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Library of Congress Cataloging-in-Publication Data

Names: Marquis, Bessie L., author. | Huston, Carol Jorgensen, author. Title: Leadership roles and management functions in nursing : theory and application / Bessie L. Marquis, Carol J. Huston. Description: Ninth edition. | Philadelphia : Wolters Kluwer Health, [2017] | Includes bibliographical references and index. Identifi ers: LCCN 2016046163 | ISBN 9781496349798 Subjects: | MESH: Nursing, Supervisory | Leadership | Nurse Administrators | Nursing—organization & administration Classifi cation: LCC RT89 | NLM WY 105 | DDC 362.17/3068—dc23 LC record available at https://lccn.loc.gov/2016046163

Care has been taken to confirm the accuracy of the information presented and to describe generally

accepted practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage

set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration

(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health-care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

LWW.com

I dedicate this book to the two most important partnerships in my life: my husband, Don Marquis,

and my colleague, Carol Huston. Bessie L. Marquis

I dedicate this book to my husband Tom, who has stood by my side for almost 45 years. I love you.

Carol Jorgensen Huston

REVIEWERS

Carol Amann, PhD, RN-BC, FNGNA Nursing Instructor Villa Maria School of Nursing Gannon University Erie, Pennsylvania

Andrea Archer, EdD, ARNP Undergraduate Nursing Department Florida International University Miami, Florida

Cynthia Banks, PhD Program Director, RN to BSN Department of Nursing Sentara College of Health Sciences Chesapeake, Virginia

Dana Botz, MSN Faculty, Department of Nursing North Hennepin Community College Brooklyn Park, Minnesota

Sharon Bradley, DNP Clinical Assistant Professor Director of Student Success College of Nursing University of Florida Gainesville, Florida

Carolyn Brose, EdD, MSN Associate Professor

MSN Program Director Missouri Western State University St. Joseph, Missouri

Beryl Broughton, MSN, CRNP, CS, CNE Nursing Instructor, Nursing Education Aria Health School of Nursing Trevose, Pennsylvania

Suzette Cardin, PhD Adjunct Associate Professor School of Nursing University of California, Los Angeles Los Angeles, California

Fran Cherkis, DHSc Associate Professor Department of Nursing Farmingdale State College Farmingdale, New York

Alice Colwell, MSN Assistant Professor Department of Nursing Kent State University Trumbull Campus Warren, Ohio

Laura Crouch, EdD, MSN Associate Clinical Professor School of Nursing Northern Arizona University Flagstaff, Arizona

Karen Davis, DNP Assistant Professor College of Nursing University of Arkansas for Medical Sciences Little Rock, Arkansas

Karen Estridge, DNP, RN Assistant Professor Department of Nursing Ashland University

Mansfield, Ohio

James Fell, MSN, MBA, BSN, BS Associate Professor Director Department of Nursing Baldwin Wallace University Berea, Ohio

Rick García, PhD Associate Professor Faculty Fellow Rory Meyers College of Nursing New York University New York, New York

Evalyn Gossett, MSN Clinical Assistant Professor School of Nursing Indiana University Northwest Gary, Indiana

Debra Grosskurth, PhD(c) Assistant Chair Department of Nursing Salve Regina University Newport, Rhode Island

Patricia Hanson, PhD Professor Department of Nursing Madonna University Livonia, Michigan

Tammy Henderson, MSN Associate Director Conemaugh School of Nursing Conemaugh Memorial Medical Center Johnstown, Pennsylvania

Barbara Hoerst, PhD, RN Assistant Professor Department of Nursing

La Salle University Philadelphia, Pennsylvania

Brenda Kucirka, PhD, RN, PMHCNS-BC, CNE Assistant Professor Department of Nursing Widener University Chester, Pennsylvania

Coleen Kumar, PhD College of Nursing State University of New York Downstate Medical Center Brooklyn, New York

Kathleen Lamaute, EdD Professor Department of Nursing Molloy College Rockville Centre, New York

Pamela Lapinski, MSN Professor Department of Nursing Valencia College Orlando, Florida

Jamie Lee, MSN, RN, CNL Assistant Professor Department of Nursing James Madison University Harrisonburg, Virginia

Carolyn Lewis, PhD Assistant Professor Department of Nursing Angelo State University San Angelo, Texas

Bette Mariani, PhD, RN Assistant Professor College of Nursing Villanova University Villanova, Pennsylvania

David Martin, MSN Director RN-BSN & Shared Curriculum Programs School of Nursing University of Kansas Kansas City, Kansas

Donna McCabe, DNP, APRN-BC, GNP Clinical Assistant Professor Department of Nursing Rory Meyers College of Nursing New York University New York, New York

Theresa Miller, PhD Associate Professor, Nursing Education OSF Saint Francis Medical Center College of Nursing Peoria, Illinois

Donna Molyneaux, PhD Associate Professor Department of Nursing Gwynedd Mercy University Gwynedd Valley, Pennsylvania

LaDonna Northington, DNS Professor, Traditional Undergraduate Nursing Program University of Mississippi School of Nursing Jackson, Mississippi

Sally Rappold, MSN, BSN Assistant Teaching Professor Department of Nursing Montana State University Missoula, Montana

Karen Ringl, MSN Faculty Department of Nursing California State University, Fullerton Fullerton, California

Joyce Shanty, PhD, RN

Associate Professor Nursing and Allied Health Professions Indiana University of Pennsylvania Indiana, Pennsylvania

Jean Short, MSN Assistant Professor Division of Post-Licensure Nursing School of Nursing Indiana Wesleyan University Marion, Indiana

Jennifer Sipe, MSN, CRNP Assistant Professor School of Nursing and Health Sciences La Salle University Philadelphia, Pennsylvania

Ana Stoehr, PhD, MSN Faculty Department of Nursing George Mason University Fairfax, Virginia

Patricia Thielemann, PhD Professor College of Nursing St. Petersburg College Pinellas Park, Florida

Charlene Thomas, PhD, MSN, BSN Associate Professor School of Nursing and Allied Health Aurora University Aurora, Illinois

Nina Trocky, DNP, RN Assistant Professor Department of Organizational Systems and Adult Health School of Nursing University of Maryland Baltimore, Maryland

Brenda Tyczkowski, DNP, RN, RHIA Assistant Professor Professional Program in Nursing University of Wisconsin Green Bay Green Bay, Wisconsin

Dannielle White, MSN Associate Professor School of Nursing Austin Peay State University Clarksville, Tennessee

Mary Williams, MS Associate Professor School of Nursing and Health Science Gordon State College Barnesville, Georgia

Connie Wilson, EdD Professor Emeritus School of Nursing University of Indianapolis Indianapolis, Indiana

Kelly Wolgast, DNP School of Nursing Vanderbilt University Nashville, Tennessee

Renee Wright, EdD Assistant Professor Department of Nursing York College, City University of New York New York, New York

Judith Young, DNP Clinical Assistant Professor, Community and Health Systems School of Nursing Indiana University Indianapolis, Indiana

