaluated on their performance. This feedback is essential for employees to be professionally accountable. (See Chapter 18 for more on performance appraisals.)
● A focus on intradisciplinary assessment and improvement. There will always be a need for groups to assess, analyze, and improve their own performance. Methods to assess performance should, however, focus on the CQI philosophy, which involves group or intradisciplinary performance. Peer review, discussed later in the chapter, is an example of intradisciplinary assessment.
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● A focus on interdisciplinary assessment and improvement. Multidisciplinary, patient- focused teamwork emphasizing collaboration, communication, coordination, and integra- tion of care is the core of CQI in health care. It is important not to disband departmental quality functions, such as patient satisfaction, utilization review, or infection control, but rather to refocus information on improving the process.
Resources are used to collect data, such as the number of postoperative infections or the number of return clinic visits, to guide the decision-making process. Throughout the evalua- tion and implementation process, the team’s focus is the patient. Implementation is continu- ally evaluated using a patient satisfaction survey, which is just one of the methods used to monitor nursing care. For example, some organizations follow up outpatient surgery clients with direct phone calls from nursing staff to ensure patients understand discharge instructions and that pain was controlled following discharge. Any potential complications are referred to the surgeon.
Six Sigma Six Sigma is another quality management program that uses, primarily, quantitative data to monitor progress. Six Sigma is a measure, a goal, and a system of management.
● As a measure. Sigma is the Greek letter—ó—for standard, meaning how much performance varies from a standard. This is similar to how CQI monitors results against an outcome measure.
● As a goal. One goal might be accuracy. How many times, for example, is the right medication given in the right amount, to the right patient, at the right time, by the right route?
● As a management system. Compared to other quality management systems, Six Sigma involves management to a greater extent in monitoring performance and ensuring favorable results.
The system has six themes:
● Customer (patient) focus ● Data driven ● Process emphasis ● Proactive management ● Boundaryless collaboration ● Aim for perfection; tolerate failure.
The first three themes are similar to other quality management programs. The focus is on the object of the service; in nursing’s case, this is the patient. Data provide the evidence of results, and the emphasis is on the processes used in the system.
The latter three themes, however, differ from other programs. Management is actively involved and boundaries are breached (e.g., the disconnect between departments). More radically, Six Sigma tolerates failure (a necessary condition for creativity) while striving for perfection.
Lean Six Sigma Lean Six Sigma focuses on improving process flow and eliminating waste. Waste occurs when the organization provides more resources than are required. Data driven, Lean Six Sigma focuses on identifying steps that have little or no value to the care and cause unnecessary delays. Further- more, the method strives to eliminate variations in care and improve efficiencies and effective- ness. Because the goal of Lean Six Sigma is to identify and reduce waste, it provides tools that can be used with a Six Sigma management system.
Studies have shown Lean Six Sigma to be effective in reducing inappropriate hospital stays, improving the quality of care and reducing costs at the same time (Yamamoto et al., 2010).
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In addition, when the method was used in one hospital, researchers found that a collaborative effort improved the care of inpatient diabetic patients (Niemeijer et al., 2010).
DMAIC Method DMAIC is a Six-Sigma process improvement method (as shown in Figure 6-2). Steps in the method are:
● Define what measures will indicate success ● Measure baseline performance ● Analyze results ● Improve performance ● Control and sustain performance (DMAIC Tools: Six Sigma Training Tools, 2011)
TQM, CQI, Six Sigma, Lean Six Sigma, and DMAIC are quantifiable systems that measure performance against set standards. The goal is to improve the quality of health care. In addition, other efforts to improve the quality of care are ongoing.
Improving the Quality of Care
National Initiatives The National Quality Forum is a nonprofit organization that strives to improve the quality of health care by building consensus on performance goals and standards for measuring and report- ing them (National Quality Forum, 2011). Additionally, the Institute of Healthcare Improvement (IHI) offers programs to assist organizations in improving the quality of care they provide (IHI, 2011). Their goals are:
● No needless deaths ● No needless pain or suffering ● No helplessness in those served or serving ● No unwanted waiting ● No waste
Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient safety goals (Joint Commission, 2011). They charge hospitals to:
● Identify patients correctly ● Improve staff communication ● Use medicines safely ● Prevent infection ● Check patient medicines ● Identify patient safety risks ● Prevent mistakes in surgery
Define
MeasureControl
Improve Analyze
Figure 6-2 • DMAIC: The Six Sigma Method. Adapted from DMAIC tools: Six Sigma training tools. Retrieved October 21, 2011, from www.dmaictools.com
www.dmaictools.com
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Joint Commission collects data on 57 inpatient measures; 31 of these are currently made public with others scheduled to be publicly reported soon (Chassin et al., 2010). The focus is now on maxi- mizing health benefits to patients. They recommend that quality measures be based on four criteria:
1. The measure must be based on research that shows improved outcomes. More than one research study is required for documentation.
2. Reports document that evidence-based practice has been given. Aspirin following an acute myocardial infarction is an example.
3. The process documents desired outcome. Appropriately administering medications is an example.
4. The process has minimal or no unintended adverse effects (Chassin et al., 2010)
Measured standards are used extensively in industrial settings to reveal errors. However, the same cannot be said when measuring human behavior, which can vary and still be effective. Also, if the organization embraces these systems to such an extent that all variance is discour- aged, then innovation is also suppressed. Improvement in quality is sacrificed at the expense of innovative ideas and processes; organizations fail to allow input, become stagnant, and cease to be effective. This is the danger of all living systems that depend on outside input for survival. This is not to say that quality systems are not essential. They are. Organizations must find ways to foster creativity and innovation without compromising quality management.
How Cost Affects Quality Quality measures can also reduce costs. Wasted resources is an example. These include the time nurses spend looking for missing supplies or lab results, the costs of agency nurses because of unfilled positions, and delays in patient discharge due to a lack of coordination or an adverse event (e.g., medication error).
Using the Institute for Healthcare Improvement (2009) project, Transforming Care at the Bedside (TCAB), Unruh, Agrawal, and Hassmiller (2011) found that improving quality reduces costs. Specifically, the researchers report that in a three-year period, RN overtime was reduced, RN turnover was lowered, and fewer patients suffered falls.
Evidence-Based Practice Evidence-based practice (EBP) suggests that using research to decide on clinical treatments would improve quality of care, and that might be the case. Barriers, however, prevent EBP from being widely used by nurses. Such barriers, consistent across settings, include lack of time, autonomy over their practice, ability to find and assess evidence, and support from administra- tion (Brown et al., 2008).
Furthermore, EBP is most reliable when the research study includes a rigorous design (Hader, 2010), and when more than one study has confirmed the results (Chassin et al., 2010). These are not easily surmountable hurdles due to the fast-paced clinical environment and the barriers mentioned above.
Electronic Medical Records Similar to the argument that EBP improves quality, electronic medical records (EMR) should do so as well. Instant access to identical records should improve accuracy and speed commu- nication among care providers. Kazley and Ozcan (2008), however, found limited correlation between the use of EMR and 10 quality indicators in their study of more than 4,000 hospitals in the U.S. In a review of the literature, Chan, Fowles, and Weiner (2010) could not link quality indicators and EMR. Cebul (2008), however, did find direct correlation between the use of EMR and the quality of care provided to diabetic patients. EMR use, is expected to expand and will provide more data for comparison with quality.
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Dashboards Dashboards are electronic tools that can provide real-time data or retrospective data, known as a scorecard. Both are useful in assessing quality. Ease of access and the visual appearance of the dashboard make its use more likely. Dashboards may report on hospital census or patient satisfac- tion results, for example. Dashboards are also useful to guide staffing and match staffing with pa- tient outcomes (Frith, Anderson, & Sewell, 2010) and to provide accurate financial data on nurse staffing and quality (Anderson, Frith, & Caspers, 2011). As technology advances, widespread use of dashboards to aggregate data and guide decision making is expected (Hyun et al., 2008).
Nurse Staffing Evidence is growing that increased nurse staffing results in better patient outcomes (Frith, Tseng, & Anderson, 2008; Anderson, Frith, & Caspers, 2011). Earlier studies found that a higher RN-to-patient ratio resulted in reduced patient mortality, fewer infections, and shortened lengths of stay (Reeves, 2007). Needleman (2008) agrees that increasing the level of nurse staffing improves quality, but asserts that higher staffing levels also increase costs.
Reducing Medication Errors Ever since Medicare discontinued payment for hospital-based errors, pressure has increased for hospitals to prevent costly errors. In 2009, the federal government passed the Health Information Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to stim- ulate technology use in health care, including improving technology for medication administration.
Studies have shown that when nurses are interrupted during medication preparation, a 25 percent rate of injury-causing errors are made (Westbrook et al., 2010). One strategy to alert others that a nurse should not be interrupted is the use of a sash or vest that the nurse dons to prepare medications (Heath & Heath, 2010).
Other strategies to reduce medication errors include computerized prescriber order entry (CPOE), electronic medication administration record (eMAR), remote order review by pharma- cists, automated dispensing at the bedside, bar code administration, smart pumps, and unit doses ready to be administered (Federico, 2010). Future strategies include radio frequency identification and electronic reconciliation, both expensive technologies currently being tested (Federico, 2010).
Peer Review In addition to its value for self-evaluation and performance appraisal (Davis, Capozzoli, & Parks, 2009), peer review can be used to identify clinical standards of practice that improve the quality of care. Used for quality improvement, the peer review process is not intended to serve as a per- formance appraisal nor to be punitive. The purpose is to review the incident, determine if clinical standards were met or not, and to propose an action plan to prevent a future incident.
The peer review process is appropriate in the following situations:
● An adverse patient outcome has occurred. ● A serious risk or injury to a patient occurred. ● A failure to rescue incident occurred (Fujita et al., 2009).
A shared governance structure facilitates the peer review process, fostering peer-to-peer accountability (Fujita et al., 2009). Furthermore, the process can help determine if a breach in practice is an isolated incident or a trend occurring across a unit or throughout the organization. In a shared governance environment, unit councils or the nursing council can address unit-wide or system problems. To aggregate trends, peer review cases can be categorized as:
● Appropriate care with no adverse outcomes ● Appropriate care with adverse/unexpected outcomes ● Inappropriate care with no adverse outcomes ● Inappropriate care with adverse/unexpected outcomes (Hitchings et al., 2008)
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Risk Management Risk management is a component of quality management, but its purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries. Risk management is a continuous daily program of detection, education, and intervention.
A risk management program involves all departments of the organization. It must be an organization-wide program, with the board of directors’ approval and input from all depart- ments. The program must have high-level commitment, including that of the chief executive officer and the chief nurse.
A risk management program:
1. Identifies potential risks for accident, injury, or financial loss. Formal and informal communication with all organizational departments and inspection of facilities are essential to identifying problem areas.
2. Reviews current organization-wide monitoring systems (incident reports, audits, committee minutes, oral complaints, patient questionnaires), evaluates completeness, and determines additional systems needed to provide the factual data essential for risk management control.
3. Analyzes the frequency, severity, and causes of general categories and specific types of incidents causing injury or adverse outcomes to patients. To plan risk intervention strategies, it is necessary to estimate the outcomes associated with the various types of incidents.
4. Reviews and appraises safety and risk aspects of patient care procedures and new programs.
5. Monitors laws and codes related to patient safety, consent, and care.
6. Eliminates or reduces risks as much as possible.
7. Reviews the work of other committees to determine potential liability and recommend prevention or corrective action. Examples of such committees are infection, medical audit, safety/security, pharmacy, nursing audit, and productivity.
8. Identifies needs for patient, family, and personnel education suggested by all of the foregoing and implements the appropriate educational program.
9. Evaluates the results of a risk management program.
10. Provides periodic reports to administration, medical staff, and the board of directors.
Nursing’s Role in Risk Management In the organizational setting, nursing is the one department involved in patient care 24 hours a day; nursing personnel are therefore critical to the success of a risk management program. The chief nursing administrator must be committed to the program. Her or his attitude will influence the staff and their participation. After all, it is the staff, with their daily patient contact, who actu- ally implement a risk management program.
High-risk areas in health care fall into five general categories:
● Medication errors ● Complications from diagnostic or treatment procedures ● Falls ● Patient or family dissatisfaction with care ● Refusal of treatment or refusal to sign consent for treatment
Nursing is involved in all areas, but the medical staff may be primarily responsible in cases involving refusal of treatment or consent to treatment.
Medical records and incidence reports serve to document organizational, nurse, and physician accountability. For every reported occurrence, however, many more are unreported. If records are
78 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
faulty, inadequate, or omitted, the organization is more likely to be sued and more likely to lose. Incident reports are used to analyze the severity, frequency, and causes of occurrences within the five risk categories. Such analysis serves as a basis for intervention.
Incident Reports Accurate and comprehensive reporting on both the patient’s chart and in the incident report is essential to protect the organization and caregivers from litigation. Incident reporting is often the nurse’s responsibility. Reluctance to report incidents is usually due to fear of the consequences. This fear can be alleviated by:
● Holding staff education programs that emphasize objective reporting ● Omitting inflammatory words and judgmental statements ● Having a clear understanding that the purposes of the incident reporting process are
documentation and follow-up ● Never using the report, under any circumstances, for disciplinary action.
Nursing colleagues and nurse managers should not berate another employee for an incident, and never in front of other staff members, patients, or patients’ family members. Peer review analysis, however, is a valuable tool to evaluate incidents (Hitchings et al., 2008).
A reportable incident should include any unexpected or unplanned occurrence that affects or could potentially affect a patient, family member, or staff. The report is only as effective as the form on which it is reported, so attention should be paid to the adequacy of the form as well as to the data required.
Reporting incidents involves the following steps:
1. Discovery. Nurses, physicians, patients, families, or any employee or volunteer may report actual or potential risk.
2. Notification. The risk manager receives the completed incident form within 24 hours after the incident. A telephone call may be made earlier to hasten follow-up in the event of a major incident.
3. Investigation. The risk manager or representative investigates the incident immediately.
4. Consultation. The risk manager consults with the referring physician, risk management committee member, or both to obtain additional information and guidance.
5. Action. The risk manager should clarify any misinformation to the patient or family, explaining exactly what happened. The patient should be referred to the appropriate source for help and, if needed, be assured that care for any necessary service will be provided free of charge.
6. Recording. The risk manager should be sure that all records, including incident reports, follow-up, and actions taken, if any, are filed in a central depository.
Examples of Risk The following are some examples of actual events in the various risk categories.
Medication Errors A reportable incident occurs when a medication or fluid is omitted, the wrong medication or fluid is administered, or a medication is given to the wrong patient, at the wrong time, in the wrong dosage, or by the wrong route. Here are some examples.
Patient A. Weight was transcribed incorrectly from emergency room sheet. Medication dose was calculated on incorrect weight; therefore, patient was given double the dose
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required. Error discovered after first dose and corrected. Second dose omitted per physician’s order.
Patient B. Tegretol dosage written in Medex as “Tegretol 100 mg chewable tab—50 mg po BID.” Tegretol 100 mg given po at 1400. Meds checked at 1430 and error noted. 50 mg Tegretol should have been given two times per day to total 100mg in 24 hours. Doctor notified. Second dose held.
Patient C. During rounds at 3:30 p.m. found .9% sodium chloride at 75 mLs per hour hanging. Order was written for D5W to run at 75 mLs per hour. Fluids last checked at 2:00 p.m. Changed to correct fluid. Doctor notified.
Diagnostic Procedure Any incident occurring before, during, or after such procedures as blood sample stick, biopsy, X-ray examination, lumbar puncture, or other invasive procedure is categorized as a diagnostic procedure incident.
Patient A. When I checked the IV site, I saw that it was red and swollen. For this reason, I discontinued the IV. When removing the tape, I noted a small area of skin breakdown where the tape had been. There was also a small knot on the medial aspect of the left antecubital above the IV insertion site. Doctor notified. Wound dressed.
Patient B. Patient found on the floor after lumbar puncture. Right side rail down. Examined by a physician, BP 120/80, T 98.6, P 72, R 18. No injury noted on exam. Patient returned to bed, side rail placed up. Will continue to monitor patient condition.
Medical–Legal Incident If a patient or family refuses treatment as ordered and prescribed or refuses to sign consent forms, the situation is categorized as a medical-legal incident.
Patient A. After a visit from a member of the clergy, patient indicated he was no longer in need of medical attention and asked to be discharged. Physician called. Doctor explained potential side effects if treatment were discontinued to patient. Patient continued to ask for discharge. Doctor explained “against medical advice” (AMA) form. Patient signed AMA form and left at 1300 without medications.
Patient B. Patient refused to sign consent for bone marrow biopsy. States side effects not understood. Doctor reviewed reasons for test and side effects three different times. Doctor informed the patient that without consent he could not perform the test. Offered to call in another physician for second opinion. Patient agreed. After doctor left, patient signed consent form.
Patient or Family Dissatisfaction with Care When a patient or family indicates general dissatisfaction with care and the situation cannot be or has not been resolved, then an incident report is filed.
Patient A. Mother complained that she had found child saturated with urine every morning (she arrived around 0800). Explained to mother that diapers and linen are changed at 0600 when 0600 feedings and meds are given. Patient’s back, buttocks, and perineal areas are free of skin breakdown. Parents continue to be distressed. Discussed with primary nurse.
Patient B. Mr. Smith appeared very angry. Greeted me at the door complaining that his wife had not been treated properly in our emergency room the night before. Wanted to speak to someone from administration. Was unable to reach the administrator on call. Suggested Mr. Smith call administrator in the morning. Mr. Smith thanked me for my time and assured me that he would call the administrator the next day.
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Root Cause Analysis Root cause analysis is a method to work backwards through an event to examine every action that led to the error or event that occurred; it is a complicated process. A simplified method to conduct an event analysis follows:
● Patient—what patient factors contributed to the event? ● Personnel—what personnel actions contributed to the event? ● Policies—are there policies for this type of event? ● Procedures—are there standard procedures for this type of event? ● Place—did the workplace environment contribute to the event? ● Politics—did institutional or outside politics play a role in the event? (Weiss, 2009)
Complaints have emerged, however, that the method uses too many resources for too few improvements (Wu, Lipshutz, & Pronovost, 2008). The authors posit that most organizations try to drill down to a single cause, ignoring system failures. Furthermore, they insist that correc- tive action is seldom taken due to lack of resources, professional disagreements, and absence of management support. They recommend improving system-wide dysfunctions and examining the broader health care environment to find improvements needed across hospitals.