PREFACE

Legacy of Leadership Roles and Management Functions in Nursing This book’s philosophy has evolved over 35 years of teaching leadership and management. We entered academe from the acute care sector of the health-care industry, where we held nursing management positions. In our first effort as authors, Management Decision Making for Nurses: 101 Case Studies, published in 1987, we used an experiential approach and emphasized management functions appropriate for first-and middle-level managers. The primary audience for this text was undergraduate nursing students. Our second book, Retention and Productivity Strategies for Nurse Managers, focused on leadership

skills necessary for managers to decrease attrition and increase productivity. This book was directed at the nurse-manager rather than the student. The experience of completing research for the second book, coupled with our clinical observations, compelled us to incorporate more leadership content in our teaching and to write this book. Leadership Roles and Management Functions in Nursing was also influenced by national events in

business and finance that led many to believe that a lack of leadership in management was widespread. It became apparent that if managers are to function effectively in the rapidly changing health-care industry, enhanced leadership and management skills are needed. What we attempted to do, then, was to combine these two very necessary elements: leadership and

management. We do not see leadership as merely one role of management nor management as only one role of leadership. We view the two as equally important and necessarily integrated. We have attempted to show this interdependence by defining the leadership components and management functions inherent in all phases of the management process. Undoubtedly, a few readers will find fault with our divisions of management functions and leadership roles; however, we felt it was necessary first to artificially separate the two components for the reader, and then to integrate the roles and functions. We do believe strongly that adoption of this integrated role is critical for success in management. The second concept that shaped this book was our commitment to developing critical thinking skills

through the use of experiential learning exercises. We propose that integrating leadership and management can be accomplished through the use of learning exercises. The majority of academic instruction continues to be conducted in a teacher-lecturer–student-listener format, which is one of the least effective teaching strategies. Few individuals learn best using this style. Instead, most people learn best by methods that

utilize concrete, experiential, self-initiated, and real-world learning experiences. In nursing, theoretical teaching is almost always accompanied by concurrent clinical practice that

allows concrete and real-world learning experience. However, the exploration of leadership and management theory may have only limited practicum experience, so learners often have little first-hand opportunity to observe middle-and top-level managers in nursing practice. As a result, novice managers frequently have little chance to practice their skills before assuming their first management position, and their decision making thus often reflects trial-and-error methodologies. For us, then, there is little question that vicarious learning, or learning through mock experience, provides students the opportunity to make significant leadership and management decisions in a safe environment and to learn from the decisions they make. Having moved away from the lecturer–listener format in our classes, we lecture for only a small

portion of class time. A Socratic approach, case study debate, and small and large group problem solving are emphasized. Our students, once resistant to the experiential approach, are now enthusiastic supporters. We also find this enthusiasm for experiential learning apparent in the workshops and seminars we provide for registered nurses. Experiential learning enables management and leadership theory to be fun and exciting, but most important, it facilitates retention of didactic material. The research we have completed on this teaching approach supports these findings. Although many leadership and management texts are available, our book meets the need for an

emphasis on both leadership and management and the use of an experiential approach. More than 280 learning exercises, representing various health-care settings and a wide variety of learning modes, are included to give readers many opportunities to apply theory, resulting in internalized learning. In Chapter 1, we provide guidelines for using the experiential learning exercises. We strongly urge readers to use them to supplement the text.

New to This Edition The first edition of Leadership Roles and Management Functions in Nursing presented the symbiotic elements of leadership and management, with an emphasis on problem solving and critical thinking. This ninth edition maintains this precedent with a balanced presentation of a strong theory component along with a variety of real-world scenarios in the experiential learning exercises. Responding to reviewer recommendations, we have added and deleted content. In particular, we have

attempted to strengthen the leadership component of the book while maintaining a balance of management content. We have also attempted to increase the focus on quality and safety as well as health-care finance, and used outpatient/community settings as the location for more learning exercises. We have also retained the strengths of earlier editions, reflecting content and application exercises

appropriate to the issues faced by nurse leader-managers as they practice in an era increasingly characterized by limited resources and emerging technologies. The ninth edition also includes contemporary research and theory to ensure accuracy of the didactic material. Additional content that has been added or expanded in this edition includes the following:

26 new learning exercises, further strengthening the problem-based element of this text. Over 200 displays, figures, and tables (17 of which are new) help readers visualize important

concepts, whereas photographs of nurses in leadership and management situations help students relate concepts to real-world practice. An expanded focus on evidence-driven leadership and management decision making Time management and productivity apps Newer care delivery models focused on ambulatory care and outpatient settings (primary care nurse coordinator in medical homes, nurse navigators, clinical nurse leaders [CNLs], leaders in patient- centered care) Impact of the 2010 Patient Protection and Affordable Care Act (PPACA) on quality and health-care finance in this country The shifting in health-care reimbursement from volume to value Personality testing as an employment selection tool Electronic health records and meaningful use Reflective practice and the assessment of continuing competency Civility, healthy workplaces, and bullying Interprofessional collaboration and workgroups Working with diverse workforces and patient populations Social media and organizational communication New quality Initiatives put forth by the Centers for Medicare & Medicaid Services, The Joint Commission, and other regulatory bodies Sentinel events Lean Six Sigma methodologies Medication reconciliation Self-appraisal, peer review, and 360-degree evaluation as performance appraisal tools

The Text Unit I provides a foundation for the decision-making, problem-solving, and critical-thinking skills as well as management and leadership skills needed to address the management–leadership problems presented in the text. Unit II covers ethics, legal concepts, and advocacy, which we see as core components of leadership

and management decision making. Units III–VII are organized using the management processes of planning, organizing, staffing, directing,

and controlling.

Features of the Text The ninth edition contains many pedagogical features designed to benefit both the student and the instructor:

Examining the Evidence, appearing in each chapter, depicts new research findings, evidence-based practice, and best practices in leadership and management.

Learning Exercises interspersed throughout each chapter foster readers’ critical-thinking skills and

promote interactive discussions. Additional learning exercises are also presented at the end of each chapter for further study and discussion. Breakout Comments are highlighted throughout each chapter, visually reinforcing key ideas. Tables, displays, figures, and illustrations are liberally supplied throughout the text to reinforce learning as well as to help clarify complex information. Key Concepts summarize important information within every chapter.

The Crosswalk

A crosswalk is a table that shows elements from different databases or criteria that interface. New to the eighth edition was a chapter crosswalk of content based on the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008), the AACN Essentials of Master’s Education in Nursing (2011), the American Organization of Nurse Executives (AONE) Nurse Executive Competencies (updated September 2015), and the Quality and Safety Education for Nurses (QSEN) Competencies (2014). For this edition, the newly revised Standards for Professional Performance from the American Nurses Association (ANA) Nursing Scope and Standards of Practice (2015) have been included. This edition, then, attempts to show how content in each chapter draws from or contributes to content identified as essential for baccalaureate and graduate education, for practice as a nurse administrator, and for safety and quality in clinical practice. In health care today, baccalaureate education for nurses is being emphasized as of increasing

importance, and the number of RN-MSN and BSN-PhD programs is always increasing. Nurses are being called on to remain lifelong learners and move with more fluidity than ever before. For these reasons, this textbook includes mapping to Essentials, Competencies, and Standards not only at the baccalaureate level but also at the master’s and executive levels, so that nurses may become familiar with the competencies expected as they continue to grow in their careers. Without doubt, some readers will disagree with the author’s determinations of which Essential,

Competency, or Standard has been addressed in each chapter, and certainly, an argument could be made that most chapters address many, if not all, of the Essentials, Competencies, or Standards in some way. The crosswalks in this book then are intended to note the primary content focus in each chapter, although additional Essentials, Competencies, or Standards may well be a part of the learning experience.

The American Association of Colleges of Nursing Essentials of Baccalaureate Education for Professional Nursing Practice The AACN Essentials of Baccalaureate Education for Professional Nursing Practice (commonly called the BSN Essentials) were released in 2008 and identified the following nine outcomes expected of graduates of baccalaureate nursing programs (Table 1). Essential IX describes generalist nursing practice at the completion of baccalaureate nursing education and includes practice-focused outcomes that integrate the knowledge, skills, and attitudes delineated in Essentials I to VIII. Achievement of the outcomes identified in the BSN Essentials will enable graduates to practice within complex health-care systems and to assume the roles of provider of care; designer/manager/coordinator of care; and member of a profession (AACN, 2008) (Table 1).

TABLE 1 AMERICAN ASSOCIATION OF COLLEGES OF NURSING ESSENTIALS OF BACCALAUREATE EDUCATION FOR PROFESSIONAL NURSING PRACTICE

Essential I: Liberal education for baccalaureate generalist nursing practice • A solid base in liberal education provides the cornerstone for the practice and education of nurses.

Essential II: Basic organizational and systems leadership for quality care and patient safety • Knowledge and skills in leadership, quality improvement, and patient safety are necessary to provide high-quality health care.

Essential III: Scholarship for evidence-based practice • Professional nursing practice is grounded in the translation of current evidence into one’s practice.

Essential IV: Information management and application of patient-care technology • Knowledge and skills in information management and patient-care technology are critical in the delivery of quality patient care.

Essential V: Health-care policy, finance, and regulatory environments • Health-care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the health-care system and thereby are important considerations in professional nursing practice.

Essential VI: Interprofessional communication and collaboration for improving patient health outcomes • Communication and collaboration among health-care professionals are critical to delivering high quality and safe patient care.

Essential VII: Clinical prevention and population health • Health promotion and disease prevention at the individual and population level are necessary to improve population health and are important components of baccalaureate generalist nursing practice.

Essential VIII: Professionalism and professional values • Professionalism and the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to the discipline of nursing.

Essential IX: Baccalaureate generalist nursing practice • The baccalaureate graduate nurse is prepared to practice with patients, including individuals, families, groups, communities, and populations across the lifespan and across the continuum of health-care environments.

• The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use of health-care

resources inherent in caring for patients.

The American Association of Colleges of Nursing Essentials of Master’s Education in Nursing The AACN Essentials of Master’s Education in Nursing (commonly called the MSN Essentials) were published in March 2011 and identified the following nine outcomes expected of graduates of master’s nursing programs, regardless of focus, major, or intended practice setting (Table 2). Achievement of these outcomes will prepare graduate nurses to lead change to improve quality outcomes, advance a culture of excellence through lifelong learning, build and lead collaborative interprofessional care teams, navigate and integrate care services across the health-care system, design innovative nursing practices, and translate evidence into practice (AACN, 2011).

TABLE 2 AMERICAN ASSOCIATION OF COLLEGES OF NURSING ESSENTIALS OF MASTER’S EDUCATION IN NURSING

Essential I: Background for practice from sciences and humanities • Recognizes that the master’s-prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.

Essential II: Organizational and systems leadership • Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems perspective.

Essential III: Quality improvement and safety • Recognizes that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization.

Essential IV: Translating and integrating scholarship into practice • Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results.

Essential V: Informatics and health-care technologies • Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care.

Essential VI: Health policy and advocacy • Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care.

Essential VII: Interprofessional collaboration for improving patient and population health outcomes • Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care.

Essential VIII: Clinical prevention and population health for improving health • Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations.

Essential IX: Master’s level nursing practice • Recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that influences health-care outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. Nursing practice interventions include both direct and indirect care components.

The American Organization of Nurse Executives Nurse Executive Competencies In 2004 (updated in 2015), the AONE published a paper describing skills common to nurses in executive practice regardless of their educational level or titles in different organizations. While these Nurse Executive Competencies differ depending on the leader’s specific position in the organization, the AONE suggested that managers at all levels must be competent in the five areas noted in Table 3 (AONE, 2015). These competencies suggest that nursing leadership/management is as much a specialty as any other clinical nursing specialty, and as such, it requires proficiency and competent practice specific to the executive role.

TABLE 3 AMERICAN ORGANIZATION OF NURSE EXECUTIVES NURSE EXECUTIVE COMPETENCIES

1. Communication and relationship building • Communication and relationship building includes effective communication, relationship management, influencing behaviors, diversity, community involvement, medical/staff relationships, and academic relationships.

2. Knowledge of the health-care environment • Knowledge of the health-care environment includes clinical practice knowledge, delivery models and work design, health-care economics

and policy, governance, evidence-based practice/outcome measurement and research, patient safety, performance improvement/metrics, and risk management.

3. Leadership • Leadership skills include foundational thinking skills, personal journey disciplines, systems thinking, succession planning, and change management.

4. Professionalism • Professionalism includes personal and professional accountability, career planning, ethics, and advocacy.

5. Business skills • Business skills include financial management, human resource management, strategic management, and information management and technology.

The American Nurses Association Standards of Professional Performance In 2015, ANA published six Standards of Practice for Nursing Administration as well as eleven Standards of Professional Performance. These standards describe a competent level of nursing practice and professional performance common to all registered nurses (Table 4). Because the Standards of Practice for nursing administration describe the nursing process and thus cross all aspects of nursing care, only the Standards of Professional Performance have been included in the crosswalk of this book (Table 4).

TABLE 4 AMERICAN NURSES ASSOCIATION NURSING ADMINISTRATION STANDARDS OF PROFESSIONAL PERFORMANCE

Standard 7. Ethics • The registered nurse practices ethically. Standard 8. Culturally congruent practice • The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles.

Standard 9. Communication • The registered nurse communicates effectively in all areas of practice. Standard 10. Collaboration • The registered nurse collaborates with health-care consumers and other key stakeholders in the conduct of nursing practice.

Standard 11. Leadership • The registered nurse leads within the professional practice setting and the profession.

Standard 12. Education • The registered nurse seeks knowledge and competence that reflects current

nursing practice and promotes futuristic thinking. Standard 13. Evidence-based practice and research • The registered nurse integrates evidence and research findings into practice.

Standard 14. Quality of practice • The registered nurse contributes to quality nursing practice. Standard 15. Professional practice evaluation • The registered nurse evaluates one’s own and others’ nursing practice. Standard 16. Resource utilization • The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

Standard 17. Environmental health • The registered nurse practices in an environmentally safe and healthy manner.