Role of the Nurse Manager The nurse manager plays a key role in the success of any risk management program. Nurse man- agers can reduce risk by helping their staff view health and illness from the patient’s perspective. Usually, the staff’s understanding of quality differs from the patient’s expectations and perceptions. By understanding the meaning of the course of illness to the patient and the family, the nurse will manage risk better because that understanding can enable the nurse to individualize patient care. This individualized attention produces respect and, in turn, reduces risk.
A patient incident or a patient’s or family’s expression of dissatisfaction regarding care indi- cates not only some slippage in quality of care but also potential liability. A distraught, dissatisfied, complaining patient is a high risk; a satisfied patient or family is a low risk. A risk management or liability control program should therefore emphasize a personal approach. Many claims are filed because of a breakdown in communication between the health care provider and the patient. In many instances, after an incident or bad outcome, a quick visit or call from an organization’s repre- sentative to the patient or family can soothe tempers and clarify misinformation.
In the examples given, prompt attention and care by the nurse manager protected the pa- tients involved and may have averted a potential liability claim. Once an incident has occurred, the important factors in successful risk management are:
● Recognition of the incident ● Quick follow-up and action ● Personal contact ● Immediate restitution (where appropriate)
The concerns of most patients’ and their families’ concerns can and should be handled at the unit level. When that first line of communication breaks down, however, the nurse manager needs a resource—usually the risk manager or nursing service administrator.
Handling Complaints Handling a patient’s or family member’s complaints stemming from an incident can be very difficult. These confrontations are often highly emotional; the patient or family member must be calmed down, yet have their concerns satisfied. Sometimes just an opportunity to release the anger or emotion is all that is needed.
The first step is to listen to the person to hear concerns and to help defuse the situation. Arguing or interrupting only increases the person’s anger or emotion. After the patient or fam- ily member has had his or her say, the nurse manager can then attempt to solve the problem by
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asking what is expected in the form of a solution. The nurse manager should ensure that immedi- ate patient care and safety needs are met, collect all facts relevant to the incident, and if possible, comply with the patient or family member’s suggested resolution.
Sometimes, a simple apology from a staff member or moving a patient to a different room on the unit can resolve a difficult situation. If the patient and/or family member’s requested resolution exceeds the nurse manager’s authority, the nurse manager should seek the assistance of a nurse administrator or hospital legal counsel. Offering vague solutions (e.g., “everything will be taken care of”) may only lead to more problems later on if expectations as to solution and timing differ.
All incidents must be properly documented. Information on the incident form should be detailed and include all the factors relating to the incident, as demonstrated in the previous ex- amples. The documentation in the chart, however, should be only a statement of the facts and of the patient’s physical response; no reference to the incident report should be made, nor should words such as error or inappropriate be used.
When a patient receives 100 mg of Demerol instead of 50 mg as ordered, the proper documen- tation in the chart is, “100 mg of Demerol administered. Physician notified.” The remainder of the documentation should include any reaction the patient has to the dosage, such as “Patient’s vital signs unchanged.” If there is an adverse reaction, a follow-up note should be written in the chart, giving an update of the patient’s status. A note related to the patient’s reaction should be written as frequently as the status changes and should continue until the patient returns to his or her previous status.
The chart must never be used as a tool for disciplinary comments, action, or expressions of an- ger. Notes such as, “Incident would never have occurred if Doctor X had written the correct order in the first place” or “This carelessness is inexcusable” or “Paged the doctor eight times, as usual, no reply” are wholly inappropriate and serve no meaningful purpose. Carelessness and incorrect orders do indeed cause errors and incidents, but the place to address and resolve these issues is in the risk management committee or in the nurse manager’s office, not on the patient chart.
Handling a complaint without punishing a staff member is a delicate situation. The manager must determine what happened in order to prevent another occurrence, but using an incident report for discipline might result in fewer or erroneous incident reports in the future. Learn how one manager handled a situation of this kind in Case Study 6-1.
A Caring Attitude With employees, the nurse manager sets the tone that contributes to a safe and low-risk environ- ment. One of the most important ways to reduce risk is to instill a sense of confidence in both patients and families by emphasizing and recognizing that they will receive personalized atten- tion and that their needs will be attended to with competence. This confidence is created envi- ronmentally and professionally.
Examples of environmental factors include cleanliness, attention to patients’ privacy, promptly responding to patients’ and family members’ requests, an orderly looking unit, and engaging in minimal social conversations in front of patients. One example of portraying pro- fessional confidence is to provide patients and families with the name of the person in charge. A sincere visit by that person is reassuring. In addition, a thorough orientation creates indepen- dence for the patient and confidence in an efficient unit.
The nurse manager needs to foster the attitude that any mistake that does occur is perceived as an opportunity to improve a system or a process rather than to punish an individual. If the nurse manager has developed a patient-focused atmosphere in which patients believe their best interests are a priority, the potential for risk will be reduced.
Creating a Blame-Free Environment The health care environment is known to be a blame culture that “is a major source of medical errors and poor quality of patient care” (Khatri, Brown, & Hicks, 2009, p. 320). Such a culture inhibits reporting of inadequate practice, underreporting of adverse events, and inattention to possible safety problems.
82 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
A just culture, in contrast, allows for reporting of errors without fear of undue retribution (Gorzeman, 2008). Khatri, Brown, & Hicks (2009) suggest that transitioning to a just culture does more than improve reporting mechanisms or initiate training programs. A just culture provides an environment in which employees can question policies and practices, express concerns, and admit mistakes without fear of retribution. A just culture requires organizational commitment, mana- gerial involvement, employee empowerment, an accountability system, and a reporting system (Gorzeman, 2008).
Accountability for errors, however, must be maintained (Gorzeman, 2008). Errors can be categorized as:
● Human errors, such as unintentional behaviors that may cause an adverse consequence ● At-risk behaviors, such as unsafe habits, negligence, carelessness ● Reckless behaviors, such as conscious disregard for standards
A just culture is prepared to handle incidents involving human error. At-risk or reckless behaviors, however, are not tolerated.
Managing and improving quality requires ongoing attention to system-wide processes and individual actions. The nurse manager is in a key position to identify problems and encourage a culture of safety and quality.
RISK MANAGEMENT Yasmine Dubois is the nurse manager for the cardiac catheterization lab and special procedures unit in a sub- urban hospital. The hospital has an excellent reputation for its cardiac care program, including the use of cut- ting-edge technology. The cath lab utilizes a specialized computer application that records the case for the nurs- ing staff, requiring little handwritten documentation at the end of a procedure.
Last month, a 56-year-old woman was brought from the ER to the cath lab at approximately 1900 for place- ment of a stent in her left anterior descending coronary artery. During the procedure, the heart wall was perfo- rated. The patient coded and was taken in critical condi- tion to the OR, where she died during surgery.
Two days following the incident, the patient’s hus- band requested a review of his wife’s medical records. During his review, he pointed out to the medical records clerk that the documentation from the cath lab stated that his wife “. . . tolerated the procedure well and was taken in satisfactory condition to the recovery area.” The documentation was signed, dated, and timed by Elizabeth Clark, RN. The medical records director
notified the hospital’s risk manager of the error. The risk manager investigated the incident and determined that Elizabeth Clark’s charting was in error.
Following her meeting with the risk manager, Yas- mine met with Elizabeth to discuss the incident. She showed Elizabeth a copy of the cath lab report. Eliza- beth asked Yasmine if she could have the chart from medical records so she could correct her mistake. Yas- mine informed Elizabeth that she couldn’t correct her charting at this point in time. But, she could, however, write an addendum to the chart, with today’s date and time, to clarify the documentation. Yasmine also told Elizabeth that the addendum would be reviewed by the risk manager and the hospital’s attorney prior to inclusion in the chart.
To ensure compliance with the hospital’s documen- tation standards and to determine if Elizabeth or any other cath lab nurse had committed any similar charting errors, Yasmine requested charts for all patients in the past 12 months who had been sent to surgery from the cath lab due to complications during a procedure. She conducted a retrospective audit and determined that this had been an isolated incident.
CASE STUDY 6-1
CHAPTER 6 • MANAGING AND IMPROVING QUALITY 83
What You Know Now • Total quality management is a philosophy committed to excellence throughout the organization. • Continuous quality improvement is a process to improve quality and performance. • Six Sigma is another quality management program that uses measures, has goals, and is a management
system. • Lean Six Sigma provides tools to improve flow and eliminate waste. • DMAIC is a Six Sigma process improvement method to define, measure, analyze, improve, and control
performance. • A culture of safety and quality permeates efforts at the national level. • Cost may increase or decrease with quality initiatives. • Evidence-based practice, electronic medical records, and dashboards can be used to improve and monitor
quality. • Reducing medication errors is a priority for health care organizations and policy makers. • A risk management program focuses on reducing accidents and injuries and intervening if either occurs. • A caring attitude and prompt attention to complaints help to reduce risk. • A just culture is more likely to encourage reporting of adverse events, including near misses, as well as
point out unsafe practices.
Tools for Managing and Improving Quality 1. Remember: Quality management is a system. When something goes wrong, it is usually due to a
flaw in the system. 2. Become familiar with standards and outcome measures and use them to guide and improve your
practice. 3. Strive for perfection, but be prepared to tolerate failure in order to encourage innovation. 4. Be sure that performance appraisals and incident reports are not used for discipline but rather are the
bases for improvements to the system and/or development of individuals. 5. Remind yourself and your colleagues that a caring attitude is the best prevention of problems.
Following an incident:
1. Meet with the risk manager and hospital attorney to review documentation and determine which staff will be interviewed regarding the incident.
2. Provide any requested information to administration in a timely manner. 3. Audit documentation and processes to determine if an incident is part of a pattern or an isolated
incident. 4. Provide the results of any audits or discussions with staff to appropriate administrators. 5. Educate staff as appropriate. 6. Determine if disciplinary action is required. 7. Follow up with risk management, nursing administration, and human resources as appropriate. 8. Continue to cooperate with the hospital attorney if the incident results in litigation.
Questions to Challenge You 1. Imagine that an organization is debating among several quality management programs. What would
you recommend? Why? 2. Do you know what standards and outcome measures are used in your clinical setting? How are data
handled? Are they shared with employees? 3. What comparable groups, both internal and external, are used for benchmarking performance in
your organization? 4. Universities also use benchmarking. What institutions does your college or university use to bench-
mark its performance? Find out. 5. Have you, a family member, or a friend ever had a serious problem in a health care organization that
resulted in injury? What was the outcome? Is this how you would have handled it? What will you do in the future in a similar situation?
6. Have you or anyone you know ever made a mistake in a clinical setting? What happened? Would you assess the organization as a blame-free environment?
84 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
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1. Define power. 2. Describe how power is used. 3. Discuss how image is a source of power. 4. Explain how to use shared visioning
as a power tool.
5. Discuss how politics influence policy. 6. Describe how nurses can use politics
to influence policies.
Learning Outcomes After completing this chapter, you will be able to:
Power Defined
Power and Leadership
Power: How Managers and Leaders Get Things Done
Using Power IMAGE AS POWER
USING POWER APPROPRIATELY
Shared Visioning as a Power Tool
Power, Politics, and Policy NURSING’S POLITICAL HISTORY
USING POLITICAL SKILLS TO INFLUENCE POLICIES
INFLUENCING PUBLIC POLICIES
Using Power and Politics for Nursing’s Future
Understanding Power and Politics7
CHAPTER
Key Terms Coercive power Connection power Expert power Information power Legitimate power Personal power
Policy Politics Position power Power Power plays Punishment
Referent power Reward power Shared visioning Stakeholders Vision
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 87
Power Defined Power is the potential ability to influence others (Hersey, 2011). Power is involved in every human encounter, whether you recognize it or not. Power can be symmetrical when two parties have equal and reciprocal power, or it may be asymmetrical with one person or group having more control than another (Mason, Leavitt, & Chaffee, 2011). Power can be exclusive to one party or may be shared among many people or groups. To acquire power, maintain it effectively, and use it skillfully, nurses must be aware of the sources and types of power that they will use to influence and transform patient care.
Power and Leadership Real power—principle-centered power—is based on honor, respect, loyalty, and commitment. Principle-centered power is a model congruent with nursing’s values. It is based on respect, honor, loyalty, and commitment. Originally conceived by Stephen Covey (1991), the model is increasingly used by leaders in many fields (Ikeda, 2009). Power sharing evolves naturally when power is centered on one’s values and principles. In fact, the notion that power is something to be shared seems to contradict the usual belief that power is something to be amassed, protected, and used for one’s own purposes.
Leadership power comes from the ability to sustain proactive influence, because followers trust and respect the leader to do the right thing for the right reason. As leaders in health care, nurses must understand and select behaviors that activate principle-centered leadership:
● Get to know people. Understanding what other people want is not always simple. ● Be open. Keep others informed. Trust, honor, and respect spread just as equally as fear,
suspicion, and deceit. ● Know your values and visions. The power to define your goals is the power to choose. ● Sharpen your interpersonal competence. Actively listen to others and learn to express your
ideas well. ● Use your power to enable others. Be attentive to the dynamics of power and pay attention
to ground rules, such as encouraging dissenting voices and respecting disagreement. ● Enlarge your sphere of influence and connectedness. Power sometimes grows out of
someone else’s need.
Power: How Managers and Leaders Get Things Done Classically, managers relied on authority to rouse employees to perform tasks and accomplish goals. In contemporary health care organizations, managers use persuasion, enticement, and inspiration to mobilize the energy and talent of a work group and to overcome resistance to change.
A leader’s use of power alters attitudes and behavior by addressing individual needs and motivations. There are seven generally accepted types of interpersonal power used in organizations to influence others (Hersey, 2011):
1. Reward power is based on the inducements the manager can offer group members in exchange for cooperation and contributions that advance the manager’s objectives. The degree of compliance depends on how much the follower values the expected benefits. For example, a nurse manager may grant paid educational leave as a way of rewarding a staff nurse who agreed to work overtime. Reward power often is used in relation to a manager’s formal job responsibilities.
2. Coercive power is based on the penalties a manager might impose on an individual or a group. Motivation to comply is based on fear of punishment (coercive power) or withholding of rewards. For example, the nurse manager might make undesirable job assignments, mete out
88 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
a formal reprimand, or recommend termination for a nurse who engages in disruptive behavior. Coercion is used in relation to a manager’s perceived authority to determine employment status.
3. Legitimate power stems from the manager’s right to make a request because of the author- ity associated with job and rank in an organizational hierarchy. Followers comply because they accept a manager’s prerogative to impose requirements, sanctions, and rewards in keeping with the organization’s mission and aims. For instance, staff nurses will com- ply with a nurse manager’s directive to take time off without pay when the workload has dropped below projected levels because they know that the manager is charged with main- taining unit expenses within budget limitations.
4. Expert power is based on possession of unique skills, knowledge, and competence. Nurse man- agers, by virtue of experience and advanced education, are often the best qualified to determine what to do in a given situation. Employees are motivated to comply because they respect the manager’s expertise. Expert power relates to the development of personal abilities through edu- cation and experience. Newly graduated nurses might ask the nurse manager for advice in learn- ing clinical procedures or how to resolve conflicts with coworkers or other health professionals.
5. Referent power is based on admiration and respect for an individual. Followers comply because they like and identify with the manager. Referent power relates to the manager’s likeability and success. For example, a new graduate might ask the advice of a more expe- rienced and admired nurse about career planning.
6. Information power is based on access to valued data. Followers comply because they want the information for their own needs. Information power depends on a manager’s or- ganizational position, connections, and communication skills. For example, the nurse man- ager is frequently privy to information about pending organizational changes that affect employees’ work situations. A nurse manager may exercise information power by sharing significant information at staff meetings, thereby improving attendance.
7. Connection power is based on an individual’s formal and informal links to influential or prestigious persons within and outside an area or organization. Followers comply because they want to be linked to influential individuals. Connection power also relates to the status and visibility of the individual as well. If, for example, a nurse manager is a neighbor of an organization’s board member, followers may believe that connection will protect or ad- vance their work situation.
Managers have both personal and position power. Position power is determined by the job description, assigned responsibilities, recognition, advancement, authority, the ability to with- hold money, and decision making. Legitimate, coercive, and reward power are positional because they relate to the “right” to influence others based on rank or role. The extent to which managers mete out rewards and punishment is usually dictated by organizational policy. Information and legitimate power are directly related to the manager’s role in the organizational structure.
Expert, referent, information, and connection power are based, for the most part, on personal traits. Personal power refers to one’s credibility, reputation, expertise, experience, control of resources or information, and ability to build trust. The extent to which one may exercise expert, referent, information, and connection power relates to personal skills and positive interpersonal relationships as well as employees’ needs and motivations. Box 7-1 illustrates how nurses can learn to use power in organizations.
Using Power Despite an increase in pride and self-esteem that comes with using power and influence, some nurses still consider power unattractive. Power grabbing, which has been the tradition- ally accepted means of relating to power for one’s own self-interests and use, is how nurses
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 89
often think of power. Rather, nurses tend to be more comfortable with power sharing and empowerment: power “with” rather than power “over” others.
Image as Power A major source of power for nurses is an image of power. Even if one does not have actual power from other sources, the perception by others that one is powerful bestows a degree of power. The same is true for the profession as a whole. If the public sees the profession of nursing as powerful, the profession’s ability to achieve its goals and agendas is enhanced.
Images emerge from interactions and communications with others. If nurses present themselves as caring and compassionate experts in health care through their interactions and communications with the public, then a strong, favorable image develops for both the individual nurse and the profession. Nurses, as the ambassadors of care, must understand the importance and benefits of positive therapeutic communications and image. Developing a positive image of power is important for both the individual and the profession.
BOX 7-1 Guidelines for the Use of Power in Organizations
Guidelines for Using Legitimate Authority
● Make polite, clear requests.
● Explain the reasons for a request.
● Don’t exceed your scope of authority.
● Verify authority if necessary.
● Follow proper channels.
● Follow-up to verify compliance.
● Insist on compliance if appropriate.
Guidelines for Using Reward Power ● Offer the type of rewards that people desire.
● Offer rewards that are fair and ethical.
● Don’t promise more than you can deliver.
● Explain the criteria for giving rewards and keep it simple.
● Provide rewards as promised if requirements are met.
● Use rewards symbolically (not in a manipulative way).
Guidelines for Using Coercive Power ● Explain rules and requirements and ensure that
people understand the serious consequences of violations.
● Respond to infractions promptly and consistently without showing any favoritism to particular individuals.
● Investigate to get the facts before using repri- mands or punishment and avoid jumping to con- clusions or making hasty accusations.
● Except for the most serious infractions, provide sufficient oral and written warnings before resorting to punishment.
● Administer warnings and reprimands in private and avoid making rash threats.