The Quality and Safety Education for Nurses Competencies Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute (2014; Cronenwett, 2007) defined six prelicensure and graduate quality and safety competencies for nursing (Table 5) and proposed targets for the knowledge, skills, and attitudes to be developed in nursing programs for each of these competencies. Led by a national advisory board and distinguished faculty, QSEN pursues strategies to develop effective teaching approaches to assure that future graduates develop competencies in patient- centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

TABLE 5 QUALITY AND SAFETY EDUCATION FOR NURSES COMPETENCIES

Patient-centered care • Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Teamwork and collaboration • Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Evidence-based practice • Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

Quality improvement • Definition: Use data to monitor the outcomes of care processes and use

improvement methods to design and test changes to continuously improve the quality and safety of health-care systems.

Safety • Definition: Minimizes the risk of harm to patients and providers through both system effectiveness and individual performance.

Informatics • Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

Leadership Roles and Management Functions in Nursing, ninth edition, has ancillary resources designed with both students and instructors in mind, available on web site.

Student Resources Available on

Glossary—Fully updated for the ninth edition, the glossary contains definitions of all important terms in the text.

Journal Articles—25 full articles from Wolters Kluwer journals (one corresponding to each chapter) —are provided for additional learning opportunities. Learning Objectives from the textbook are available in Microsoft Word for your convenience. Nursing Professional Roles and Responsibilities

Instructor’s Resources Available on

Competency Maps pull together the mapping provided in the crosswalk feature for each chapter, showing how the book content as a whole integrates key competencies for practice.

An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. An Instructor’s Guide includes information on experiential learning and guidelines on how to use the text for various types of learners and in different settings as well as information on how to use the various types of Learning Exercises included in the text. Learning Management System Course Cartridges PowerPoint presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, either via slide shows or handouts. Audience response questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. Sample Syllabi provide guidance for structuring your leadership and management course and are provided for two different course lengths: 7 and 14 weeks. Strategies for Effective Teaching offer creative approaches for engaging students. A Test Generator lets you put together exclusive new tests from a bank containing over 750

questions to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives. Access to all student resources.

Comprehensive, Integrated Digital Learning Solutions We are delighted to introduce an expanded suite of digital solutions to support instructors and students using Leadership Roles and Management Functions in Nursing, ninth edition. Now for the first time, our textbook is embedded into two integrated digital learning solutions—one specific for prelicensure programs and the other for postlicensure—that build on the features of the text with proven instructional design strategies. To learn more about these solutions, visit http://www.nursingeducationsuccess.com/ or contact your local Wolters Kluwer representative.

Our prelicensure solution, Lippincott CoursePoint, is a rich learning environment that drives course and curriculum success to prepare students for practice. Lippincott CoursePoint is designed for the way students learn. The solution connects learning to real-life application by integrating content from Leadership Roles and Management Functions in Nursing with video cases, interactive modules, and journal articles. Ideal for active, case-based learning, this powerful solution helps students develop higher level cognitive skills and asks them to make decisions related to simple-to-complex scenarios. Lippincott CoursePoint for Leadership and Management features the following:

Leading content in context: Digital content from Leadership Roles and Management Functions in Nursing is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level. The complete interactive eBook features annual content updates with the latest evidence-based practices and provides students with anytime, anywhere access on multiple devices. Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available.

Powerful tools to maximize class performance: Additional course-specific tools provide case- based learning for every student: Video Cases help students anticipate what to expect as a nurse, with detailed scenarios that capture their attention and integrate clinical knowledge with leadership and management concepts that are critical to real-world nursing practice. By watching the videos and completing related activities, students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and in preparation for practice.

Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the digital textbook are integrated throughout. Curated collections of journal articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice.

Data to measure students’ progress: Student performance data provided in an intuitive display lets instructors quickly assess whether students have viewed interactive modules and video cases outside of class as well as see students’ performance on related NCLEX-style quizzes, ensuring students are coming to the classroom ready and prepared to learn.

To learn more about Lippincott CoursePoint, please visit: http://www.nursingeducationsuccess.com/coursepoint

Lippincott RN to BSN Online: Leadership and Management is a postlicensure solution for online and hybrid courses, marrying experiential learning with the trusted content in Leadership Roles and Management Functions in Nursing, ninth edition. Built around learning objectives that are aligned to the BSN Essentials and QSEN nursing curriculum

standards, every aspect of Lippincott RN to BSN Online is designed to engage, challenge, and cultivate postlicensure students.

Self-paced interactive modules employ key instructional design strategies—including storytelling, modeling, and case-based and problem-based scenarios—to actively involve students in learning new material and focus students’ learning outcomes on real-life application.

Pre-and post-module assessments activate students’ existing knowledge prior to engaging with the module and then assess their competency after completing the module. Discussion board questions create an ongoing dialogue to foster social learning. Writing and group work assignments hone students’ competence in writing and communication, instilling the skills needed to advance their nursing careers. Collated journal articles acquaint students to the body of nursing research ongoing in recent literature. Case study assignments, including unfolding cases that evolve from cases in the interactive modules, aid students in applying theory to real-life situations. Best Practices in Scholarly Writing Guide covers American Psychological Association formatting and style guidelines.

Used alone or in conjunction with other instructor-created resources, Lippincott RN to BSN Online adds interactivity to courses. It also saves instructors time by keeping both textbook and course resources current and accurate through regular updates to the content. To learn more about Lippincott RN to BSN Online, please visit

http://www.nursingeducationsuccess.com/nursing-education-solutions/lippincott-rn-bsn-online/

Closing Note It is our hope and expectation that the content, style, and organization of this ninth edition of Leadership Roles and Management Functions in Nursing will be helpful to those students who want to become skillful, thoughtful leaders and managers. Bessie L. Marquis, RN, MSN Carol J. Huston, RN, MSN, DPA, FAAN

R E F E R E N C E S

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for

professional nursing practice. Retrieved October 17, 2015, from http://www.aacn.nche.edu/education-resources/baccessentials08.pdf

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CONTENTS

I The Critical Triad: Decision Making, Management, and Leadership

1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning: Requisites for Successful Leadership and Management Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning Vicarious Learning to Increase Problem-Solving and Decision-Making Skills Theoretical Approaches to Problem Solving and Decision Making Critical Elements in Problem Solving and Decision Making Individual Variations in Decision Making Overcoming Individual Vulnerability in Decision Making Decision Making in Organizations Decision-Making Tools Pitfalls in Using Decision-Making Tools Integrating Leadership Roles and Management Functions in Decision Making Key Concepts Additional Learning Exercises and Applications

2 Classical Views of Leadership and Management Managers Leaders Historical Development of Management Theory Historical Development of Leadership Theory (1900 to Present) Integrating Leadership Roles and Management Functions Key Concepts Additional Learning Exercises and Applications

3 Twenty-First-Century Thinking About Leadership and Management New Thinking About Leadership and Management Transition From Industrial Age Leadership to Relationship Age Leadership

Integrating Leadership Roles and Management Functions in the 21st Century Key Concepts Additional Learning Exercises and Applications