● Stay calm and avoid the appearance of hostility or personal rejection.
● Express a sincere desire to help the person com- ply with role expectations and thereby avoid punishment.
● Invite the person to suggest ways to correct the problem and seek agreement on a concrete plan.
● Maintain credibility by administering punishment if noncompliance continues after threats and warnings have been made.
Guidelines for Using Expert Power ● Explain the reasons for a request or proposal and
why it is important. ● Provide evidence that a proposal will be successful. ● Don’t make rash, careless, or inconsistent
statements. ● Don’t exaggerate or misrepresent the facts. ● Listen seriously to the person’s concerns and
suggestions. ● Act confidently and decisively in a crisis.
Ways to Acquire and Maintain Referent Power ● Show acceptance and positive regard. ● Act supportive and helpful. ● Use sincere forms of ingratiation. ● Defend and back up people when appropriate. ● Do unsolicited favors. ● Make self-sacrifices to show concern. ● Keep promises.
Adapted from Yukl, G. (2007). Leadership in organizations (6th ed.) (pp. 150–156). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.
90 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Individual nurses can promote an image of power by a variety of means, such as:
1. Appropriately introducing yourself by saying your name, making eye contact, and shaking hands can immediately establish you as a powerful person. If nurses introduce themselves by first name to the physician, Dr. Smith, they have immediately set forth an unequal power relationship unless the physician also uses his or her first name. Although women are not socialized to initiate handshakes, it is a power strategy in male-dominated circles, including health care organizations. In Western cultures, eye contact conveys a sense of confidence and connection to the individual to whom one is speaking. These seemingly minor behaviors can have a major impact on how competent and powerful the nurse is perceived.
2. Attire can symbolize power and success (Sullivan, 2013). Although nurses may believe that they are limited in choice of attire by uniform codes, it is in fact the presentation of the uniform that can hold the key to power. For example, a nurse manager needs a powerful image both with unit staff and with administrators and other professionals who are setting organizational policy. An astute nurse manager might wear a suit rather than a uniform to work on the day of a high-level interdisciplinary committee meeting. Certainly, attention to details of grooming and uniform selection can enhance the power of the staff nurse as well.
3. Conveying a positive and energetic attitude sends the message that you are a “doer” and someone to be sought out for involvement in important issues. Chronic complaining con- veys a sense of powerlessness, whereas solving problems and being optimistic promote a “can do” attitude that suggests power and instills confidence in others.
4. Pay attention to how you speak and how you act when you speak. Nonverbal signs and signals say more about you than words. Stand erect and move energetically. Speak with an even pace and enunciate words clearly. Make sure your words are reflected in your body language. Keep your facial expression consistent with your message.
5. Use facts and figures when you need to demonstrate your point. Policy changes usually evolve from data presented in a compelling story. Positioning yourself as a powerful player requires the ability to collect and analyze data. Technology facilitates data retrieval. For example, Chapter 6 lists various quality initiatives that yield useful data, including bench- marks and dashboards. Remember that power is a matter of perception; therefore, you must use whatever data are available to support your judgment.
6. Knowing when to be at the right place at the right time is crucial to gain access to key per- sonnel in the organization. This means being invited to events, meetings, and parties not necessarily intended for nurses. It means demanding to sit at the policy table when decisions affecting staffing and patient care are made. Influence is more effective when it is based on personal relationships and when people see others in person: “If I don’t see you, I can’t ask you for needed information, analysis, and alternative recommendations.” Become vis- ible. Be available. Offer assistance. You can be invaluable in providing policy makers with information, interpreting data, and teaching them about the nursing side of health care.
7. In dealing with people outside of nursing, it is important to develop powerful partnerships. Learn how to share both credit and blame. When working on collaborative projects, use “we” instead of “they,” and be clear about what is needed. If something isn’t working well, say so. Never accept another’s opinion as fact. Facts can be easily manipulated to fit one’s personal agenda. Learn how to probe and obtain additional information. Don’t assume you have all the information. Beware of unsolicited commentary. Don’t be fearful of giving strong criticism, but always put criticisms in context. Before giving any criticism, give a compliment, if appropriate. Also, make sure your partners are ready to hear all sides of the issue. It’s never superfluous to ask, “Do you want to talk about such and such right now?” Once an issue is decided—really decided—don’t raise it again.
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 91
8. Make it a point to get to know the people who matter in your sphere of influence. Become a part of the power network so that when people are discussing issues or seeking people for important appointments of leadership, your name comes to mind. Be sure to deal with senior people. The more contact you have with the “power brokers,” the more support you can generate in the future should the need arise. The more power you use, the more you get.
9. Know who holds the power. Identify the key power brokers. Develop a strategy for gaining access to power brokers through joining alliances and coalitions. Learn how to question others and how to become part of the organizational infrastructure. There is an art to de- termining when, what, and how much information is exchanged and communicated at any one time and to determining who does so. Powerful people have a keen sense of timing. Be sure to position yourself to be at the right place at the right time. Any strategy will involve a good deal of energy and effort. Direct influence and efforts toward issues of highest prior- ity or when greatest benefits are likely to result.
10. Use power appropriately to promote consensus in organizational goals, develop common means to achieve these goals, and enhance a common culture to bind organizational mem- bers together. As the health care providers closest to the patient, nurses best understand patients’ needs and wants. In the hospital, nurses are present on the first patient contact and thereafter for 24 hours a day, 7 days a week. In the clinic, the nurse may be the person the patient sees first and most frequently. By capitalizing on the special relationship that they have with patients, nurses can use marketing principles to enhance their position and image as professional caregivers.
Nursing as a profession must market its professional expertise and ability to achieve the objectives of health care organizations. From a marketing perspective, nursing’s goal is to ensure that identified markets (e.g., patients, physicians, other health professionals, community members) have a clear understanding of what nursing is, what it does, and what it is going to do. In doing so, nursing is seen as a profession that gives expert care with a scientific knowledge base.
Nursing care often is seen as an indicator of an organization’s overall quality. Regardless of the setting, quality nursing care is something that is desired and valued. Through understanding patients’ needs and preferences for programs that promote wellness and maintain and restore health, nurses become the organization’s competitive edge to enhancing revenues. Marketing an image of expertise linked with quality and cost can position nursing powerfully and competi- tively in the health care marketplace.
Using Power Appropriately Using power not only affects what happens at the time, but also has a lasting effect on your re- lationships. Therefore, it is best to use the least amount of power necessary to accomplish your goals. Also, use power appropriate to the situation (Sullivan, 2013). Table 7-1 lists rules for us- ing power.
Improper use of power can destroy a manager’s effectiveness. Power can be overused or un- derused. Overusing power occurs when you use excessive power relative to the situation. If you fail to use power when it is needed, you are underusing your power. In addition to the immediate loss of influence, you may lose credibility for the future.
Power plays are another way that power is used inappropriately. Power plays are attempts by others to diminish or demolish their opponents. Typical power plays include:
“Let’s be fair.” “Can you prove that?” “It’s either this or that; which is it? Take your pick.” “But you said . . . and now you say. . . .”
92 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Such statements engender feelings of insecurity, incompetence, confusion, embarrassment, and anger. You do not need to respond directly in these situations but, rather, you can simply restate your initial point in a firm manner. Keep your expression neutral, ignore accusations, and restate your position, if appropriate. If you refuse to respond to these thinly veiled attacks, your opponent is unable to intimidate and manipulate you.
Nursing must perceive power for what it really is—the ability to mobilize and focus energy and resources. What better position can nurses be in but to assume power to face new problems and re- sponsibilities in reshaping nursing practice to adapt to environmental changes? Power is the means, not the end, to seek new ways for doing things in this uncertain and unsettling time in health care.
Shared Visioning as a Power Tool Shared visioning is a powerful tool to influence the organization’s future. Shared visioning is an interactive process in which both leaders and followers commit to the organization’s goals (Kantabutra, 2009; Pearce, Conger, & Locke, 2008). A vision is a mental model of a possible future (Kantabutra, 2008). It should inspire and challenge both leaders and followers to accom- plish the organization’s goals set forth in the vision.
Top-down management is an out-of-date concept (Pearce, Conger, & Locke, 2008). Today’s leaders recognize that their power must be shared and that integrated leadership styles—bottom-up and lateral—are essential for success. Consensus about the organization’s future can motivate leaders and employees alike to envision their preferred future and do their best to achieve it. In addition, a shared vision makes implementing the necessary, and often difficult, changes easier.
Kantabutra (2009) posits that the leader is not a passive participant in the visioning process. The leader should be an active group member, leading the group toward the desired vision in a participative fashion. The leader helps guide the group toward consensus.
Furthermore, innovation is necessary for organizations to effect positive change (McKeown, 2008). Innovation requires employee buy-in to flourish (Melnyk & Davidson, 2009). Shared visioning is a strategy that encourages innovation.
Power, Politics, and Policy While power is the potential ability to influence others, politics is the art of influencing others to achieve a goal (Mason, Chaffee, & Leavitt, 2011).
TABLE 7-1 Rules for Using Power
1. Use the least amount of power you can to be effective in your interactions with others.
2. Use power appropriate to the situation.
3. Learn when not to use power.
4. Focus on the problem, not the person.
5. Make polite requests, never arrogant demands.
6. Use coercion only when other methods don’t work.
7. Keep informed to retain your credibility when using your expert power.
8. Understand you may owe a return favor when you use your connection power.
From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 93
Politics:
● Is an interpersonal endeavor—uses communication and persuasion ● Is a collective activity—requires the support and action of many people ● Calls for analysis and planning—requires an assessment of the issue and a plan to resolve it ● Involves image—hinges on the image people have of change makers
Nursing’s Political History Nurses’ political activities began with Florence Nightingale, continued with the emergence of nursing schools and women’s suffrage, and improved with the establishment of nursing organizations and the feminist movement (Sullivan, 2013). Establishing the National Center for Nursing Research (later changed to the National Institute of Nursing Research) within the National Institutes of Health is an example of nurses’ powerful political action.
A Brief History of the National Institute of Nursing Research
After the Institute of Medicine report recommended a federal nursing research entity as part of the mainstream scientific community in the early 1980s, nursing leaders in the United States began promoting establishment of a nursing institute at the National Insti- tutes of Health. This effort involved lobbying Congress, the Reagan administration, and the other institutes at NIH—a formidable task. A few members of Congress were interested in the potential that nursing science had for improving health, but the administration was not in favor of another institute at NIH, and the other institutes seemed puzzled as to why nursing would need its own institute to do research. Couldn’t nurse researchers receive funding through existing institutes? Medicine did so without a separate institute.
Step by step, nursing leaders persuaded (harassed?) institute directors and Congress, insisting that nursing research would improve human response to illness and assist in maintaining and enhancing health. A bill was born. Concern about cost and increasing bureaucracy emerged and was overcome. The bill passed only to be vetoed by President Reagan. Then a funny thing happened. Nursing made an unprecedented move. The profession came together, united with one goal: to override President Reagan’s veto (none had been successfully overridden before).
One by one, across the country, nurses called their senators and congressional represen- tatives urging support for a nursing institute, explaining that nurses were represented only among a few funded researchers at other institutes who did not understand the impact of nursing interventions on health and recovery. A modest investment, they explained, would yield exponentially greater results. Thanks to a few persuasive members of Congress, a compromise was negotiated and the National Center for Nursing Research was estab- lished in 1985. Through a statutory revision in 1993, the Center became an Institute.
Similarly, Georgia nurses successfully changed that state’s practice act to include prescrip- tive authority for advanced practice nurses, overcoming fierce opposition from the medical as- sociation (Beall, 2007). Working in concert with each other and with consumers and the media, they generated a letter-writing campaign that countered every obstacle the medical association tried. Georgia became the last state to grant prescribing privileges to nurse practitioners.
Policy, on the other hand, is the decision that determines action. Policies result from political action.
Using Political Skills to Influence Policies Political skill, per se, is not included in nursing education (nor is it tested on state board exams), yet it is a vital skill for nurses to acquire. To improve your political skill:
● Learn self-promotion—report your accomplishments appropriately. ● Be honest and tell the truth—say what you mean and mean what you say. ● Use compliments—recognize others’ accomplishments.
94 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
● Discourage gossip—silence is the best response. ● Learn and use quid pro quo—do and ask for favors. ● Remember: appearance matters—attend to grooming and attire. ● Use good manners—be courteous. (Green & Chaney, 2006)
Health care involves multiple special-interest groups all competing for their share of a limited pool of resources. The delivery of nursing services occurs at many levels in health care organizations. The effectiveness of care delivery is linked to the application of power, politics, and marketing. Nurses belong to a complex organization that is continually confronted with limited resources and is in competition for those resources.
How politically savvy are you? Ask yourself the following questions:
● Do you get credit for your ideas? ● Do you know how to deal with a difficult colleague? ● Do you have a mentor? ● Are you “in the loop”? ● Can you manage and influence others’ perceptions of you and your work? ● Are you able to convert enemies to friends? ● Do your ideas get a fair hearing? ● Do you know when and how to present them? (Reardon, 2011)
To take action, first decide what you want to accomplish. Is it realistic? Will you have supporters? Who will be the detractors? The steps in political action are shown in Table 7-2.
Try to find out what other people involved, called stakeholders, want. Maybe you could piggyback on their ideas. Members of Congress do this all the time by adding amendments to proposed bills in an attempt to satisfy their opponents.
Start telling your supporters about your idea and see if they will join with you in a coalition. This is not necessarily a formal group but allows you to know who you can count on in the discussions.
Find out exactly what objections your opponents have. Try to figure out a way to alter your plan accordingly or help your opponents understand how your proposal might help them. Political action is never easy, but the most politically astute people accomplish goals far more often than those who don’t even try.
A case study that exemplifies a nurse using organizational politics is shown in Case Study 7-1.
Influencing Public Policies What happens in the workplace both depends on and influences what is happening in the larger community, professional organizations, and government. Developing influence in each of these three groups takes time and a long-range plan of action. Although the nurse’s first priority should be to establish influence in the workplace, the nurse can gradually increase connections and in- fluence with other groups and, later on, make these other groups a priority.
TABLE 7-2 Steps in Political Action
1. Determine what you want. 2. Learn about the players and what they want. 3. Gather supporters and form coalitions. 4. Be prepared to answer opponents. 5. Explain how what you want can help them.
From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 95
In order to influence public policies, nurses need to know how to work with the public officials who enact those policies. Table 7-3 lists guidelines for working with public officials.
First, be respectful. Public officials have many constituents and demands on their support. Build relationships with officials. Don’t just contact them when you have a request. Keep in touch at other times.
Communicating with Elected Officials Nurses often wish to contact elected officials to support or oppose legislation. You can call, e-mail, tweet, or write to public officials. (Links to state legislators and contact information for federal government officials are listed in the Web resources for this chapter.)
Here’s how to contact state or federal elected officials. Call the official’s staff and ask to speak to the person who handles the issue that concerns you. Tell the aide that you support or oppose a certain bill and state the reasons why. Name the bill by number.
USING ORGANIZATIONAL POLITICS FOR PERSONAL ADVANTAGE Juanita Pascheco has been nurse manager of medical and surgical ICUs in a large, urban, for-profit hospital for the past seven years. Two years ago, Juanita completed her master’s degree in nursing administration. Her the- sis research centered on the acceptance of standardized and computerized documentation methods for critical care units. Juanita is well respected in her current role and is a member of several key committees addressing the need for a replacement health information system (HIS) for the hospital. She reports directly to the director of critical care services.
Although Juanita enjoys her work as nurse man- ager, she believes she is ready to assume additional responsibilities at the director level. Through her work on the hospital’s HIS selection team and as the nursing representative to the physician’s technology committee, Juanita identifies the need for a clinical informatics di- rector role. One of Juanita’s responsibilities on the HIS selection team is to identify talent from clinical areas who could support the HIS implementation. Juanita has also agreed to chair several working committees that will assist in determining required clinical functionality for the HIS.
During her tenure at the hospital, Juanita has cul- tivated solid working relationships with several key de- cision makers within the organization. The human re- sources director, Ken Harding, has worked with Juanita on several large projects over the past two years, in- cluding implementation of multidisciplinary teams in the ICUs. Juanita schedules a lunch with Ken to discuss growth opportunities in the information technology department, the process for creating new roles, and in particular, who will determine the need for and ap- proval of new information technology positions. Using this knowledge and her experience on the HIS selection
team and the physicians’ technology committee, Juanita develops a proposal for the clinical informatics director position.
As the HIS selection team draws closer to selecting a final vendor for the computerized health information system and an implementation timeline is established by the information technology department, Juanita ap- proaches her supervisor, Sherrie Wright, with her pro- posal. Juanita also provides Sherrie with an overview of the clinical support that will be necessary for successful implementation of the HIS product. Since the critical care units are targeted for the initial phase of imple- mentation, Sherrie is aware that Juanita’s high interest in technology and her clinical expertise in the ICU would be invaluable for successful implementation. As a strong manager, Juanita can build acceptance of this change among the nurses, physicians, and other members of the health care team.
Sherrie agrees to take Juanita’s proposal to the chief nursing officer for formal consideration.
Manager’s Checklist The nurse manager is responsible for:
● Knowing and understanding the formal lines of authority within the organization.
● Identifying key decision makers and understanding their priorities and how those priorities affect any new initiatives.
● Recognizing the importance of timing when initiating change.
● Being ready to take advantage of new opportunities. ● Building strong and credible working relationships
with decision makers. ● Being willing to take on new and challenging tasks
that may lead to more responsibility.
CASE STUDY 7-1
96 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
E-mail or write directly to the official. Identify the bill in question, state your position on the bill, and explain why you support or oppose it. Keep your comments brief, and address only one issue per correspondence. Hand-written letters get more attention than form letters distributed by organizations.
Use this format to address members of the U.S. Senate:
The Honorable (full name of senator) __(Rm.#)__(name of) Senate Office Building United States Senate Washington, DC 20510
Dear Senator:
To contact the member of the U.S. Congress, use a similar format.
The Honorable (full name) __(Rm.#)__(name of) House Office Building United States House of Representatives Washington, DC 20515
Dear Representative:
Meeting with Elected Officials To meet in person with an elected official, make an appointment, arrive on time, and come pre- pared. Understand the pros and cons of the issue you are bringing to the person’s attention. Be a constructive opponent. Argue for your position and be prepared with additional information and alternative suggestions. Still, be realistic. What you want may not be possible, or it may not be likely at the present time. Always be helpful. Show how your issue benefits the official’s constituents and, thus, the representative.