II Foundation for Effective Leadership and Management Ethics, Law, and Advocacy

4 Ethical Issues Moral Issues Faced by Nurses Ethical Frameworks for Decision Making Principles of Ethical Reasoning American Nurses Association Code of Ethics and Professional Standards Ethical Problem Solving and Decision Making The Moral Decision-Making Model Working Toward Ethical Behavior as the Norm Integrating Leadership Roles and Management Functions in Ethics Key Concepts Additional Learning Exercises and Applications

5 Legal and Legislative Issues Sources of Law Types of Laws and Courts Legal Doctrines and the Practice of Nursing Professional Negligence Avoiding Malpractice Claims Extending the Liability Incident Reports and Adverse Event Forms Intentional Torts Other Legal Responsibilities of the Manager Legal Considerations of Managing a Diverse Workforce Professional Versus Institutional Licensure Integrating Leadership Roles and Management Functions in Legal and Legislative Issues Key Concepts Additional Learning Exercises and Applications

6 Patient, Subordinate, Workplace, and Professional Advocacy Becoming an Advocate Patient Advocacy Patient Rights Subordinate and Workplace Advocacy

Whistleblowing as Advocacy Professional Advocacy Integrating Leadership Roles and Management Functions in Advocacy Key Concepts Additional Learning Exercises and Applications

III Roles and Functions in Planning

7 Organizational Planning Looking to the Future Proactive Planning Strategic Planning at the Organizational Level Organizational Planning: The Planning Hierarchy Vision and Mission Statements Organizational Philosophy Societal Philosophies and Values Related to Health Care Individual Philosophies and Values Goals and Objectives Policies and Procedures Rules Overcoming Barriers to Planning Integrating Leadership Roles and Management Functions in Planning Key Concepts Additional Learning Exercises and Applications

8 Planned Change Lewin’s Change Theory of Unfreezing, Movement, and Refreezing Lewin’s Change Theory of Driving and Restraining Forces A Contemporary Adaptation of Lewin’s Model Classic Change Strategies Resistance: The Expected Response to Change Planned Change as a Collaborative Process The Leader-Manager as a Role Model During Planned Change Organizational Change Associated With Nonlinear Dynamics Organizational Aging: Change as a Means of Renewal Integrating Leadership Roles and Management Functions in Planned Change Key Concepts Additional Learning Exercises and Applications

9 Time Management Three Basic Steps to Time Management

Personal Time Management Integrating Leadership Roles and Management Functions in Time Management Key Concepts Additional Learning Exercises and Applications

10 Fiscal Planning Balancing Cost and Quality Responsibility Accounting and Forecasting Basics of Budgets Steps in the Budgetary Process Types of Budgets Budgeting Methods Critical Pathways Health-Care Reimbursement Medicare and Medicaid The Prospective Payment System Managed Care Health-Care Reform and the Patient Protection and Affordable Care Act Integrating Leadership Roles and Management Functions in Fiscal Planning Key Concepts Additional Learning Exercises and Applications

11 Career Planning and Development in Nursing Career Stages Justifications for Career Development Individual Responsibility for Career Development The Organization’s Role in Employee Career Development Career Coaching Management Development Continued Competency as Part of Career Development Professional Specialty Certification Reflective Practice and the Professional Portfolio Career Planning and the New Graduate Nurse Transition-to-Practice Programs/Residencies for New Graduate Nurses Resumé Preparation Integrating Leadership Roles and Management Functions in Career Planning and Development Key Concepts Additional Learning Exercises and Applications

IV Roles and Functions in Organizing

12 Organizational Structure Formal and Informal Organizational Structure Organizational Theory and Bureaucracy Components of Organizational Structure Limitations of Organization Charts Types of Organizational Structures Decision Making Within the Organizational Hierarchy Stakeholders Organizational Culture Shared Governance: Organizational Design for the 21st Century? Magnet Designation and Pathway to Excellence Committee Structure in an Organization Responsibilities and Opportunities of Committee Work Organizational Effectiveness Integrating Leadership Roles and Management Functions Associated With Organizational Structure Key Concepts Additional Learning Exercises and Applications

13 Organizational, Political, and Personal Power Understanding Power The Authority–Power Gap Mobilizing the Power of the Nursing Profession An Action Plan for Increasing Professional Power in Nursing Strategies for Building a Personal Power Base The Politics of Power Integrating Leadership Roles and Management Functions When Using Authority and Power in Organizations Key Concepts Additional Learning Exercises and Applications

14 Organizing Patient Care Traditional Modes of Organizing Patient Care Disease Management Selecting the Optimum Mode of Organizing Patient Care New Roles for the Changing Health Care Arena: Nurse Navigators, Clinical Nurse Leaders, and Leaders in Patient-Centered Care Integrating Leadership Roles and Management Functions in Organizing Patient Care Key Concepts Additional Learning Exercises and Applications

V

Roles and Functions in Staffing

15 Employee Recruitment, Selection, Placement, and Indoctrination Predicting Staffing Needs Is a Nursing Shortage Imminent? Supply and Demand Factors Leading to a Potential Nursing Shortage Recruitment Interviewing as a Selection Tool Tips for the Interviewee Selection Placement Indoctrination Integrating Leadership Roles and Management Functions in Employee Recruitment, Selection, Placement, and Indoctrination Key Concepts Additional Learning Exercises and Applications

16 Socializing and Educating Staff in a Learning Organization The Learning Organization Staff Development Learning Theories Assessing Staff Development Needs Evaluation of Staff Development Activities Shared Responsibility for Implementing Evidence-Based Practice Socialization and Resocialization Overcoming Motivational Deficiencies Coaching as a Teaching Strategy Meeting the Educational Needs of a Culturally Diverse Staff Integrating Leadership and Management in Team Building Through Socializing and Educating Staff in a Learning Organization Key Concepts Additional Learning Exercises and Applications

17 Staffing Needs and Scheduling Policies Unit Manager’s Responsibilities in Meeting Staffing Needs Centralized and Decentralized Staffing Complying With Staffing Mandates Staffing and Scheduling Options Workload Measurement Tools The Relationship Between Nursing Care Hours, Staffing Mix, and Quality of Care Managing a Diverse Staff Generational Considerations for Staffing

The Impact of Nursing Staff Shortages on Staffing Fiscal and Ethical Accountability for Staffing Developing Staffing and Scheduling Policies Integrating Leadership Roles and Management Functions in Staffing and Scheduling Key Concepts Additional Learning Exercises and Applications

VI Roles and Functions in Directing

18 Creating a Motivating Climate Intrinsic Versus Extrinsic Motivation Motivational Theory Creating a Motivating Climate Strategies for Creating a Motivating Climate Promotion: A Motivational Tool Promoting Self-Care Integrating Leadership Roles and Management Functions in Creating a Motivating Climate at Work Key Concepts Additional Learning Exercises and Applications

19 Organizational, Interpersonal, and Group Communication The Communication Process Variables Affecting Organizational Communication Organizational Communication Strategies Communication Modes Elements of Nonverbal Communication Verbal Communication Skills Listening Skills Written Communication Within the Organization Technology as a Tool in Contemporary Organizational Communication Communication, Confidentiality, and Health Insurance Portability and Accountability Act Electronic Health Records and Meaningful Use Group Communication Group Dynamics Integrating Leadership and Management in Organizational, Interpersonal, and Group Communication Key Concepts Additional Learning Exercises and Applications