The American Association of Critical-Care Nurses suggests pointers for working with public officials (AACN, 2010). In addition, the American Nurses Association (ANA) has legislative and government information for nurses (ANA, 2011). (See links to these organizations in the Web resources for this chapter.)
Using Power and Politics for Nursing’s Future Kelly (2007) suggests that apathy prevents nurses from using their political skills. Becoming active in professional associations, learning the legislative issues that affect nursing, gaining political skills, and being willing to advocate for nursing’s causes are necessary for the profes- sion to flex its considerable political muscles. All nurses can participate to some extent in these activities.
Nurses can have a tremendous impact on health care policy. The best impact is often made with a bit of luck and timing, but never without knowledge of the whole system. This includes
TABLE 7-3 How to Work with Public Officials
1. Be respectful. 5. Understand the issue. 2. Build relationships. 6. Be a constructive opponent. 3. Keep in touch. 7. Be realistic. 4. Arrive informed. 8. Be helpful.
From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.
CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 97
knowledge of the policy agenda, the policy makers, and the politics that are involved. Once you gain this knowledge, you are ready to move forward with a political base to promote nursing.
To convert your policy ideas into political realities, consider the following power points:
● Use persuasion over coercion. Persuasion is the ability to share reasons and rationale when making a strong case for your position while maintaining a genuine respect for an- other’s perspective.
● Use patience over impatience. Despite the inconveniences and failings caused by health care restructuring, impatience in the nursing community can be detrimental. Patience, along with a long-term perspective on the health care system, is needed.
● Be open-minded rather than closed-minded. Acquiring accurate information is essential if you want to influence others effectively.
● Use compassion over confrontation. In times of change, errors and mistakes are easy to pinpoint. It takes genuine care and concern to change course and make corrections.
● Use integrity over dishonesty. Honest discourse must be matched with kind thoughts and actions. Control, manipulations, and malice must be pushed aside for change to occur.
By using their political skills, nurses can improve patient care in individual institutions, help organizations survive and thrive, and influence public officials.
What You Know Now • Power is the potential ability to influence others. • Power can be positional or personal. • Types of power include reward, coercive, legitimate, expert, referent, information, and connection. • Image is a source of power. • Power can be overused, underused, or used inappropriately. To be effective, the power used must be appro-
priate to the situation. • Shared visioning is an interactive process in which both leaders and followers commit to the organiza-
tion’s goals. • Politics is the art of influencing others to achieve a goal. • Policy is the decision that determines action. Policies result from political action. • Nurses can use political action to influence policies in the organization and to influence public policies.
Tools for Using Power and Politics 1. Learn the formal lines of authority within your organization. 2. Identify key decision makers and build strong and credible relationships with them. 3. Identify decision makers’ priorities and how those affect any new initiatives. 4. Learn the rules for using power and put them into practice. 5. Offer solutions to problems and take advantage of new opportunities. 6. Exhibit a willingness to take on new and challenging tasks that may lead to more responsibility. 7. Pay attention to people who are influential and adopt their strategies if appropriate. 8. Learn strategies for working with public officials.
Questions to Challenge You 1. Consider a person you believe to have power. What are the bases of that person’s power? 2. Evaluate how the person you named uses his or her power. Is it positive or negative? 3. Have you observed people using power inappropriately? Describe what they did and what happened
as a result.
98 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
4. Assess your own power using the seven types of power discussed in the chapter. Name three ways you could increase your power.
5. How politically savvy are you? Did you discover areas to challenge you? 6. Have you been involved in developing policies in your organization or have you worked with public
officials? Explain.
References American Association of Critical
Care Nurses. (2010). Advo- cacy 101: Golden rules for those who work with public officials. Retrieved October 22, 2010 from http://www. aacn.org/wd/practice/ content/publicpolicy/ goldenrules.pcms?pid=1& mid=2874&menu=Comm unity
American Nurses Association. (2011). RN activist kit. Retrieved June 3, 2011 from www.nursingworld. org/gova
Beall, F. (2007). Overview and summary: Power to influence patient care: Who holds the keys? Online Journal of Is- sues in Nursing, 12(1). Retrieved October 22, 2010 from http://www. nursingworld.org/MainMe- nuCategories/ANAMar- ketplace/ANAPeriodicals/ OJIN/TableofContents/ Volume122007/No1Jan07/ tpc32ntr16088.aspx
Covey, S. R. (1991). Principle- centered leadership. New York: Simon & Schuster.
Green, C. G., & Chaney, L. H. (2006). The game of office politics. Supervision, 67(8), 3–6.
Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.
Ikeda, J. (2009). Principle cen- tered power. Retrieved April 12, 2011 from http:// www.leadwithhonor. com/blog/2009/03/26/ principle-centered-power/
Kantabutra, S. (2008). What do we know about vision? Journal of Applied Business Research, 24(2), 323–342.
Kantabutra, S. (2009). Toward a behavioral theory of vision in organizational settings. Leadership & Organiza- tional Development Jour- nal, 30(4), 319–337.
Kelly, K. (2007). From apathy to political activism. American Nurse Today, 2(8), 55–56.
Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2011). Policy and politics in nurs- ing and health care (6th ed.). Philadelphia: W. B. Saunders.
McKeown, M. (2008). The truth about innovation. Great Britain: Pearson Education Limited.
Melnyk, B. M., & Davidson, S. (2009). Creating a culture of innovation in nursing education through shared vision, leader- ship, interdisciplinary partnerships, and positive deviance. Nursing Admin- istration Quarterly, 33(4), 288–295.
Pearce, C. L., Conger, J. A., & Locke, E. A. (2008). Shared leadership theory. The Leadership Quarterly, 19(3), 622–628.
Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health.
Web Resources American Association of Critical-Care Nurses: www.aacn.org American Nurses Association: www.nursingworld.org United States House of Representatives: www.house.gov United States Senate: www.senate.gov National Conference of State Legislatures: www.ncsl.org
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
www.nursingworld.org/gova
www.nursingworld.org/gova
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/
http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/
www.aacn.org
www.nursingworld.org
www.house.gov
www.senate.gov
www.ncsl.org
www.nursing.pearsonhighered.com
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community
http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/
http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx
CHAPTER
Critical Thinking CRITICAL THINKING IN NURSING
USING CRITICAL THINKING
CREATIVITY
Decision Making TYPES OF DECISIONS
DECISION-MAKING CONDITIONS
THE DECISION-MAKING PROCESS
DECISION-MAKING TECHNIQUES
GROUP DECISION MAKING
Problem Solving PROBLEM-SOLVING METHODS
THE PROBLEM-SOLVING PROCESS
GROUP PROBLEM SOLVING
Stumbling Blocks
Innovation
Thinking Critically, Making Decisions, Solving Problems
8
Key Terms Adaptive decisions Artificial intelligence Brainstorming Creativity Critical thinking Decision making Democratic leadership Descriptive rationality model Experimentation
1. Discuss how to use the critical-thinking process.
2. Describe ways to foster creativity. 3. Develop a plan to improve your
decision-making and problem-solving skills.
4. Compare and contrast individual and collective decision-making processes in various situations.
5. Recognize stumbling blocks to making decisions and solving problems.
6. Foster innovation in your work and that of others.
Learning Outcomes After completing this chapter, you will be able to:
Expert systems Groupthink Innovation Innovative decisions Objective probability Political decision-making
model Probability Probability analysis
Problem solving Rational decision-making
model Routine decisions Satisficing Subjective probability Trial-and-error method
100 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
N urse managers are expected to use knowledge from various disciplines to solve prob-lems with patients, staff, and the organization as well as problems in their own personal and professional lives. They must make decisions in dynamic situations, such as: ● After a position vacates should we refill it, given the tighter economy? ● Is the present policy requiring 12-hour shifts adequate for both patients and nurses? ● Which is the best staffing pattern to prevent turnover and ensure quality patient care? ● What is the best time to have staff meetings and council meetings in order to involve the
night shift too?
This chapter explains and differentiates critical thinking, decision making, and problem solv- ing and describes processes and techniques for using each.
Critical Thinking Critical thinking is the process of examining underlying assumptions, interpreting and evaluat- ing arguments, imagining and exploring alternatives, and developing a reflective criticism for the purpose of reaching a conclusion that can be justified. Critical thinking is not the same as criticism, though it does call for inquiring attitudes, knowledge about evidence and analysis, and skills to combine them.
Critical-thinking skills can be used to resolve problems rationally. Identifying, analyz- ing, and questioning the evidence and implications of each problem stimulate and illuminate critical thought processes. Critical thinking is also an essential component of decision making. However, compared to problem solving and decision making, which involve seeking a single solution, critical thinking is a higher-level cognitive process that includes creativity, problem solving, and decision making (Figure 8-1).
Critical Thinking in Nursing The need for critical thinking in nursing has long been accepted. Zori, Nosek, and Musil (2010) used the California Critical Thinking Disposition Inventory to measure critical thinking in nurses. The researchers found that the nurses supervised by managers with higher critical think- ing skills perceived their work environment to be more positive than those whose managers scored lower on critical-thinking skills.
Case scenarios and discussion of clinical experiences taught newly licensed nurses critical thinking and improved their retention rate in one facility (Ashcraft, 2010). Bittner and Gravlin (2009) studied nurses’ critical-thinking skills when delegating to assistive personnel. They found that the nurse’s lack of critical thinking more often resulted in missed or omitted routine care.
Problem solving
Creativity
Decision making
Critical thinking
Figure 8-1 • Critical-thinking model.
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 101
The Carnegie Foundation’s call for reform in nursing education argues, however, that nurs- ing should move beyond critical thinking toward clinical reasoning and diverse thinking (Benner et al., 2009).
Using Critical Thinking The critical-thinking process seems abstract unless it can be related to practical experiences. One way to develop this process is to consider a series of questions when examining a specific problem or making a decision, such as:
1. What are the underlying assumptions? Underlying assumptions are unquestioned beliefs that influence an individual’s reasoning. They are perceptions that may or may not be grounded in reality. For example, some people believe the AIDS epidemic is punishment for homosexual behavior. This attitude toward people with AIDS could alter one’s approach to care for an AIDS patient.
2. How is evidence interpreted? What is the context? Interpretation of information also can be value laden. Is the evidence presented completely and clearly? Can the facts be substan- tiated? Are the people presenting the evidence using emotional or biased information? Are there any errors in reasoning?
3. How are the arguments to be evaluated? Is there objective evidence to support the arguments? Have all value preferences been determined? Is there a good chance that the arguments will be accepted? Are there enough people to support decisions? Health care organizations were able to change to smoke-free environments once societal values favored nonsmokers, and public policies reflected those values.
4. What are the possible alternative perspectives? Using different basic assumptions and paradigms can help the critical thinker develop several different views of an issue. Com- pare how a nurse manager who assumes that more RNs equal better care will deal with a budget cut with a manager who is committed to adding assistive personnel instead. What evidence supports the alternatives? What solutions do staff members, patients, physicians, and others propose? What would be the ideal alternative?
Critical-thinking skills are used throughout the nursing process (see Table 8-1). Nurses can build on the knowledge base they began acquiring in school to make the critical-thinking process a conscious one in daily activities. Learning to be a critical thinker requires a commitment over time, but the skills can be learned. The characteristics of an expert critical thinker are shown in Box 8-1.
Creativity Creativity is an essential part of the critical-thinking process. Creativity is the ability to develop and implement new and better solutions. Creativity demands a certain amount of exposure to outside contacts, receptiveness to new and seemingly strange ideas, a certain amount of free- dom, and some permissive management.
Most nurses, however, are employed in bureaucratic settings that do not foster creativity. Control is exercised over staff, and rigid adherence to formal channels of communication jeopardizes innovation. In addition, there is little room for failure, and when failures do occur they are not well tolerated. When staff are afraid of the consequences of failure, their creativity is inhibited and innovation does not take place. (See later section on innovation.)
Maintaining a certain level of creativity is one way to keep an organization alive. New employees, who are not encumbered with details of accepted practices often can make sugges- tions based on their prior experiences or insights before they get set in their ways or have their innovative ideas “turned off.” The advantages offered by new employees should be explored because all staff gain from such use of valuable human resources.
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BOX 8-1 Characteristics of an Expert Critical Thinker
● Outcome-directed ● Open to new ideas ● Flexible ● Willing to change ● Innovative ● Creative ● Analytical ● Communicator ● Assertive
● Persistent ● Caring ● Energetic ● Risk taker ● Knowledgeable ● Resourceful ● Observant ● Intuitive ● “Out of the box” thinker
From Ignatavicius, D.D. (2001). Six critical thinking skills for at-the-bedside success. Nursing Management, 32(1), 37–39.
TABLE 8-1 Critical Thinking Through the Nursing Process
The Nursing Process Critical-Thinking Skills
Assessment Observing Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating data Organizing data Categorizing data
Diagnosis Finding patterns and relationships Making inferences Stating the problem Suspending judgment
Planning Generalizing Transferring knowledge from one situation to another Hypothesizing
Implementation Applying knowledge Testing hypotheses
Evaluation Deciding whether hypotheses are correct Making criterion-based evaluations
From Wilkinson, J. (1992). Nursing process in action: A critical thinking approach. Redwood City, CA: Addison-Wesley Nursing, p. 29.
The climate must promote the survival of potentially useful ideas. The nurse manager can foster a climate of support by giving new ideas a fair and adequate hearing, and thereby reduce the tendency to discourage the creative process in individuals and within groups. The challenge for nurse managers is to know when, for whom, and to what extent control is appropriate. If cre- ativity does have a priority in the health care setting, then the reward system should be geared to and commensurate with that priority.
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 103
Preparation
Steps Definition
Information gathering
Incubation
Insight
Verification
Unconscious work going on
Solutions emerge
Solutions evaluated
Figure 8-2 • The creative process.
Creativity has four stages: preparation, incubation, insight, and verification. Even people who think they are not naturally creative can learn this process (Figure 8-2).
1. Preparation. A carefully designed planning program is essential. First, acquire informa- tion necessary to understand the situation. Individuals can do this on their own, or groups can work together.
The process follows this sequence:
• Pick a specific task • Gather relevant facts • Challenge every detail • Develop preferred solutions • Implement improvements
2. Incubation. After all the information available has been gathered, allow as much time as possible to elapse before deciding on solutions.
3. Insight. Often solutions emerge after a period of reflection that would not have occurred to anyone without this time lapse.
4. Verification. Once a solution has been implemented, evaluate it for effectiveness. You may need to restart the process or go back to another step and create a different solution.
Case Study 8-1 describes how one nurse manager used creativity to solve a problem.
Decision Making Considering all the practice individuals get in making decisions, it would seem they might become very good at it. However, the number of decisions a person makes does not correspond to the person’s skill at making them. The assumption is that decision making comes naturally, like breathing. It does not.
The decision-making process described in this chapter provides nurses with a system for making decisions that is applicable to any decision. It is a useful procedure for making practical choices. A decision not to solve a problem is also a decision.
Although decision making and problem solving appear similar, they are not synonymous. Decision making may or may not involve a problem, but it always involves selecting one of several alternatives, each of which may be appropriate under certain circumstances. Problem solving, on the other hand, involves diagnosing a problem and solving it, which may or may not entail deciding on one correct
104 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
solution. Most of the time, decision making is a subset of problem solving. However, some decisions are not of a problem-solving nature, such as decisions about scheduling, equipment, or in-services.
Types of Decisions The types of problems nurses and nurse managers encounter and the decisions they must make vary widely and determine the problem-solving or decision-making methods they should use. Relatively well defined, common problems can usually be solved with routine decisions, often using established rules, policies, and procedures. For instance, when a nurse makes a medica- tion error, the manager’s actions are guided by policy and the report form. Routine decisions are more often made by first-level managers than by top administrators.
Adaptive decisions are necessary when both problems and alternative solutions are some- what unusual and only partially understood. Often they are modifications of other well-known problems and solutions. Managers must make innovative decisions when problems are unusual and unclear and when creative, novel solutions are necessary.
Decision-Making Conditions The conditions surrounding decision making can vary and change dramatically. Consider the total system. Whatever solutions are created will succeed only if they are compatible with other parts of the system. Decisions are made under conditions of certainty, risk, or uncertainty.
Decision Making Under Certainty When you know the alternatives and the conditions surrounding each alternative, a state of cer- tainty is said to exist. Suppose a nurse manager on a unit with acutely ill patients wants to decrease the number of venipunctures a patient experiences when an IV is started, as well as reduce costs resulting from failed venipunctures. Three alternatives exist:
● Establish an IV team on all shifts to minimize IV attempts and reduce costs ● Establish a reciprocal relationship with the anesthesia department to start IVs when nurses
experience difficulty ● Set a standard of two insertion attempts per nurse per patient, although this does not sub-
stantially lower equipment costs
CREATIVE PROBLEM SOLVING Jeffrey was just promoted to manager of an acute care clinic, which recently expanded its hours from 6 A.M. un- til 10 P.M. He soon realizes that staff nurses are reluctant to sign up on the schedule and do quality chart audits, an important process used to review clinic operations and patients’ care. He gathers information about qual- ity improvement, reviews the literature on motivation and incentives, and discusses the issue with other nurse managers (preparation).
Jeffrey continues to manage the clinic, thinking about the information he has gathered but does not consciously make a decision or reject new ideas (incuba- tion). When working on a new problem, self-scheduling for the change in hours, he realizes a connection between the two problems. Many nurses complain that by the time they receive the schedule the day shifts are filled.
Jeffrey decides to review the chart audits. Nurses who regularly participate in quality improvement projects will receive a “perk.” They will be allowed, on a rotating basis, first choice at selecting the schedule they want to work (this is the insight stage). He discusses the plan with the staff and proposes a two-month trial period to deter- mine whether the solution is effective (verification).
Manager’s Checklist The nurse manager is responsible for:
● Identifying problem areas ● Generating ideas that might serve as possible
solutions ● Checking with others for advice ● Selecting motivators ● Implementing a solution ● Evaluating the results
CASE STUDY 8-1
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 105
The manager knows the alternatives (IV team, anesthesia department, standards) and the conditions associated with each option (reduced costs, assistance with starting IVs, minimum attempts and some cost reduction). A condition of strong certainty is said to exist and the decision can be made with full knowledge of what the payoff probably will be.
Decision Making Under Uncertainty and Risk Seldom do decision makers know everything there is to know about a subject or situation. If everything was known, the decision would be obvious for all to realize.
Most critical decision making in organizations is done under conditions of uncertainty and risk. The individual or group making the decision does not know all the alternatives, attendant risks, or possible consequences of each option. Uncertainty and risk are inevitable because of the complex and dynamic nature of health care organizations.
Here is an example: If the weather forecaster predicts a 40 percent chance of snow, the nurse manager is operating in a situation of risk when trying to decide how to staff the unit for the next 24 hours.
In a risk situation, availability of each alternative, potential successes, and costs are all as- sociated with probability estimates. Probability is the likelihood, expressed as a percentage, that an event will or will not occur. If something is certain to happen, its probability is 100 percent. If it is certain not to happen, its probability is 0 percent. If there is a 50–50 chance, its probability is 50 percent.
Here is another example: Suppose a nurse manager decides to use agency nurses to staff a unit during heavy vacation periods. Two agencies look attractive, and the manager must decide between them. Agency A has had modest growth over the past 10 years and offers the manager a three-month contract, freezing wages during that time. In addition, the unit will have first choice of available nurses. Agency B is much more dynamic and charges more but explains that the reason they have had a high rate of growth is that their nurses are the best and the highest paid in the area. The nurse manager can choose Agency A, which will pro- vide a safe, constant supply of nursing personnel, or B, which promises better care but at a higher cost.
The key element in decision making under conditions of risk is to determine the probabili- ties of each alternative as accurately as possible. The nurse manager can use a probability anal- ysis, whereby expected risk is calculated or estimated. Using the probability analysis shown in Table 8-2, it appears as though Agency A offers the best outcome. However, if the second agency had a 90 percent chance of filling shifts and a 50 percent chance of fixing costs, a completely different situation would exist.
The nurse manager might decide that the potential for increased costs was a small trade-off for having more highly qualified nurses and the best probability of having the unit fully staffed during vacation periods. Objective probability is the likelihood that an event will or will not occur based on facts and reliable information. Subjective probability is
TABLE 8-2 Probability Analysis
Probability Analysis
Agency A 60% Filling shifts 100% Fixed wages
Agency B 50% Filling shifts 70% Fixed wage
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the likelihood that an event will or will not occur based on a manager’s personal judgment and beliefs.
Janeen, a nurse manager of a specialized cardiac intensive care unit, faces the task of recruiting scarce and highly skilled nurses to care for coronary artery bypass graft patients. The obvious alternative is to offer a salary and benefits package that rivals that of all other institutions in the area. However, this means Janeen will have costly special- ized nursing personnel in her budget who are not easily absorbed by other units in the organization. The probability that coronary artery bypass graft procedures will become obsolete in the future is unknown. In addition, other factors (e.g., increased competi- tion, government regulations regarding reimbursement) may contribute to conditions of uncertainty.
The Decision-Making Process The rational decision-making model is a series of steps that managers take in an effort to make logical, well-grounded rational choices that maximize the achievement of objec- tives. First identify all possible outcomes, examine the probability of each alternative, and then take the action that yields the highest probability of achieving the most desirable outcome. Not all steps are used in every decision nor are they always used in the same order. The rational decision-making model is thought of as the ideal but often cannot be fully used.
Individuals seldom make major decisions at a single point in time and often are unable to recall when a decision was finally reached. Some major decisions are the result of many small actions or incremental choices the person makes without regarding larger issues. In addition, decision processes are likely to be characterized more by confusion, disorder, and emotionality than by rationality. For these reasons, it is best to develop appropriate technical skills and the capacity to find a good balance between lengthy processes and quick, decisive action.
The descriptive rationality model, developed by Simon in 1955 and supported by research in the 1990s (Simon, 1993), emphasizes the limitations of the rationality of the decision maker and the situation. It recognizes three ways in which decision makers depart from the rational decision-making model:
● The decision maker’s search for possible objectives or alternative solutions is limited be- cause of time, energy, and money
● People frequently lack adequate information about problems and cannot control the condi- tions under which they operate
● Individuals often use a satisficing strategy
Satisficing is not a misspelled word; it is a decision-making strategy whereby the individual chooses an alternative that is not ideal but either is good enough (suffices) under existing cir- cumstances to meet minimum standards of acceptance or is the first acceptable alternative. Many problems in nursing are ineffectively solved with satisficing strategies.
Elena, a nurse manager in charge of a busy neurosurgical floor with high turnover rates and high patient acuity levels, uses a satisficing alternative when hiring replace- ment staff. She hires all nurse applicants in order of application until no positions are open. A better approach would be for Elena to replace staff only with nurse applicants who possess the skills and experiences required to care for neurosurgical patients, re- gardless of the number of applicants or desire for immediate action. Elena also should develop a plan to promote job satisfaction, the lack of which is the real reason for the vacancies.
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Individuals who solve problems using satisficing may lack specific training in problem solv- ing and decision making. They may view their units or areas of responsibility as drastically sim- plified models of the real world and be content with this simplification because it allows them to make decisions with relatively simple rules of thumb or from force of habit.
The political decision-making model describes the process in terms of the particular inter- ests and objectives of powerful stakeholders, such as hospital boards, medical staffs, corporate officers, and regulatory bodies. Power is the ability to influence or control how problems and objectives are defined, what alternative solutions are considered and selected, what information flows, and, ultimately, what decisions are made (see Chapter 7).
The decision-making process begins when a gap exists between what is actually happening and what should be happening, and it ends with action that will narrow or close this gap. The simplest way to learn decision-making skills is to integrate a model into one’s thinking by break- ing the components down into individual steps. The seven steps of the decision-making process (Box 8-2) are as applicable to personal problems as they are to nursing management problems. Each step is elaborated by pertinent questions clarifying the statements, and they should be fol- lowed in the order in which they are presented.
Decision-Making Techniques Decision-making techniques vary according to the nature of the problem or topic, the decision maker, the context or situation, and the decision-making method or process. For routine decisions, choices that are tried and true can be made for well-defined, known situations or problems. Well-designed policies, rules, and standard operating procedures can produce satisfactory results with a minimum of time. Artificial intelligence, including programmed computer systems such as expert systems that can store, retrieve, and manipulate data, can diagnose problems and make limited decisions.
For adaptive decisions involving moderately ambiguous problems and modification of known and well-defined alternative solutions, there are a variety of techniques. Many types of decision grids or tables can be used to compare outcomes of alternative solutions. Decisions about units or services can be facilitated, with analyses comparing output, revenue, and costs over time or under different conditions. Analyzing the costs and revenues of a proposed new service is an example.
Regardless of the decision-making model or strategy chosen, data collection and analy- sis are essential. In many health care organizations, quality teams are using a variety of tools to gather, organize, and analyze data about their work such as decision grids, flow
BOX 8-2 Steps in Decision Making
1. Identify the purpose: Why is a decision necessary? What needs to be determined? State the issue in the broadest possible terms.
2. Set the criteria: What needs to be achieved, preserved, and avoided by whatever decision is made? The answers to these questions are the standards by which solutions will be evaluated.
3. Weigh the criteria: Rank each criterion on a scale of values from 1 (totally unimportant) to 10 (extremely important).
4. Seek alternatives: List all possible courses of action. Is one alternative more significant than another? Does one alternative have weaknesses in some areas? Can these be overcome? Can two alternatives or features of many alternatives be combined?
5. Test alternatives: First, using the same methodology as in step 3, rank each alternative on a scale of 1 to 10. Second, multiply the weight of each criterion by the rating of each alternative. Third, add the scores and compare the results.
6. Troubleshoot: What could go wrong? How can you plan? Can the choice be improved? 7. Evaluate the action: Is the solution being implemented? Is it effective? Is it costly?
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charts, or cause-and-effect diagrams. Figure 8-3 illustrates a cause-and-effect diagram that a team of nurses created to help them improve the documentation process for their ambulatory oncology unit.
Another example of a decision tool is the Dynamic Network Analysis Decision Support (DyNADS) project at the University of Arizona College of Nursing (see http://www.dynads.nursing. arizona.edu). This simulation product enables the manager to predict the consequences of decisions on patient safety and quality outcomes. The tool simulates virtual nursing units, identifies potential errors, and predicts the likely result. Using the tool, the manager can discover if an innovation or a combination of innovations is likely to be successful (Effkenet al., 2010). DyNADS is a decision support tool that improves predictability in today’s complex environment.
Group Decision Making The widespread use of participative management, quality improvement teams, and shared gover- nance in health care organizations requires every nurse manager to determine when group, rather than individual, decisions are desirable and how to use groups effectively. A number of stud- ies have shown that professional people do not function well in a micromanaged environment. As an alternative, group problem solving of substantial issues casts the manager in the role of facilitator and consultant. Compared to individual decision making, groups can provide more in- put, often produce better decisions, and generate more commitment. One group decision-making technique is brainstorming.
In brainstorming, group members meet together and generate many diverse ideas about the nature, cause, definition, or solution to a problem without consideration of their relative value. The focus team whose work is shown in Figure 8-3 used brainstorming.
With brainstorming, a premium is placed on generating lots of ideas as quickly as pos- sible and on coming up with unusual ideas. Most importantly, members do not critique ideas as they are proposed. Evaluation takes place after all the ideas have been generated. Members are
Cause
Equipment
Effect
Materials Methods
People
Staff MDs
Chart design
Lack of chart racks
Inadequate forms
Treatment nurses
Lack of focus
Clinicians
Fellows
Poor communication
Unclear chemotherapy orders
Less than adequate nursing
documentation Patient chart movement from clinics
Lack of procedures and guidelines
Lack of appropriate documentation forms
Figure 8-3 • Brainstorming session of a nursing quality focus team.
http://www.dynads.nursing.arizona.edu
http://www.dynads.nursing.arizona.edu
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 109
encouraged to improve on each other’s ideas. These sessions are enjoyable but are often unsuc- cessful because members inevitably begin to critique ideas, and as a result, meetings shift to the ordinary interacting group format. Criticisms of this approach are the high cost factor, the time consumed, and the superficiality of many solutions.
Problem Solving People use problem solving when they perceive a gap between an existing state (what is going on) and a desired state (what should be going on). How one perceives the situation influences how the problem is identified or solved. Therefore, perceptions need to be clarified before prob- lem solving can occur.
Problem-Solving Methods A variety of methods can be used to solve problems. People with little management experience tend to use the trial-and-error method, applying one solution after another until the problem is solved or appears to be improving. These managers often cite lack of experience and of time and resources to search for alternative solutions.
In a step-down unit with an increasing incidence of medication errors, Max, the nurse manager, uses various strategies to decrease errors, such as asking nurses to use calcu- lators, having the charge nurse check medications, and posting dosage and medication charts in the unit. After a few months, by which time none of the methods has worked, it occurs to Max that perhaps making nurses responsible for their actions would be more effective. Max develops a point system for medication errors: When nurses accumulate a certain amount of points, they are required to take a medication test; repeated failure of the test may eventually lead to termination. Max’s solution is effective and a low level of medication errors is restored.
As the above example shows, a trial-and-error process can be time-consuming and may even be detrimental. Although some learning can occur during the process, the nurse manager risks being perceived as a poor problem solver who has wasted time and money on ineffective solutions.
Experimentation, another type of problem solving, is more rigorous than trial and error. Pilot projects or limited trials are examples of experimentation. Experimentation in- volves testing a theory (hypothesis) or hunch to enhance knowledge, understanding, or pre- diction. A project or study is carried out in either a controlled setting (e.g., in a laboratory) or an uncontrolled setting (e.g., in a natural setting such as an outpatient clinic). Data are collected and analyzed and results interpreted to determine whether the solution tried has been effective.
Lin, a nurse manager of a pediatric floor, has received many complaints from mothers of children who think the nurses are short-tempered. Lin has a hunch that 12-hour shifts, which have been recently implemented on her floor, are contributing to the problem; she believes that nurses who must interact frequently with families would perform better on eight-hour shifts. She can test her theory by setting up a small study comparing the two staffing patterns with patient satisfaction.
Experimentation may be creative and effective or uninspired and ineffective, depending on how it is used. As a major method of problem solving, experimentation may be inefficient be- cause of the amount of time and control involved. However, a well-designed experiment can be persuasive in situations in which an idea or activity, such as a new staffing system or care proce- dure, can be tried in one of two similar groups and results objectively compared.
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Still other problem-solving techniques rely on past experience and intuition. Everyone has various and countless experiences. Individuals build a repertoire of these experiences and base future actions on what they considered successful solutions in the past. If a particular course of action consistently resulted in positive outcomes, the person will try it again when similar cir- cumstances occur. In some instances, an individual’s past experience can determine how much risk he or she will take in present circumstances.
The nature and frequency of the experience also contribute significantly to the effectiveness of this problem-solving method. How much the person has learned from these experiences, posi- tive or negative, can affect the current viewpoint and can result in either subjective, narrow judg- ments or wise ones. This is especially true in human relations problems. Intuition relies heavily on past experience and trial and error. The extent to which past experience is related to intuition is difficult to determine, but nurses’ wisdom, sensitivity, and intuition are known to be valuable in solving problems.
Some problems are self-solving: if permitted to run a natural course, they are solved by those personally involved. This is not to say that a uniform laissez-faire management style solves all problems. The nurse manager must not ignore managerial responsibilities, but often difficult situations become more manageable when participants are given time, resources, and support to discover their own solutions.
This typically happens, for example, when a newly graduated nurse joins a unit where most of the staff are associate degree RNs who resent the new nurse’s level of education as well as the nurse’s lack of experience. If the nurse manager intervenes, a problem that the staff might have worked out on their own becomes an ongoing source of conflict. The important skill required here is knowing when to act and when not to act. (See Chapter 12 for a discussion of conflict.)
The Problem-Solving Process Many nursing problems require immediate action. Nurses don’t have time for formalized pro- cesses of research and analysis specified by the scientific method. Therefore, learning an orga- nized method for problem solving is invaluable. One practical method for problem solving is to follow this seven-step process, which is also outlined in Box 8-3.
1. Define the problem. The definition of a problem should be a descriptive statement of the state of affairs, not a judgment or conclusion. If one begins the statement of a problem with a judgment, the solution may be equally judgmental, and critical descriptive elements could be overlooked.
Suppose a nurse manager reluctantly implements a self-scheduling process and finds that each time the schedule is posted, evenings and some weekend shifts are not adequately covered. The manager might identify the problem as the immaturity of the staff and their inability to function under democratic leadership. The causes may be lack of interest in group decision making, minimal concern over providing adequate patient coverage, or, per- haps more correctly, a few nurses’ lack of understanding of the process.
If the nurse manager defines the above problem as immaturity and reverts to making out the schedules without further fact-finding, a minor problem could develop into a major upheaval.
BOX 8-3 Steps in Problem Solving
1. Define the problem. 2. Gather information. 3. Analyze the information. 4. Develop solutions.
5. Make a decision. 6. Implement the decision. 7. Evaluate the solution.
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 111
Premature interpretation can alter one’s ability to deal with facts objectively. For example, are there other explanations for the apparent behavior that do not entail negative assumptions about the maturity of the staff?
Accurate assessment of the scope of the problem also determines whether the manager needs to seek a lasting solution or just a stopgap measure. Is this just a situational problem requiring only intervention with a simple explanation, or is it more complex, involving the leadership style of the manager? The manager must define and classify problems in order to take action.
To define a problem, ask:
• Do I have the authority to do anything about this myself? • Do I have all the information? The time? • Who else has important information and can contribute? • What benefits could be expected? A list of potential benefits provides the basis for
comparison and choice of solutions. The list also serves as a means for evaluating the solution.
2. Gather information. Problem solving begins with collecting facts. This information gath- ering initiates a search for additional facts that provides clues to the scope and solution of the problem. This step encourages people to report facts accurately. Everyone involved can contribute. Although this may not always provide objective information, it reduces misin- formation and allows everyone an opportunity to tell what he or she thinks is wrong with a situation.
Experience is another source of information—one’s own experience as well as the experience of other nurse managers and staff. The people involved usually have ideas about what should be done. Some data will be useless, some inaccurate, but some will be useful to develop innovative ideas worth pursuing.
3. Analyze the information. Analyze the information only when all of it has been sorted into some orderly arrangement as follows:
• Categorize information in order of reliability. • List information from most important to least important. • Set information into a time sequence. What happened first? Next? What came before
what? What were the concurrent circumstances? • Examine information in terms of cause and effect. Is A causing B, or vice versa? • Classify information into categories: human factors, such as personality, maturity, educa-
tion, age, relationships among people, and problems outside the organization; technical factors, such as nursing skills or the type of unit; temporal factors, such as length of ser- vice, overtime, type of shift, and double shifts; and policy factors, such as organizational procedures or rules applying to the problem, legal issues, and ethical concerns.
• Consider how long the situation has been going on.
Because no amount of information is ever complete or comprehensive enough, critical- thinking skills, discussed earlier, help the manager examine the assumptions, evidence, and potential value conflicts.
4. Develop solutions. As an individual or a group analyzes information, numerous possible solutions will suggest themselves. Do not consider only simple solutions, because that may stifle creative thinking and cause over concentration on detail. Developing alternative solu- tions makes it possible to combine the best parts of several solutions into a superior one. Also, alternatives are valuable in case the first-order solutions prove impossible to implement.
When exploring a variety of solutions, maintain an uncritical attitude toward the way the problem has been handled in the past. Some problems have had a long-standing
112 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
history by the time they reach you, and attempts may have been made to resolve them over a period of time. “We tried this before and it didn’t work” is often said and may apply—or more likely, may not apply—in a changed situation. Past experience may not always supply an answer, but it can aid the critical-thinking process and help prepare for future problem solving.
5. Make a decision. After reviewing the list of potential solutions, select the one that is most applicable, feasible, satisfactory, and has the fewest undesirable consequences. Some solutions have to be put into effect quickly; matters of discipline or compromises in patient safety, for example, need immediate intervention. You must have legitimate authority to act in an emergency and know the penalties to be imposed for various infractions.
If the problem is a technical one and its solution brings about a change in the method of doing work (or using new equipment), expect resistance. Changes that threaten individuals’ personal security or status are especially difficult. In those cases, the change process must be initiated before solutions are implemented. If the solution involves change, the manager should fully involve those who will be affected by it, if possible, or at least inform them of the process. (See Chapter 5 for discussion of the change process.)
6. Implement the decision. Implement the decision after selecting the best course of action. If unforeseen new problems emerge after implementation, evaluate these impediments. Be careful, however, not to abandon a workable solution just because a few people object; a minority always will. If the previous steps in the problem-solving process have been followed, the solution has been carefully thought out, and potential problems have been addressed, implementation should move forward.
7. Evaluate the solution. After the solution has been implemented, review the plan and compare the actual results and benefits to those of the idealized solution. People tend to fall back into old patterns of habit, only giving lip service to change. Is the solution being implemented? If so, are the results better or worse than expected? If they are better, what changes have contributed to its success? How can we ensure that the solution continues to be used and to work? Such a periodic checkup gives you valuable insight and experience to use in other situations and keeps the problem-solving process on course.