20 Delegation Delegating Effectively Common Delegation Errors

Delegation as a Function of Professional Nursing Subordinate Resistance to Delegation Delegating to a Multicultural Work Team Integrating Leadership Roles and Management Functions in Delegation Key Concepts Additional Learning Exercises and Applications

21 Effective Conflict Resolution and Negotiation The History of Conflict Management Intergroup, Intrapersonal, and Interpersonal Conflict The Conflict Process Conflict Management Managing Unit Conflict Bullying, Incivility, Mobbing, and Workplace Violence Negotiation Alternative Dispute Resolution Seeking Consensus Integrating Leadership Skills and Management Functions in Managing Conflict Key Concepts Additional Learning Exercises and Applications

22 Collective Bargaining, Unionization, and Employment Laws Unions and Collective Bargaining Historical Perspective of Unionization in America Union Representation of Nurses American Nurses Association and Collective Bargaining Employee Motivation to Join or Reject Unions Averting the Union Union-Organizing Strategies Steps to Establish a Union The Managers’ Role During Union Organizing The Nurse as Supervisor: Eligibility for Protection Under the National Labor Relations Act Employment Legislation State Health Facilities Licensing Boards Integrating Leadership Skills and Management Functions When Working With Collective Bargaining, Unionization, and Employment Laws Key Concepts Additional Learning Exercises and Applications

VII Roles and Functions in Controlling

23 Quality Control Defining Quality Health Care Quality Control as a Process The Development of Standards Audits as a Quality Control Tool Standardized Nursing Languages Quality Improvement Models Who Should Be Involved in Quality Control? Quality Measurement as an Organizational Mandate Professional Standards Review Organizations The Joint Commission Centers for Medicare & Medicaid Services National Committee for Quality Assurance National Database of Nursing Quality Indicators Report Cards Medical Errors: An Ongoing Threat to Quality of Care The Leapfrog Group Six Sigma Approach and Lean Manufacturing Reforming the Medical Liability System Integrating Leadership Roles and Management Functions With Quality Control Key Concepts Additional Learning Exercises and Applications

24 Performance Appraisal Using the Performance Appraisal to Motivate Employees Strategies to Ensure Accuracy and Fairness in the Performance Appraisal Performance Appraisal Tools Planning the Performance Appraisal Interview Overcoming Appraisal Interview Difficulties Performance Management Coaching: A Mechanism for Informal Performance Appraisal When Employees Appraise Their Manager’s Performance Using Leadership Skills and Management Functions in Conducting Performance Appraisals Key Concepts Additional Learning Exercises and Applications

25 Problem Employees: Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired Constructive Versus Destructive Discipline Self-Discipline and Group Norms Fair and Effective Rules Discipline as a Progressive Process

Disciplinary Strategies for the Manager Disciplining the Unionized Employee The Disciplinary Conference The Termination Conference Grievance Procedures Transferring Employees The Marginal Employee The Chemically Impaired Employee Recognizing the Chemically Impaired Employee Integrating Leadership Roles and Management Functions When Dealing With Problem Employees Key Concepts Additional Learning Exercises and Applications

Appendix Solutions to Selected Learning Exercises

Index

1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning: Requisites for Successful Leadership and Management

. . . again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made.

—Robert H. Schuller

. . . in any moment of decision the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.

—Theodore Roosevelt

This chapter addresses:

BSN Essential I: Liberal education for baccalaureate generalist nursing practice BSN Essential III: Scholarship for evidence-based practice BSN Essential IV: Information management and application of patient care technology BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

MSN Essential I: Background for practice from sciences and humanities MSN Essential IV: Translating and integrating scholarship into practice AONE Nurse Executive Competency I: Communication and relationship building AONE Nurse Executive Competency III: Leadership ANA Standard of Professional Performance 13: Evidence-based practice and research ANA Standard of Professional Performance 16: Resource utilization QSEN Competency: Informatics QSEN Competency: Evidence-based practice

The learner will:

differentiate between problem solving, decision making, critical thinking, and clinical reasoning describe how case studies, simulation, and problem-based learning can be used to improve the quality of decision making

explore strengths and limitations of using intuition and heuristics as adjuncts to problem solving and decision making

identify characteristics of successful decision makers use a PICO (patient or population, intervention, comparison, and outcome) format to search for current best evidence or practices to address a problem

identify strategies the new nurse might use to promote evidence-based practice select appropriate models for decision making in specific situations describe the importance of individual variations in the decision making process identify critical elements of decision making identify strategies that help decrease individual subjectivity and increase objectivity in decision making

explore his or her personal propensity for risk taking in decision making discuss the effect of organizational power and values on individual decision making differentiate between the economic man and the administrative man in decision making select appropriate management decision-making tools that would be helpful in making specific decisions

differentiate between autocratic, democratic, and laissez-faire decision styles and identify situation variables that might suggest using one decision style over another

Introduction Decision making is often thought to be synonymous with management and is one of the criteria on which management expertise is judged. Much of any manager’s time is spent critically examining issues, solving problems, and making decisions. The quality of the decisions that leader-managers make is the factor that often weighs most heavily in their success or failure. Decision making, then, is both an innermost leadership activity and the core of management. This

chapter explores the primary requisites for successful management and leadership: decision making, problem solving, and critical thinking. Also, because it is the authors’ belief that decision making, problem solving, and critical thinking are learned skills that improve with practice and consistency, an introduction to established tools, techniques, and strategies for effective decision making is included. This chapter also introduces the learning exercise as a new approach for vicariously gaining skill in management and leadership decision making. Finally, evidence-based decision making is introduced as an imperative for both personal and professional problem solving.

Decision Making, Problem Solving, Critical Thinking, and Clinical

Reasoning Decision making is a complex, cognitive process often defined as choosing a particular course of action. BusinessDictionary.com (2016, para. 1) defines decision making as “the thought process of selecting a logical choice from the available options.” This implies that doubt exists about several courses of action and that a choice is made to eliminate uncertainty. Problem solving is part of decision making and is a systematic process that focuses on analyzing a

difficult situation. Problem solving always includes a decision-making step. Many educators use the terms problem solving and decision making synonymously, but there is a small yet important difference between the two. Although decision making is the last step in the problem-solving process, it is possible for decision making to occur without the full analysis required in problem solving. Because problem solving attempts to identify the root problem in situations, much time and energy are spent on identifying the real problem. Decision making, on the other hand, is usually triggered by a problem but is often handled in a way that

does not focus on eliminating the underlying problem. For example, if a person decided to handle a conflict when it occurred but did not attempt to identify the real problem causing the conflict, only decision-making skills would be used. The decision maker might later choose to address the real cause of the conflict or might decide to do nothing at all about the problem. The decision has been made not to problem solve. This alternative may be selected because of a lack of energy, time, or resources to solve the real problem. In some situations, this is an appropriate decision. For example, assume that a nursing supervisor has a staff nurse who has been absent a great deal over the last 3 months. Normally, the supervisor would feel compelled to intervene. However, the supervisor has reliable information that the nurse will be resigning soon to return to school in another state. Because the problem will soon no longer exist, the supervisor decides that the time and energy needed to correct the problem are not warranted. Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and has a

broader scope than decision making and problem solving. Dictionary.com (2016) defines critical thinking as “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion” (para. 1). Critical thinking also involves reflecting on the meaning of statements, examining the offered evidence and reasoning, and forming judgments about facts.