See Case Study 8-2 to learn how one nurse manager used critical thinking to solve a problem.
Group Problem Solving Traditionally, managers solved most problems in isolation. This practice, however, is outdated. Both the complexity of problems and the staff’s desire for meaningful involvement create the impetus for using group approaches to problem solving. Today consensus-based problem solv- ing, inherent in shared governance, is the norm.
Advantages of Group Problem Solving Groups collectively possess greater knowledge and information than any single member and may access more strategies to solve a problem. Under the right circumstances and with appropriate leadership, groups can deal with more complex problems than a single individual, especially if there is no one right or wrong solution to the problem. Individuals tend to rely on a small number of familiar strategies; a group is more likely to try several approaches.
Group members may have a greater variety of training and experiences and approach prob- lems from more diverse points of view. Together, a group may generate more complete, accurate, and less biased information than one person. Groups may deal more effectively with problems that cross organizational boundaries or involve change that requires support from other units or
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 113
departments. Participative problem solving has additional advantages: it increases the likelihood of acceptance and understanding of the decision, and it enhances cooperation in implementation.
Disadvantages of Group Problem Solving Group problem solving also has disadvantages: it takes time and resources and may involve con- flict. Group problem solving also can lead to the emergence of benign tyranny within the group. Members who are less informed or less confident may allow stronger members to control group discussion and problem solving. A disparity in participation may contribute to a power struggle between the nurse manager and a few assertive group members.
Also managers may resist using groups to make decisions. They may fear that they may not agree with the decision the group makes or that they will not be needed if all decisions are made by the group. Neither is the case. Some decisions are rightfully the managers’ (e.g., handling the budget), others are staff decisions (e.g., peer review, self-scheduling), and some are shared (e.g., joint hiring decisions). Figure 8-4 illustrates this.
CRITICAL THINKING AND PROBLEM SOLVING Latonia Wilson is nurse manager for a busy 20-bed telemetry unit. In addition to providing postsurgical care for cardiac patients, nurses also prepare patients for cardiac catheterization lab procedures. Latonia’s staff includes eight new graduate nurses, almost half of her nursing staff. The new nurses have attended most of the required nursing orientation for the hospital.
Three times in one month, telemetry unit patients who had orders for heparin drips were administered heparin flush instead. Premixed IV bags for heparin drips as well as heparin flush for indwelling arterial catheters are stocked on the IV solutions cart in the medication room. While no adverse patient outcomes had been re- ported, procedures have been delayed.
Geena Donati is a graduate nurse on the telem- etry unit. Recently, she took a bag of heparin drip from the IV cart and started to attach it to the IV tubing. She noticed that the label stated heparin flush in- stead of heparin. Upon returning to the med room, she checked the heparin drip bin and found heparin flush bags mixed in with the heparin drip. The phar- macy technician came into the med room and began stocking the IV cart. Geena noticed that the pharmacy technician put extra heparin drip bags in the heparin flush bin. She questioned the pharmacy technician and he told Geena that since the unit used a lot of heparin
solution, he had started bringing extra to decrease his trips to the unit.
Geena met with Latonia later during her shift. She told her manager about the extra heparin bags be- ing mixed into the wrong bins. Latonia asked Geena if she would be interested in working with two other RNs on the unit to develop new procedures to decrease heparin medication errors. Geena and the task force worked with the pharmacy department to change the label color for heparin drip and heparin flush solutions, physically separated the bins on the IV cart onto differ- ent shelves, and provided a short educational segment at the monthly staff meeting. Since the new procedures were developed, no further heparin errors have oc- curred on the telemetry unit.
Manager’s Checklist The nurse manager is responsible for:
● Tracking and identifying recurring negative perfor- mance issues on the unit
● Analyzing adverse outcomes to determine what fac- tors contributed to the outcome
● Empowering staff to improve work processes on the unit
● Understanding the organizational structure and helping staff work with other departments within the organization
CASE STUDY 8-2
Staff decisions
Shared decision making
field
Manager decisions
Figure 8-4 • Shared decision making goal. From Shiparski, L. (2005). Engaging in shared decision making: Leveraging staff and management expertise. Nurse Leader, 3(1), 40.
114 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Group problem solving also can be affected by groupthink. Groupthink is a negative phenomenon that occurs in highly cohesive groups that become isolated. Through prolonged close association, group members come to think alike and have similar prejudices and blind spots, such as stereotypical views of outsiders. They exhibit a strong tendency to seek concurrence, which interferes with critical thinking about important decisions. In addition, the leadership of such groups suppresses open, free- wheeling discussion and controls what ideas will be discussed and how much dissent will be tolerated. Groupthink seriously impairs critical thinking and can result in erroneous and damaging decisions.
Also groups tend to make riskier decisions than individuals. Groups are more likely to sup- port unusual or unpopular positions (e.g., public demonstrations). Groups tend to be less con- servative than individual decision makers and frequently display more courage and support for unusual or creative solutions to problems.
Individuals who lack information about alternatives may make a safe choice, but after group dis- cussion they acquire additional information and become more comfortable with a less secure alterna- tive. The group setting also allows for the diffusion of responsibility. If something goes wrong, others also can be assigned the blame or risk. In addition, leaders may be greater risk takers than individuals, and group members may attach a social value to risk taking because they identify it with leadership.
Stumbling Blocks The leader’s personality traits, inexperience, lack of adaptability, and preconceived ideas may be obstacles to decision making and problem solving.
Personality The leader’s personality can and often does affect how and why certain decisions are made. Managers are often selected because of their expert clinical, not managerial, skills. Inexperi- enced in management, they may resort to various unproductive actions. On the one hand, a nurse manager who is insecure may base decisions primarily on approval seeking. When a truly diffi- cult situation arises, the manager, rather than face rejection from the staff, makes a decision that will placate people rather than one that will achieve the larger goals of the unit and organization.
On the other hand, a nurse manager who demonstrates an authoritative type of personality might make unreasonable demands on the staff, fail to reward staff for long hours because he or she has a “workaholic” attitude, or give the staff little control over unit decisions. Similarly, an inexperienced manager may cause a unit to flounder because the manager is not inclined to act on new ideas or solutions to problems. Optimism, humor, and a positive approach are crucial to energizing staff and promoting creativity.
Rigidity Rigidity, an inflexible management style, is another obstacle to problem solving. It may result from ineffective trial-and-error solutions, fear of risk taking, or inherent personality traits. Avoid ineffective trial-and-error problem solving by gathering sufficient information and determining a means for early correction of wrong or inadequate decisions. Also, to minimize risk in problem solving, understand alternative risks and expectations.
The person who uses a rigid style in problem solving easily develops tunnel vision—the ten- dency to look at new things in old ways and from established frames of reference. It then becomes difficult to see things from another perspective, and problem solving becomes a process whereby one person makes all of the decisions with little information or data from other sources. In today’s rapidly changing health care setting, rigidity can be a barrier to effective problem solving.
Preconceived Ideas Effective leaders do not start out with the preconceived idea that one proposed course of action is right and all others wrong. Nor do they assume that only one opinion can be voiced and others
CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 115
will be silent. They start out with a commitment to find out why others disagree. If the staff, other professionals, or patients see a different reality or even a different problem, leaders need to integrate this information into developing additional problem-solving alternatives.
Innovation Innovation is a strategy to bridge the gap between an existing state and a desired state (Porter- O’Grady & Malloch, 2010). Organized nursing has recognized the importance of innovation to solve health care’s many problems (Lachman, Glasgow, & Donnelly, 2009). The American Academy of Nursing’s campaign “Raise the Voice” highlights “edge runners,” those nurses who create innovative solutions for the health care system (see www.aannet.org).
To stimulate innovation, several techniques include:
● Simulations—uses actors representing standardized patients or high-tech mannequins ● Case studies—encourages participants to use critical thinking to analyze actual patient
situations ● Problem-based learning—incorporates additional information into the case study over
time ● Debate—helps participants examine an issue from more than one viewpoint (Lachman,
Glasgow, & Donnelly, 2009)
One university has even developed a post-master’s certificate program in innovation (Dreher, 2008). Using a case-study model, Drexel University’s College of Nursing offers an online program in innovation and entrepreneurship (see www.Drexel.edu) designed to foster cre- ative thinking to solve internal and external problems (Lachman, Glasgow, & Donnelly, 2009).
Critical thinking, creativity, and innovative thinking, along with the appropriate tools and techniques, will enable nurses and their managers to make decisions and solve problems in the least time and with the best outcomes.
What You Know Now • Critical thinking requires examining underlying assumptions about current evidence, interpreting infor-
mation, and evaluating the arguments presented to reach a new and exciting conclusion. • The creative process involves preparation, incubation, insight, and verification, which can be learned by
individuals and groups. • Problem-solving and decision-making processes use critical-thinking skills. • The decision-making process may employ several models: rational, descriptive rationality, satisficing, and
political. • Decision-making techniques vary according to the problem and the degree of risk and uncertainty in the
situation. • Methods of problem solving include trial and error, intuition, experimentation, past experience, tradition,
and recognizing that some problems are self-solving. • The problem-solving process involves defining the problem, gathering information, analyzing information,
developing solutions, making a decision, implementing the decision, and evaluating the solution. • Group problem solving can be positive, providing more information and knowledge than an individual. It
can also be negative if it generates disruptive conflict or groupthink. • Stumbling blocks to making decisions and solving problems include the leader’s personality, rigidity, or
preconceived ideas. • Innovation helps bridge the gap between the existing state and the desired state.
Tools for Making Decisions and Solving Problems 1. Identify problem areas. 2. Ask questions, interpret data, and consider alternatives to make decisions and solve problems. 3. Evaluate the level of certainty, uncertainty, and risk, and consider appropriate alternatives.
www.aannet.org
www.Drexel.edu
116 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
4. Identify opportunities to use groups appropriately to make decisions and solve problems. 5. Follow the problem-solving process described in the chapter. 6. Challenge yourself to look for creative and innovation solutions.
Questions to Challenge You 1. Identify someone you believe has critical-thinking skills. What critical thinking attributes does this
person possess? 2. Describe a situation when you made an important decision. What content in the chapter applied to
that situation? What was the outcome? 3. Have you been involved in group decision making at school or at work? What techniques were used?
Were they effective? 4. A number of ways that problem solving might fail were discussed in the chapter. Name three
more. 5. Have you ever proposed a creative or innovative idea at work or school? Describe the idea and
explain what happened.
Web Resources DyNADS project: http://www.dynads.nursing.arizona.edu Post-Master’s Certificate Program in Innovation and Intra/Entrepreneurship: http://www.drexel.edu/
gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/ American Academy of Nursing Edge Runners: http://www.aannet.org/edgerunners American Academy of Nursing Raise the Voice: http://www.aannet.org/raisethevoice
References Ashcraft, T. (2010). Solving the
critical thinking puzzle. Nursing Management, 41(1), 8–10.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating Nurses: A call for radical transformation. San Fran- cisco: Jossey-Bass.
Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39(3), 142–146.
Dreher, H. M. (2008). Innova- tion in nursing education:
Preparing for the future of nursing. Holistic Nursing Practice, 22(2), 77–80.
Effken, J. A., Verrn, J. A., Logue, M. D., & Hsu, Y. C. (2010). Nurse managers’ decisions. Journal of Nurs- ing Administration, 40(4), 188–195.
Lachman, V. D., Smith Glasgow, M. E., & Donnelly, G. F. (2009). Teaching in- novation. Nursing Ad- ministration Quarterly, 33(3), 205–211.
Porter-O’Grady, T. & Mal loch, K. (2010). In novation leadership:
Creating the landscape of healthcare. Sudbury, MA: Jones & Bartlett.
Simon, H. A. (1993). Decision making: Rational, non- rational, and irrational. Education Administra- tion Quarterly, 29(3), 392–411.
Zori, S., Nosek, L. J., & Musil, C. M. (2010). Critical thinking of nurse manag- ers related to staff RNs’ perceptions of the practice environment. Journal of Nursing Scholarship, 42(3), 305–313.
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
http://www.dynads.nursing.arizona.edu
http://www.drexel.edu/gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/
http://www.drexel.edu/gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/
http://www.aannet.org/edgerunners
http://www.aannet.org/raisethevoice
www.nursing.pearsonhighered.com
CHAPTER
Communication MODES OF COMMUNICATION
DISTORTED COMMUNICATION
DIRECTIONS OF COMMUNICATION
EFFECTIVE LISTENING
Effects of Differences in Communication GENDER DIFFERENCES IN COMMUNICATION
GENERATIONAL AND CULTURAL DIFFERENCES IN COMMUNICATION
DIFFERENCES IN ORGANIZATIONAL CULTURE
The Role of Communication in Leadership EMPLOYEES
ADMINISTRATORS
COWORKERS
MEDICAL STAFF
OTHER HEALTH CARE PERSONNEL
PATIENTS AND FAMILIES
Collaborative Communication
Enhancing Your Communication Skills
Communicating Effectively 9
Key Terms Communication Diagonal communication Downward communication Fogging
1. Identify the factors that influence communication.
2. Discuss how communication can be distorted and misunderstood.
3. Choose which communication mode to use depending on the message and the relationship.
4. Explain how communication strategies vary according to the situation and those involved.
5. Improve your collaborative communication skills.
6. Develop a plan to enhance your communi- cation skills.
Learning Outcomes After completing this chapter, you will be able to:
Intersender conflict Intrasender conflict Lateral communication Metacommunications
Negative assertion Negative inquiry Upward communication
118 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Communication Communication is a complex, ongoing, dynamic process in which the participants simulta- neously create shared meaning in an interaction. The goal of communication is to approach, as closely as possible, a common understanding of the message sent and the one received. At times, this can be difficult because both participants are influenced by past condition- ing; the present situation; each person’s purpose in the current communication; and each per- son’s attitudes toward self, the topic, and each other. It is important that participants construct messages as clearly as possible, listen carefully, monitor each other’s response, and provide feedback.
Modes of Communication Messages may be oral (face-to-face, one-on-one, or in groups; by telephone, text, voice mail or posted on a social media site; or written (handwritten or typed) and sent by mail, e-mail, or fax. The purpose of the message determines the best mode to use. In general, the more important or delicate the issue, the more intimate the mode should be. Any difficult issue should be commu- nicated face-to-face, such as terminating an individual’s employment. Conflict or confrontation also is usually best handled in person so that the individual’s response, especially nonverbal signals (discussed later), can be seen and answered appropriately.
What mode to use depends on the level of intimacy required based on the person, your rela- tionship, and the message. The levels of intimacy, in descending order, are:
● in person ● by phone ● voice mail ● text ● e-mail ● postal mail ● posting on social media sites, including blogs
Meeting someone face-to-face is the most intimate contact. The individual can see your face, see your body movements, and hear your words simultaneously. The telephone is slightly less intimate than in-person communication. Tone of voice, for instance, can be conveyed, and phone conversations can be two-way. Voice mail is the next level of communication. Voice mail is useful to convey information that is not necessarily sensitive and may or may not require a reply. The time and place of an upcoming meeting, for example, can be communicated by voice mail, which has the added advantage of avoiding “phone tag.”
E-mail is useful for information similar to that conveyed by voice mail and, like some voice mail systems, can be broadcast to large groups at once. The dates and times for a blood drive are a good example of a broadcast message. Conveying complicated information that may require thought before the receiver replies is another value of using e-mail. Texting is similar to e-mail, although briefer. Posting on social media sites or blogs is the least personal communication (Kaplan & Haenlein, 2010).
The level of formality of the communication also affects the mode used. Applying for a position requires a written format even if the letter is e-mailed rather than mailed. The relation- ship between the sender and receiver also affects the mode. If a staff nurse, for example, wants to nominate a coworker for an award given by the hospital board of directors, a written letter or e-mail is required. Memos are less formal than written messages and can be e-mailed, faxed, or mailed. Social media postings are public and impersonal (Raso, 2010; Trossman, 2010).
Distorted Communication Oral messages are accompanied by a number of nonverbal messages known as metacommuni- cations. These behaviors include head or facial agreement or disagreement; eye contact; tone,
CHAPTER 9 • COMMUNICATING EFFECTIVELY 119
volume, and inflection of the voice; gestures of the shoulders, arms, hands, or fingers; body pos- ture and position; dress and appearance; timing; and environment.
Nonverbal communication is more powerful than the words one speaks and can distort the meaning of the spoken words. When a verbal message is incongruent with the nonverbal message, the recipient has difficulty interpreting the intended meaning; this results in intrasender conflict. For example, a manager who states, “Come talk to me anytime,” but keeps on typing at the keyboard while you talk, sends a conflicting message to the staff. Intersender conflict occurs when a person receives two conflicting messages from differing sources. For example, the risk manager may en- courage a nurse to report medication errors, but the nurse manager follows up with discipline over the error. The nurse is caught between conflicting messages from the two managers.
Other common causes of distorted communication are:
● Using inadequate reasoning ● Using strong, judgmental words ● Speaking too fast or too slowly ● Using unfamiliar words ● Spending too much time on details
Distortion also occurs when the recipient is busy or distracted, bases understanding on pre- vious unsatisfactory experience with the sender, or has a biased perception of the meaning of the message or the messenger. Consider the example of distortion of written communication provided in Box 9-1.
BOX 9-1 Distortion in Written Communication
There is ample opportunity for distortion in the complicated process of sending, receiving, and responding to mes- sages, as demonstrated by the following correspondence between a plumber and an official of the National Bureau of Standards (Donaldson & Scannell, 1979).
Bureau of Standards Washington, D.C. Gentlemen:
I have been in the plumbing business for over 11 years and have found that hydrochloric acid works real fine for cleaning drains. Could you tell me if it’s harmless?
Sincerely, Tom Brown, Plumber
Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:
The efficacy of hydrochloric acid is indisputable, but the chlorine residue is incompatible with metallic permanence!
Sincerely, Bureau of Standards
Bureau of Standards Washington, D.C. Gentlemen:
I have your letter of last week and am mightily glad you agree with me on the use of hydrochloric acid.
Sincerely, Tom Brown, Plumber
Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:
We wish to inform you we have your letter of last week and advise that we cannot assume responsibility for the production of toxic and noxious residues with hydrochloric acid and further suggest you use an alter- nate procedure.
Sincerely, Bureau of Standards
Bureau of Standards Washington, D.C. Gentlemen:
I have your most recent letter and am happy to find you still agree with me.
Sincerely, Tom Brown, Plumber
Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:
Don’t use hydrochloric acid, it eats the hell out of pipes!
Sincerely, Bureau of Standards
For communication among more than two people, the chance of distortion increases proportionally.
120 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
E-mail is particularly fraught with opportunities for misunderstanding. From the greeting (e.g., dear, hi, hello, or no salutation) to the sign-off (e.g., warm regards, best wishes, best, or no sign-off), the sender conveys more than the choice of words. A speedy reply is expected and en- courages a response, sometimes without adequate thought. Finally, the possibility of sending the message to the wrong person, especially the dreaded “reply to all,” is another chance for your message to be misinterpreted. Texting shares many of the same dangers as e-mail and has added pressure for a faster response.
Directions of Communication Formal or informal communication may be downward, upward, lateral, or diagonal. Downward communication (manager to staff) is often directive. The staff is told what needs to be done or given information to facilitate the job to be done. Upward communication occurs from staff to management or from lower management to middle or upper management. Upward commu- nication often involves reporting pertinent information to facilitate problem solving and deci- sion making. Lateral communication occurs between individuals or departments at the same hierarchical level (e.g., nurse managers, department heads). Diagonal communication involves individuals or departments at different hierarchical levels (e.g., staff nurse to chief of the medi- cal staff). Both lateral and diagonal communication involve information sharing, discussion, and negotiation.
An informal channel commonly seen in organizations is the grapevine (e.g., rumors and gossip). Grapevine communication is usually rapid, haphazard, and prone to distortion. It can also be useful. Sometimes the only way to learn about a pending change is through the grape- vine. One problem with grapevine communication, however, is that no one is accountable for any misinformation that is relayed. Keep in mind, too, that information gathered this way is a slightly altered version of the truth, changing as the message passes from person to person.
Effective Listening Most nurses believe they are good listeners. Observing and listening to patients are skills nurses learn early in their careers and use every day. Being a good listener, however, involves more than just hearing words and watching body language (Sullivan, 2013). Maintaining eye contact is misleading; it may or may not signal that a person is listening. Barriers to effective listening include preconceived beliefs, lack of self-confidence, flagging energy, defensiveness, and habit (Donaldson, 2007).
Preconceived Beliefs The longer your relationship with someone is, the more apt you are to think you know what the person says or means and, thus, the more likely you are to not listen. This holds true in personal as well as professional relationships and applies to groups of people (known as stereotyping). Not expecting others to have anything worthwhile to say also is an example of preconceptions about them.
Lack of Self-Confidence Listening is difficult if you are nervous, and weak self-confidence frequently is the cause. People tend to talk too much or think about what they’re planning to say next to pay attention to the per- son speaking. Often their mind is racing and they may not be listening even when they’re talking themselves.
Flagging Energy Listening takes energy and sometimes we simply don’t have enough energy to listen carefully. Too many people speaking at once, having too much to do, being worried, or being too tired can all interfere with our ability to listen.
CHAPTER 9 • COMMUNICATING EFFECTIVELY 121
Defensiveness Survival required that we learned to hear danger approaching, but today humans have translated defense mechanisms into a way to avoid hearing bad news. Then, we think, we don’t have to deal with it. The opposite is true, however. Only when we can hear and consider information can we handle it.
Habit Over time, many people develop the habit of thinking ahead during conversations. Thinking ahead is valuable in most aspects of life, but it’s deadly when you need to be listening. Like all behaviors that have become habits, changing this one is not easy. Reminding yourself to refocus on the speaker can help.
Effects of Differences in Communication
Gender Differences in Communication Men and women communicate differently (Feldhahn, 2009; Tannen, 2001). They have become socialized through communication patterns that reflect their societal roles. Men tend to talk more, longer, and faster, whereas women are more descriptive, attentive, and perceptive. Women tend to use tag questions (e.g., “I can take off this weekend, can’t I?”) and tend to self-disclose more than men. Women tend to ask more questions and solicit more input than their male coun- terparts. Table 9-1 lists differences in the ways that men and women communicate.
Helgeson and Johnson (2010) suggest ways that women can improve their communication at work. Neither men nor women should raise their voices no matter what the provocation. Nor should one omit important details or assume everyone knows what you mean. Not allowing questions or objections also should be avoided, and never walk away and talk at the same time (Donaldson, 2007).
Using gender-neutral language in communication helps bridge the gap between the way men and women communicate. Men and women can improve their ability to communicate with each other by following the recommendations for gender-neutral communication found in Table 9-2.
Generational and Cultural Differences in Communication Generational differences, discussed in Chapter 1, affect communication styles, patterns, and expectations. Traditionals tend to be more formal, following the chain of command without question. Baby boomers question more. They enjoy the process of group problem solving
TABLE 9-1 Gender Differences in Communication
Men tend to Women tend to
Interrupt more frequently Wait to be noticed
Talk more, longer, louder, and faster Use qualifiers (prefacing and tagging)
Disagree more Use questions in place of statements
Focus on the issue more than the person Relate personal experiences
Boast about accomplishments Promote consensus
Use banter to avoid a one-down position Withdraw from conflict
From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 57. Reprinted by permission.
122 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
and decision making. Independent Generation X members are just the opposite and want decisions made without unnecessary discussion. Collegial millennials (Generation Y) expect immediate feedback to their messages. E-mail, text, or voice mail is the best way to connect with them. Mutual respect and understanding of the unique differences between and among groups will help to minimize conflict and maximize satisfaction for both managers and staff (Hahn, 2009).
Cultural attitudes, beliefs, and behaviors also affect communication (Robertson-Malt, Herrin-Griffith, & Davies, 2010). Such elements as body movement, gestures, tone, and spatial orientation are culturally defined. A great deal of misunderstanding results from a lack of under- standing of each other’s cultural expectations. For example, people of Asian descent take great care in exchanges with supervisors so that there is no conflict or “loss of face” for either person.
Understanding the cultural heritage of employees and learning to interpret cultural mes- sages is essential to communicate effectively with staff from diverse backgrounds. Personal and professional cultural enrichment training is recommended. This includes reading the literature and history of the culture; participating in open, honest, respectful communication; and explor- ing the meaning of behavior. It is important to recognize, however, that subcultures exist within all cultures; therefore, what applies to one individual will not be true for everyone else in that culture.
Differences in Organizational Culture As discussed in Chapter 2, the customs, norms, and expectations within an organization are powerful forces that shape behavior. Focusing on relevant issues regarding the organizational culture can identify failures in communication. Poor communication is a frequent source of job dissatisfaction as well as a powerful determinant of an organization’s effectiveness. Just as violation of other norms within the organization results in repercussions, so does violation of communication rules.
To discover what rules affect communication in your organization, ask yourself:
● Who has access to what information? Is information withheld? Is it shared widely? ● What modes of communication are used for which messages? Are they used
appropriately? ● How clear are the messages? Or are they often distorted? ● Does everyone receive the same information? ● Do you receive too much information? Not enough? ● How effective is the message?
TABLE 9-2 Recommendations for Gender-Neutral Communication
Men may need to Women may need to
Listen to objections and suggestions State your message clearly and concisely
Listen without feeling responsible Solve problems without personalizing them
Suspend judgment until information is in Say what you want without hinting
Explain your reasons Eliminate unsure words (“sort of”) and nonwords (“truly”)
Not yell Not cry
From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 58. Reprinted by permission.
CHAPTER 9 • COMMUNICATING EFFECTIVELY 123
The Role of Communication in Leadership Although communication is inherent in the manager’s role, the manager’s ability to communi- cate often determines his or her success as a leader. Leaders who engage in frank, open, two-way communication and whose nonverbal communication reinforces the verbal communication are seen as informative. Communication is enhanced when the manager listens carefully and is sen- sitive to others. The major underlying factor, however, is an ongoing relationship between the manager and employees.
Successful leaders are able to persuade others and enlist their support. The most effective means of persuasion is the leader’s personal characteristics. Competence, emotional control, as- sertiveness, consideration, and respect promote trustworthiness and credibility. A participative leader is seen as a careful listener who is open, frank, trustworthy, and informative.
Employees Depending on the organization’s policies, the nurse manager’s responsibilities may include se- lecting, interviewing, evaluating, counseling, and disciplining employees; handling their com- plaints; and settling conflicts. The principles of effective communication are especially pertinent in these activities because good communication is the adhesive that builds and maintains an effective work group.
Giving direction is not, in itself, communication. If the manager receives an appropriate response from the subordinate, however, communication has occurred. To give directions and achieve the desired results, develop a message strategy. The techniques that follow can help im- prove effective responses from others.
● Know the context of the instruction. Be certain you know exactly what you want done, by whom, within what time frame, and what steps should be followed to do it. Be clear in your own mind what information a person needs to carry out your instruction, what the outcome will be if the instruction is carried out, and how that outcome can or will be eval- uated. When you have thought through these questions, you are ready to give the proper instruction.
● Get positive attention. Avoid factors that interfere with effective listening. Informing the person that the instructions will be given is one simple way to try to get positive attention. Highlighting the background, giving a justification, or indicating the importance of the instructions also may be appropriate.
● Give clear, concise instructions. Use an inoffensive and nondefensive style and tone of voice. Be precise, and give all the information receivers need to carry out your expecta- tions. Follow a step-by-step procedure if several actions are needed.
● Verify through feedback. Make sure the receiver has understood your specific request for action. Ask for a repeat of the instructions.
● Provide follow-up communication. Understanding does not guarantee performance. Fol- low up to discover if your instruction is clear and if the person has any questions.
The nurse manager is responsible both for the quality of the work life of individual em- ployees and for the quality of patient care in the entire unit. To carry out this job, acknowledge the needs of individual employees, especially if the needs of one conflict with needs of the unit, speak directly with those involved, and state clearly and accurately the rationale for the deci- sions made.
Administrators The manager’s interaction with higher administration is comparable to the interaction between the manager and an employee, except that the manager is now the subordinate. Higher ad- ministration is responsible for the consequences of decisions made for a larger area, such as all of nursing service or the entire organization. The principles used in communicating with
124 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
subordinates are equally appropriate. Managers should be organized and prepared to state their needs clearly, explain the rationale for requests, suggest benefits for the larger organization, and use appropriate channels. Listen objectively to your supervisor’s response and be willing to con- sider reasons for possible conflict with needs of other areas.
Working effectively with an administrator is important because this person directly influ- ences personal success in a career and within the organization. Managing a supervisor, or man- aging upward, is a crucial skill for nurses. To manage upward, remember that the relationship requires participation from both parties. Managing upward is successful when power and influ- ence move in both directions. Rules for managing your supervisor are found in Box 9-2.
One aspect of managing upward is to understand the supervisor’s position from her or his frame of reference. This will make it easier to propose solutions and ideas that the supervisor will accept. Understand that a supervisor is a person with even more responsibility and pressure. Learn about the supervisor from a personal perspective: What pressures, both personal and pro- fessional, does the supervisor face? How does the supervisor respond to stress? What previous experiences are liable to affect today’s issues? This assessment will allow you to identify ways to help your supervisor with his or her job and for your supervisor to help you with yours.
Influencing Your Supervisor Nurses need to approach their supervisor to exert their influence on a variety of issues and prob- lems. Support for the purchase of capital equipment, for changes in staffing, or for a new policy or procedure all require communicating with a supervisor. Your rationale, choice of form or format, and possible objections all are important factors to consider as you prepare to make such a request. Timing is critical; choose an opportunity when the supervisor has time and appears receptive. Also, consider the impact of your ideas on other events occurring at that time.
Should ideas be presented in spoken or written form? Usually some combination is used. Even if you have a brief meeting about a relatively small request, it is a good idea to follow up with an e-mail, detailing your ideas and the plans to which you both agreed. Sometimes the pro- cedure works in reverse. If you provide the supervisor with a written proposal prior to a meeting, both of you will be familiar with the idea at the start. In the latter case, careful preparation of the written material is essential.
What can be done if, in spite of careful preparation, your supervisor says no? First, make sure you have understood the objections and associated feelings. Negative inquiry (e.g., “I don’t understand”) is a helpful technique to use. Do not interrupt or become defensive or distraught; remain diplomatic. Fogging, agreeing with part of what was said, or negative assertion, accept- ing some blame, are two additional techniques that you can use.
The next step is confrontation. Keep your voice low and measured; use “I” language; and avoid absolutes, why questions, put-downs, inflammatory statements, and threatening gestures. Finally, if you feel you have lost and compromise is unlikely, table the issue by saying, “Could
BOX 9-2 Rules for Managing Your Boss
● Give immediate positive feedback for good things that the supervisor does; positive feedback is a wel- come change.
● Never let your supervisor be surprised; keep her or him informed.
● Always tell the truth. ● Find ways to compensate for weaknesses of your su-
pervisor. Fill in weak areas tactfully. Volunteer to do something the supervisor dislikes doing.
● Be your own publicist. Don’t brag, but keep your supervisor informed of what you achieve.
● Keep aware of your supervisor’s achievements and acknowledge them.
● If your supervisor asks you to do something, do it well and ahead of the deadline if possible. If appro- priate, add some of your own suggestions.
● Establish a positive relationship with the supervisor’s assistant.
CHAPTER 9 • COMMUNICATING EFFECTIVELY 125
we continue discussing this at another time?” Then, think through your supervisor’s reasoning and evaluate it.
Afterward ask yourself: “What new information did I get from the supervisor?” “What are ways I can renegotiate?” “What do I need to know or do to overcome objections?” Once you can answer these questions, approach your supervisor again with the new information. This behav- ior shows that the proposal is a high priority, and the new information may cause him or her to reevaluate.
Managers often succeed in influencing supervisors through persistence and repetition, espe- cially if supporting data and documentation are supplied. If the issue is important enough, you may want to take it to a higher authority. If so, tell your supervisor you would like an administra- tor at a higher level to hear the proposal. Keep an open mind, listen, and try to meet objections with suggestions of how to solve problems. Be prepared to compromise, which is better than no movement at all, or to be turned down.
Taking a Problem to Your Supervisor No one wants to hear about a problem, and your boss is no different. Nonetheless, work involves problems, and the manager’s job is to solve them. Go to your supervisor with a goal to problem solve together. Have some ideas about solving the problem in hand if you can but do not be so wedded to them that you are unable to listen to your supervisor’s ideas. Keep an open mind. Use the following steps to take a problem to your supervisor:
● Find an appropriate time to discuss a problem, scheduling an appointment if necessary. ● State the problem succinctly and explain why it is interfering with work. ● Listen to your supervisor’s response and provide more information if needed. ● If you agree on a solution, offer to do your part to solve it. If you cannot discover an
agreeable solution, schedule a follow-up meeting or decide to gather more information. ● Schedule a follow-up appointment.
By solving the problem together and, if necessary, by taking active steps together, you and your supervisor are more likely to accept the decision and be committed to it. Setting a specific follow-up date can prevent a solution from being delayed or forgotten.
If All Else Fails Sometimes no matter what you do, working with your supervisor seems nearly impossible. Some managers foster a negative work environment, and employees become dissatisfied, angry, and depressed. High absenteeism and turnover result. As a manager you are charged with sup- porting your supervisor. If working with that person is too difficult for you to manage your work satisfactorily, you may have to transfer elsewhere or leave.
Coworkers Interactions with coworkers are inevitable. Relationships can vary from comfortable and easy to challenging and complex. Coworkers often share similar concerns. Camaraderie may be present; coworkers can exchange ideas and address problems creatively. They can provide support, and the strengths of one can be developed in the other.
Conversely, there may also be competition or conflicts (e.g., battles over territory, personal- ity clashes, differences of opinion) affected by history, the organization’s mores, or generational or cultural differences. Even when there are conflicts, coworkers should interact on a profes- sional level. Chapter 12 suggests ways to handle conflict.
Medical Staff Communication with the medical staff may be difficult for the nurse manager because the re- lationship of physicians and nurses has been that of superior and subordinate (Kripalani et al., 2007). Complicating physician–nurse relationships is the employee status of the medical staff.
126 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
They may not be employees of the organization but still have considerable power because of their ability to attract patients to the organization, and, finally, the medical staff is in itself di- verse, consisting of physicians who are organizational employees, residents, physicians in pri- vate practice, and consulting physicians.
One program designed to help physicians improve their communication skills is LegacyMd (see http://legacymd.com/). Using improvisational techniques, participants practice interacting in scenes depicting workplace examples, receive feedback, and replay the scene with enhanced skills.
(See the next section on collaborative communication for how to interact more effectively with physicians.)
Other Health Care Personnel The nurse manager has the overwhelming task of coordinating the activities of a number of per- sonnel with varied levels and types of preparation and different kinds of tasks. The patient may receive regular care from a registered nurse, unlicensed assistive personnel, a respiratory thera- pist, a physical therapist, and a dietitian, among others. The nurse manager may supervise all of them. Regardless, the manager needs considerable skill to communicate effectively with diverse personnel, recognize their commonalities, and deal with their differences.
Patients and Families Nurse managers deal with many difficult issues. Patient or family complaints about the delivery of care (e.g., complaints about a staff member, violations of policy) are one example. When dealing with patient or family complaints, keep the following principles in mind:
● The patient and family are the principal customers of the organization. Treat patients and families with respect; keep communication open and honest. Dissatisfied customers fail to continue to use a service and also inform their friends and families about their neg- ative experiences. Handle complaints or concerns tactfully and expeditiously. Many times lawsuits can be avoided if the patient or family feels that someone has taken the time to listen to their complaints. (See the section on risk management in Chapter 6.)
● Most individuals are unfamiliar with medical jargon. Use words that are appropriate to the recipient’s level of understanding. However, take care not to be condescending or intimidating. It is just as important to assess the person’s knowledge base and level of un- derstanding as it is to know his or her vital signs or liver status.
● Maintain privacy and identify a neutral location for dealing with difficult interactions. ● Make special efforts to find interpreters if a patient or family does not speak English.
Have readily available a list of individuals who are able to communicate in a variety of languages. The list also should include individuals experienced in sign language and Braille. Another resource is AT&T’s language line service (800-752-6096), which pro- vides interpreters for over 140 languages 24 hours a day.
● Recognize cultural differences in communicating with patients and their families. People in some cultures do not ask questions for fear of imposing on others (Huber, 2009). Some cultures prefer interpreters from their own culture; others do not. Cultural education for the staff can help identify some of these differences and teach them appro- priate, culturally sensitive responses (Raingruber et al., 2010).
Collaborative Communication Collaboration is central to patient safety, according to a study by Vitalsmarts™ (Maxfield et al., 2005). The researchers found seven areas where health care workers found it difficult to speak up, including seeing colleagues make mistakes, perform incompetently, disrespect others, break rules, fail to support colleagues, exhibit poor teamwork, or micromanage inappropriately.