Insight, intuition, empathy, and the willingness to take action are components of critical thinking.

Whatever definition of critical thinking is used, most agree that it is more complex than problem solving or decision making, involves higher order reasoning and evaluation, and has both cognitive and affective components. The authors believe that insight, intuition, empathy, and the willingness to take action are additional components of critical thinking. These same skills are necessary to some degree in decision making and problem solving. See Display 1.1 for additional characteristics of a critical thinker.

DISPLAY 1.1 Characteristics of a Critical Thinker

Open to New Ideas Flexible Creative Intuitive Empathetic Insightful Energetic Caring Willing to take action Analytical Observant Outcome directed Persistent Risk taker Willing to change Assertive Resourceful Knowledgeable Communicative “Outside-the-box” thinker Circular thinker

Nurses today must have higher order thinking skills to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. When nurses integrate and apply different types of knowledge to weigh evidence, critically think about arguments, and reflect on the process used to arrive at a diagnosis, this is known as clinical reasoning. Thus, clinical reasoning is a collaborative and reflective process that involves content-specific knowledge, engagement of the patient and family in understanding the clinical problem, and incorporation of critical contextual factors (Furze, Gale, Black, Cochran, & Jensen, 2015). All of these factors lead to deliberative decision making and sound clinical judgment. Thus, clinical reasoning uses both knowledge and experience to make decisions at the point of care.

Vicarious Learning to Increase Problem-Solving and Decision- Making Skills Decision making, one step in the problem-solving process, is an important task that relies heavily on critical thinking and clinical reasoning skills. How do people become successful problem solvers and decision makers? Although successful decision making can be learned through life experience, not everyone learns to solve problems and judge wisely by this trial-and-error method because much is left to chance. Some educators feel that people are not successful in problem solving and decision making because individuals are not taught how to reason insightfully from multiple perspectives. Moreover, information and new learning may not be presented within the context of real-life situations,

although this is changing. For example, in teaching clinical reasoning, nurse educators strive to see that the elements of clinical reasoning, such as noticing crucial changes in patient status, analyzing these changes to decide on a course of action, and evaluating responses to modify care, are embedded at every opportunity throughout the nursing curricula (Rischer, 2017). In addition, time is included for meaningful reflection on the decisions that are made and the outcomes that result. Such learning can occur in both real-world settings and through vicarious learning, where students problem solve and make decisions based on simulated situations that are made real to the learner.

Case Studies, Simulation, and Problem-Based Learning

Case studies, simulation, and problem-based learning (PBL) are some of the strategies that have been developed to vicariously improve problem solving and decision making. Case studies may be thought of as stories that impart learning. They may be fictional or include real persons and events, be relatively short and self-contained for use in a limited amount of time, or be longer with significant detail and complexity for use over extended periods of time. Case studies, particularly those that unfold or progress over time, are becoming much more common in nursing education because they provide a more interactive learning experience for students than the traditional didactic approach. Similarly, simulation provides learners opportunities for problem solving that have little or no risk to

patients or to organizational performance. For example, some organizations are now using computer simulation (known as discrete event simulation) to imitate the operation of a real-life system such as a hospital. The learner’s actions in the simulation provide insight to the quality of the learner’s decision making based on priority setting, timeliness of action, and patient outcomes. In addition, simulation models are increasingly being used by schools of nursing to allow students the

opportunity to gain skill mastery before working directly with acutely ill and vulnerable clients. For example, research by Shelestak, Meyers, Jarzembak, and Bradley (2015) found that the majority of students who successfully recognized cues in human patient simulation were able to make correct judgments and decisions in clinical practice (see Examining the Evidence 1.1). In addition, simulation allows students to apply and improve the critically important “nontechnical” skills of communication, teamwork, leadership, and decision making.

EXAMINING THE EVIDENCE 1.1

Source: Shelestak, D. S., Meyers, T. W., Jarzembak, J. M., & Bradley, E. (2015). A process to assess clinical decision-making during human patient simulation: A pilot study. Nursing Education Perspectives, 36(3), 185–187. doi:10.5480/13-1107.1

The purpose of this pilot study of senior nursing students was to describe a process to measure clinical decision making and to examine clinical judgment of nursing students using human patient simulation (HPS). A total of 51 students participated in the study. Data were collected over six simulation sessions, with 10 students in each group. Students alternated between active participant and observer roles during the simulation; at any given time, five students had active roles and five students were observers. A descriptive design was used to assess students’ understanding at

various critical decision points during an HPS. The HPS consisted of two separate situations where changes in the patient’s condition warranted action by the nurse. The scenario was developed using American Cardiac Life Support (ACLS) guidelines for bradycardia and pulseless ventricular algorithms. At Time 1, 49% correctly identified the situation; at Time 2, 71% correctly recognized the cues. The descriptive results of this pilot study suggest that correctly identifying cues is foundational to clinical decision making. The majority of students who correctly recognized cues also provided correct judgments and decisions.

PBL also provides opportunities for individuals to address and learn from authentic problems vicariously. Typically, in PBL, learners meet in small groups to discuss and analyze real-life problems. Thus, they learn by problem solving. The learning itself is collaborative as the teacher guides the students to be self-directed in their learning, and many experts suggest that this type of active learning helps to develop critical thinking skills.

The Marquis-Huston Critical Thinking Teaching Model

The desired outcome for teaching and learning decision making and critical thinking in management is an interaction between learners and others that results in the ability to critically examine management and leadership issues. This is a learning of appropriate social/professional behaviors rather than a mere acquisition of knowledge. This type of learning occurs best in groups, using a PBL approach. In addition, learners retain didactic material more readily when it is personalized or when they can

relate to the material being presented. The use of case studies that learners can identify with assists in retention of didactic materials. Also, although formal instruction in critical thinking is important, using a formal decision-making

process improves both the quality and consistency of decision making. Many new leaders and managers struggle to make quality decisions because their opportunity to practice making management and

leadership decisions is very limited until they are appointed to a management position. These limitations can be overcome by creating opportunities for vicariously experiencing the problems that individuals would encounter in the real world of leadership and management. The Marquis-Huston model for teaching critical thinking assists in achieving desired learner

outcomes (Fig. 1.1). Basically, the model comprises four overlapping spheres, each being an essential component for teaching leadership and management. The first is a didactic theory component, such as the material that is presented in each chapter; second, a formalized approach to problem solving and decision making must be used. Third, there must be some use of the group process, which can be accomplished through large and small groups and classroom discussion. Finally, the material must be made real for the learner so that the learning is internalized. This can be accomplished through writing exercises, personal exploration, and values clarification, along with risk taking, as case studies are examined.