CHAPTER 9 • COMMUNICATING EFFECTIVELY 127
Propp and colleagues (2010) found that two processes were critical to ensuring collabora- tion with physicians and other members of the health care team. These were ensuring quality de- cisions and promoting team synergy (see Table 9-3). Developing a collaborative practice model, nurses can build their credibility with physicians and enhance the workplace environment.
Another study found that communication and role understanding crucial to collaborative practice (Suter et al., 2009). Appreciation of one another’s roles was key to improving com- munication and positive patient outcomes. Focusing educational objectives on communication and understanding others’ roles, rather than more diffuse skills, such as respect, is more likely to lead to better practices, the researchers assert.
To support greater collaboration between nurses and physicians and to improve the product of nursing service—patient care—keep these principles in mind:
● Respect physicians as persons, and expect them to respect you. ● Consider yourself and your staff equal partners with physicians in health care. ● Build your staff’s clinical competence and credibility. Ensure that your staff has the clini-
cal preparation necessary to meet required standards of care. ● Actively listen and respond to physician complaints as customer complaints. Create a
problem-solving structure. Stop blaming physicians exclusively for communication problems. ● Use every opportunity to increase your staff’s contact with physicians and to include your
staff in meetings that include physicians. Remember that limited interactions contribute to poor communication.
● Establish a collaborative practice committee on your unit whose membership is composed equally of nurses and physicians. Identify problems, develop mutually satisfactory solu- tions, and learn more about each other. Emphasize similarities and the need for quality care. Begin with those physicians who have a positive attitude toward collaboration.
● Serve as a role model to your staff in nurse–physician communication. ● Support your staff in participating in collaborative efforts by words and by your actions.
If you are confronted with power plays or intimidation, what is the best way to respond? Intimidation can be counteracted by increasing self-confidence and personal feelings of power. Four ways that generate power are:
1. With words: • Use the other person’s name frequently. • Use strong statements. • Avoid discounters, such as “I’m sorry, but . . . ?” • Avoid clichés, such as “hit the nail on the head,” “goes without saying,” “easier said than
done.” • Avoid fillers (such as “ah,” “uh,” and “um”).
TABLE 9-3 Improving Communication
1. Consider your relationship to the receiver.
2. Craft your message, including your goal and how to answer responses.
3. Decide on the medium based on your relationship, the content, and the setting.
4. Check your timing.
5. Deliver your message.
6. Attend to verbal or written responses.
7. Reply appropriately.
8. Conclude when both parties’ messages have been understood.
9. Evaluate communication process.
128 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
2. Through delivery: • Be enthusiastic. • Speak clearly and forcefully. • Make one point at a time. • Do not tolerate interruptions.
3. By listening: • Listen for facts. • Pay attention to emotions. • Listen for what is not being said (e.g., body language, mixed messages, hidden messages).
4. Through body posture and body language: • Sit next to your antagonist; turn 30 degrees toward the person when you address him or her. • Lean forward. • Expand your personal space. • Use gestures. • Stand when you talk. • Smile when you are pleased, not in order to please. • Maintain eye contact, but do not stare.
One nurse manager handled a problem with a physician as shown in Case Study 9-1. Additional techniques to counteract intimidation and threat are included in Chapters 12, 21, and 22.
COMMUNICATION Josie Randolph is nurse manager of a perioperative unit, including responsibility for the preoperative testing unit, 18 OR suites, pre-op holding, and sterile process- ing. The OR department supports the hospital’s Level I trauma service as well as all other surgical services.
Dr. Jonas Welborne is a plastic surgeon with a his- tory of aggressive behavior. He has several cases on today’s OR schedule. While he is in his first surgery, a trauma case is brought to the OR. Susan Richardson, the OR charge nurse, decides to bump Dr. Welborne’s sec- ond case out of OR #3 to make room for the trauma case. When Dr. Welborne has finished his first case, he is informed of the delay in his second case. Dr. Welborne storms into the OR scheduling office and begins yelling at Susan. The situation quickly escalates to the point where Dr. Welborne uses obscenities and throws several charts on the floor. Loretta Donnelly, an OR tech, runs to Josie’s office and asks her to come immediately to the OR scheduling office.
Susan and Dr. Welborne continue to yell at one anoth- er, in full view of patients in the pre-op area. Josie imme- diately steps between Dr. Welborne and Susan and firmly asks both of them to lower their voices. She instructs Susan to wait in the staff lounge while she speaks with Dr. Welborne. Josie asks Dr. Welborne to step into her of- fice so they can calmly discuss the situation. Dr. Welborne is still visibly agitated but agrees to discuss the problem.
After hearing his side of the story, Josie apologizes for the inconvenience, but reminds him of the OR poli- cies. Emergent cases take precedence over elective cases, and no other elective cases were on the schedule at that time. She asks Dr. Welborne if there are alternatives to scheduling his cases that would minimize delays or bumps. As they talk, Dr. Welborne becomes calmer.
Josie informs Dr. Welborne that his earlier behavior is unacceptable. Within a few minutes, he apologizes to Josie and asks to speak with Susan. He also apologizes to Susan. Josie and Susan discuss the incident and ways Susan can help diffuse similar situations in the future. As with Dr. Welborne, Josie indicates that Susan’s behav- ior was unprofessional and, as the OR charge nurse, she is always expected to act as a nursing professional and role model.
Manager’s Checklist The nurse manager is responsible for:
● Mediating conflict in a timely manner ● Knowing organizational policies and procedures that
support staff decisions ● Allowing open and complete discussion of the
problem ● Actively listening to both participants ● Using assertive communication to facilitate problem
solving
CASE STUDY 9-1
CHAPTER 9 • COMMUNICATING EFFECTIVELY 129
Enhancing Your Communication Skills Communication skills can be learned. Suggestions to improve your communication skills are shown in Table 9-3.
To communicate effectively, first consider your relationship to the receiver (e.g., boss or patient). Then craft your message. Be clear about your goal in your mind so that you can com- municate it appropriately. Then think about what the other person is liable to say and consider how you might respond.
Next decide on the medium. Is this message best conveyed in person, by phone, e-mail, or text? Should you leave a message if the person isn’t available? Note the personal intimacy con- tent earlier in the chapter for guidance.
Timing plays a critical role in successful communication. Catch your boss in the midst of planning for a budget shortfall and you are less apt to get a receptive hearing.
Be prepared when you deliver your message. The best-crafted message, delivered by the appro- priate medium can misfire by a sender who fails to listen carefully, avoids responding out of fear of consequences, or undermines the message with qualifiers, such as “I don’t know if you’re interested.”
(For more information on communicating effectively, see Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.
What You Know Now • Communication is a complex, ongoing, dynamic process. • How to deliver a message depends on the purpose, the content, and the relationship. • Messages can be distorted or misconstrued. • Gender, generation, cultural background, and the organizational culture influence communication and its
outcome. • Expert communication skills are essential for a leader to be successful. • Communication strategies vary according to the situation and the roles of people involved. • Collaborative communication is challenging, and specific skills can help. • Nurses can enhance their communication skills with effort and practice.
Tools for Communicating Effectively 1. Identify and use the appropriate method (in person, phone, voice mail, text, e-mail, letter) for your
communications. 2. Evaluate your communication skills in various situations. Think of ways to improve. 3. Practice using the skills described in specific situations, such as with your coworkers, the medical
staff, and with patients and their families. 4. Become sensitive to others’ responses, both verbal and nonverbal, and craft your messages
appropriately. 5. Gather feedback and continue to assess the effectiveness of your communications. 6. Strive to improve your communication skills.
Questions to Challenge You 1. Consider a recent interaction you witnessed.
Did the sender express the message clearly? Use the appropriate medium? Listen and respond to questions and comments? What was the outcome?
2. Now think about a recent interaction where you were the sender using the above criteria. If you could replay the interaction, what would you do differently?
3. How well does communication function in your workplace, school, or clinical site? 4. To improve your communication, practice the skills described in the chapter by role playing or
recording yourself (Sullivan, 2013).
130 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
References
Donaldson, M. C. (2007). Nego- tiating for dummies (2nd ed.). New York: Wiley Publishing.
Feldhahn, S. (2009). The male factor: The unwritten rules, misperceptions, and secret beliefs of men in the work- place. New York: Crown Business.
Hahn, J. (2009). Effectively manage a multigenerational staff. Nursing Management, 40(9), 8–10.
Helgesen, S., & Johnson, J. (2010). The female vision: Women’s real power at work. San Francisco: Berrett-Koehler Publications.
Huber, L. M. (2009). Making community health care culturally correct. American Nurse Today, 4(5), 13–15.
Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.
Kripalani, S., LeFevre, F., Phil- lips, C., Williams, M., Basaviah, P., & Baker, D. (2007). Deficits in com- munication and informa- tion transfer between
hospital-based and primary care physicians. Journal of American Medical Associa- tion, 297(8), 831–841.
Maxfield, D., Grenny, J., Lavandero, R., & Groah, L. (2005). The silent treat- ment: Why safety tools and checklists aren’t enough to save lives. Retrieved April 11, 2011 from http://www. silencekills.com/UPDL/Si- lenceKillsExecSummary.pdf
Propp, K. M., Apker, J., Zabava Ford, W. S., Wallace, N., Servenski, M., & Hofmeis- ter, N. (2010). Meeting the complex needs of the health care team: Identification of nurse-team communica- tion practices perceived to enhance patient outcomes. Qualitative Health Research, 20(1), 15–28.
Raingruber, B., Teleten, O., Curry, H., Vang-Yang, B., Kuzmenko, L., Marquez, V., & Hill, J. (2010). Improving nurse-patient communica- tion and quality of care: The transcultural, linguistic care team. Journal of Nurs- ing Administration, 40(6), 258–260.
Raso, R. (2010). Social media for nurse managers: What
does it all mean? Nursing Management, 41(8), 23–25.
Robertson-Malt, S., Herrin- Griffith, D. M., & Davies, J. (2010). Designing a patient care model with relevance to the cultural setting. Journal of Nursing Admin- istration, 40(6), 277–282.
Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.
Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23(1), 41–51.
Tannen, D. (2001). Talking from 9 to 5: How women’s and men’s conversational styles affect who gets heard, who gets credit, and what gets done at work. New York: Harper.
Trossman, S. (2010). Sharing too much? Nurses nationwide need more information on social networking pitfalls. American Nurse Today, 5(11), 38–39.
Web Resources LegacyMD: http://legacymd.com Silence Kills: The Seven Crucial Conversations in HealthCare:
http://silenttreatmentstudy.com/Silent%20Treatment%20Executive%20Summary.pdf
Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com
Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!
http://www.silencekills.com/UPDL/Si-lenceKillsExecSummary.pdf
http://www.silencekills.com/UPDL/Si-lenceKillsExecSummary.pdf
http://silenttreatmentstudy.com/Silent%20Treatment%20Executive%20Summary.pdf
www.nursing.pearsonhighered.com
http://www.silencekills.com/UPDL/Si-lenceKillsExecSummary.pdf
CHAPTER
Delegation
Benefits of Delegation BENEFITS TO THE NURSE
BENEFITS TO THE DELEGATE
BENEFITS TO THE MANAGER
BENEFITS TO THE ORGANIZATION
The Five Rights of Delegation
The Delegation Process
Accepting Delegation
Ineffective Delegation ORGANIZATIONAL CULTURE
LACK OF RESOURCES
AN INSECURE DELEGATOR
AN UNWILLING DELEGATE
UNDERDELEGATION
REVERSE DELEGATION
OVERDELEGATION
Delegating Successfully 10
Key Terms Accountability Assignment Authority
Delegation Overdelegation Responsibility
Reverse delegation Underdelegation
1. Describe how delegation involves responsi- bility, accountability, and authority.
2. Describe how effective delegation benefits the delegator, the delegate, the unit, and the organization.
3. Discuss how to be an effective delegator. 4. Identify obstacles that can impede effec-
tive delegation. 5. Explain how liability affects delegation.
Learning Outcomes After completing this chapter, you will be able to:
132 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Delegation Delegation is the process by which responsibility and authority for performing a task (function, activity, or decision) is transferred to another individual who accepts that authority and responsi- bility. Although the delegator remains accountable for the task, the delegate is also accountable to the delegator for the responsibilities assumed. Delegation can help others to develop or en- hance their skills, promote teamwork, and improve productivity.
It is easy to say delegate, but delegation is a difficult leadership skill for nurses to learn and one that may not be taught in undergraduate education. Given the confusion over what tasks assistive personnel can perform and what are those that are the unique purview of RNs, nurses and nurse managers may be reluctant to delegate. Never before, however, has delegation been as critical a skill for nurses and nurse managers to perfect as it is today, with the emphasis on doing more with less.
The benefits of delegating appropriately are many. (See the next section.) In fact, a leader who models delegation promotes collaboration between nurses and support personnel (Orr, 2010) as well as a positive workplace environment (Standing & Anthony, 2008).
Responsibility, accountability, and authority are concepts related to delegation. Although responsibility and accountability are often used synonymously, the two words represent differ- ent concepts that go hand in hand. Responsibility denotes an obligation to accomplish a task, whereas accountability is accepting ownership for the results or lack thereof. Responsibility can be transferred, but accountability is shared.
You can delegate only those tasks for which you are responsible. If you have no direct respon- sibility for the task, then you can’t delegate that task. For instance, if a manager is responsible for filling holes in the staffing schedule, the manager can delegate this responsibility to another indi- vidual. However, if staffing is the responsibility of a central coordinator, the manager can make suggestions or otherwise assist the staffing coordinator, but cannot delegate the task.
Likewise, if an orderly who is responsible for setting up traction is detained and a nurse asks a physical therapist on the unit to assist with traction, this is not delegation, because setting up traction is not the responsibility of the nurse. However, if the orderly (the person responsible for the task) had asked the physical therapist to help, this could be an act of delegation if the other principles of delegation are met.
Along with responsibility, you must transfer authority. Authority is the right to act. There- fore, by transferring authority, the delegator is empowering the delegate to accomplish the task. Too often this principle of delegation is neglected. Nurses retain authority, crippling the del- egate’s abilities to accomplish the task, setting the individual up for failure, and minimizing efficiency and productivity.
Delegation is often confused with work assignment. Delegation involves transfer of respon- sibility and authority. In assignment no transfer of authority occurs. Instead, assignments are a bureaucratic function that reflect job descriptions and patient or organizational needs. Effective delegation benefits the delegator, the delegate, the manager, and the organization.
Benefits of Delegation
Benefits to the Nurse Nurses also benefit from delegation. If the nurse is able to delegate some tasks to UAPs, more time can be devoted to those tasks that cannot be delegated, especially complex patient care. Thus, patient care is enhanced, the nurse’s job satisfaction increases, and retention is improved.
Nancy, RN, has three central line dressing changes to complete as well as two patients to transfer to another unit before the end of shift in one hour. Nancy delegates the transfer duties to Shelley, LPN, and completes the central line dressing changes.
CHAPTER 10 • DELEGATING SUCCESSFULLY 133
Benefits to the Delegate The delegate also benefits from delegation. The delegate gains new skills and abilities that can facilitate upward mobility. In addition, delegation can bring trust and support, and thereby build self-esteem and confidence. Subsequently, job satisfaction and motivation are enhanced as in- dividuals feel stimulated by new challenges. Morale improves; a sense of pride and belonging develops as well as greater awareness of responsibility. Individuals feel more appreciated and learn to appreciate the roles and responsibilities of others, increasing cooperation and enhancing teamwork.
Benefits to the Manager Delegation also yields benefits for the manager. First, if staff are using UAPs appropriately, the manager will have a better functioning unit. Also the manager may be able to delegate some tasks to staff members and devote more time to management tasks that cannot be delegated. With more time available, the manager can develop new skills and abilities, facilitating the op- portunity for career advancement.
Benefits to the Organization As teamwork improves, the organization benefits by achieving its goals more efficiently. Over- time and absences decrease. Subsequently, productivity increases, and the organization’s finan- cial position may improve. As delegation increases efficiency, the quality of care improves. As quality improves, patient satisfaction increases.
The Five Rights of Delegation Fear of liability often keeps nurses from delegating. State nurse practice acts determine the legal parameters for practice, professional associations set practice standards, and organizational pol- icy and job descriptions define delegation appropriate to the specific work setting. Also guide- lines from the National Council of State Boards of Nursing (NCSBN) can help.
The NCSBN identified the five rights of delegation shown in Table 10-1. In addition, each state board of nursing has its own rules regarding delegation.
● The right task specifies what can be safely delegated to a specific patient. These are com- monly assigned tasks. Tasks that require nursing assessment or judgment should not be delegated (Austin, 2008).
● The right circumstances include an appropriate setting and available resources. Evaluate the patient’s needs and the skills of personnel who could be assigned to meet those specific needs.
● The right person refers to both the delegator and the delegate. The delegator must have the authority and responsibility for the patient’s care and for the task to be assigned. The del- egate must be capable of performing the task and be available to assist. Give the right task to the right person for the right patient.
TABLE 10-1 The Five Rights of Delegation
● Right task ● Right circumstances ● Right person ● Right direction and communication ● Right supervision
National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved June 28, 2011 at https://www.ncsbn.org/Joint_statement.pdf
www.ncsbn.org/Joint_statement.pdf
134 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT
Is the task consistent with the recommended criteria for delegation to nursing assistive personnel (NAP)?
Are there agency policies, procedures and/or protocols in place for this task/activity?
Is appropriate supervision available?
Proceed with delegation
Does the nursing assistive personnel have the appropriate knowledge, skills and abilities (KSA) to accept the delegation?
Does the ability of the NAP match the care needs of the client?
Is the delegating nurse competent to make delegation decisions?
Has there been assessment of the client needs?
Is the task within the scope of the delegating nurse?
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Are there laws and rules in place that support the delegation?
Do not delegate
Do not delegate
Do not delegate
Do not delegate
Do not delegate
Do not delegate
Assess client needs then delegate appropriately
Figure 10-1 • Decision tree for delegation to nursing assistive personnel. Source: Adapted from National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved December 2007 from www.ncsbn.org/Joint_ statement.pdf
● The right direction and communication requires the delegator to give clear, concise description of the task as well as describe the objectives, the limits, and the expectations as a result. The delegate should be able to recognize that the patient is responding as expected.
● The right supervision includes monitoring the delegate, evaluating the person’s perfor- mance, giving feedback as required, and intervening if necessary. The delegator remains responsible for the patient’s care regardless of who performs it.
Also the National Council of State Boards of Nursing decision tree can help guide nurses’ decisions about delegation. (See Figure 10-1.)
The Delegation Process The delegation process has five steps as shown in Table 10-2.
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