This book was developed with the perspective that experiential learning provides mock experiences that have tremendous value in applying leadership and management theory. The text includes numerous opportunities for readers to experience the real world of leadership and management. Some of these learning situations, called learning exercises, include case studies, writing exercises, specific management or leadership problems, staffing and budgeting calculations, group discussion or problem- solving situations, and assessment of personal attitudes and values. Some exercises include opinions, speculation, and value judgments. All of the learning exercises, however, require some degree of critical thinking, problem solving, decision making, or clinical reasoning.

Experiential learning provides mock experiences that have tremendous value in applying leadership and management theory.

Some of the case studies have been solved (solutions are found at the back of the book) so that readers can observe how a systematic problem-solving or decision-making model can be applied in solving problems common to nurse-managers. The authors feel strongly, however, that the problem solving

suggested in the solved cases should not be considered the only plausible solution or “the right solution” to that learning exercise. Most of the learning exercises in the book have multiple solutions that could be implemented successfully to solve the problem.

Theoretical Approaches to Problem Solving and Decision Making Most people make decisions too quickly and fail to systematically examine a problem or its alternatives for solution. Instead, most individuals rely on discrete, often unconscious processes known as heuristics, which allows them to solve problems more quickly and to build on experiences they have gained in their lives. Thus, heuristics use trial-and-error methods or a rule-of-thumb approach to problem solving rather than set rules. Although heuristics are often considered “second-best solutions” as a result of relying heavily on

intuition and nonscientific strategies, Bodemer, Hanoch, and Katsikopoulos (2015) suggest that heuristics can actually be more accurate, faster, and easier to apply in comparison to more complex strategies. “This holds particularly true for uncertain situations such as emergency medicine where knowledge, time, and resources are limited. However, arguing for heuristics does not assume an argument against more complex, statistical tools. The quality of any strategy depends on the environment” (p. 203). Typically, formal process and structure can benefit the decision-making process, as they force decision

makers to be specific about options and to separate probabilities from values. A structured approach to problem solving and decision making increases clinical reasoning and is the best way to learn how to make quality decisions because it eliminates trial and error and focuses the learning on a proven process. A structured or professional approach involves applying a theoretical model in problem solving and decision making. Many acceptable problem-solving models exist, and most include a decision-making step; only four are reviewed here.

A structured approach to problem solving and decision making increases clinical reasoning.

Traditional Problem-Solving Process

One of the most well-known and widely used problem-solving models is the traditional problem-solving model. The seven steps are shown in Display 1.2. (Decision making occurs at step 5.)

DISPLAY 1.2 Traditional Problem-Solving Process

1. Identify the problem. 2. Gather data to analyze the causes and consequences of the problem. 3. Explore alternative solutions. 4. Evaluate the alternatives.

5. Select the appropriate solution. 6. Implement the solution. 7. Evaluate the results.

Although the traditional problem-solving process is an effective model, its weakness lies in the amount of time needed for proper implementation. This process, therefore, is less effective when time constraints are a consideration. Another weakness is lack of an initial objective-setting step. Setting a decision goal helps to prevent the decision maker from becoming sidetracked.

Managerial Decision-Making Models

To address the weaknesses of the traditional problem-solving process, many contemporary models for management decision making have added an objective-setting step. These models are known as managerial decision-making models or rational decision-making models. One such model suggested by Decision-making-confidence.com (2006–2015) includes the six steps shown in Display 1.3.

DISPLAY 1.3 Managerial Decision-Making Model

1. Determine the decision and the desired outcome (set objectives). 2. Research and identify options. 3. Compare and contrast these options and their consequences. 4. Make a decision. 5. Implement an action plan. 6. Evaluate results.

In the first step, problem solvers must identify the decision to be made, who needs to be involved in the decision process, the timeline for the decision, and the goals or outcomes that should be achieved. Identifying objectives to guide the decision making helps the problem solver determine which criteria should be weighted most heavily in making their decision. Most important decisions require this careful consideration of context. In step 2, problem solvers must attempt to identify as many alternatives as possible. Alternatives are

then analyzed in step 3, often using some type of SWOT (strengths, weaknesses, opportunities, and threats) analysis. Decision makers may choose to apply quantitative decision-making tools, such as decision- making grids and payoff tables (discussed further later in this chapter), to objectively review the desirability of alternatives. In step 4, alternatives are rank ordered on the basis of the analysis done in step 3 so that problem

solvers can make a choice. In step 5, a plan is created to implement desirable alternatives or combinations of alternatives. In the final step, challenges to successful implementation of chosen alternatives are identified and strategies are developed to manage those risks. An evaluation is then

conducted of both process and outcome criteria, with outcome criteria typically reflecting the objectives that were set in step 1.

The Nursing Process

The nursing process, developed by Ida Jean Orlando in the late 1950s, provides another theoretical system for solving problems and making decisions. Originally a four-step model (assess, plan, implement, and evaluate), diagnosis was delineated as a separate step, and most contemporary depictions of this model now include at least five steps (Display 1.4).

DISPLAY 1.4 Nursing Process

1. Assess. 2. Diagnose. 3. Plan. 4. Implement. 5. Evaluate.

As a decision-making model, the greatest strength of the nursing process may be its multiple venues for feedback. The arrows in Figure 1.2 show constant input into the process. When the decision point has been identified, initial decision making occurs and continues throughout the process via a feedback mechanism.

Although the process was designed for nursing practice with regard to patient care and nursing accountability, it can easily be adapted as a theoretical model for solving leadership and management problems. Table 1.1 shows how closely the nursing process parallels the decision-making process.

The weakness of the nursing process, like the traditional problem-solving model, is in not requiring clearly stated objectives. Goals should be clearly stated in the planning phase of the process, but this step is frequently omitted or obscured. However, because nurses are familiar with this process and its proven effectiveness, it continues to be recommended as an adapted theoretical process for leadership and managerial decision making.

Integrated Ethical Problem-Solving Model

A more contemporary model for effective thinking and problem solving was developed by Park (2012) upon review of 20 existing models for ethical decision making (Display 1.5). Although developed primarily for use in solving ethical problems, the model also works well as a general problem-solving model. Similar to the three models already discussed, this model provides a structured approach to problem solving that includes an assessment of the problem, problem identification, the analysis and selection of the best alternative, and a means for evaluation. The model does go one step further, however, in requiring the learner to specifically identify strategies that reduce the likelihood of a problem recurring.

DISPLAY 1.5 Integrated Ethical Problem-Solving Model

1. State the problem. 2. Collect additional information and analyze the problem. 3. Develop alternatives and analyze and compare them. 4. Select the best alternative and justify your decision. 5. Develop strategies to successfully implement a chosen alternative and take action. 6. Evaluate the outcomes and prevent a similar occurrence.

Many other excellent problem analysis and decision models exist. The model selected should be one with which the decision maker is familiar and one appropriate for the problem to be solved. Using models or processes consistently will increase the likelihood that critical analysis will occur. Moreover, the quality of management/leadership problem solving and decision making will improve tremendously via a scientific approach.

LEARNING EXERCISE 1.1

Applying Scientific Models to Decision Making

You are a registered nurse. Since your graduation 3 years ago, you have worked as a full-time industrial health nurse for a large manufacturing plant. Although you love your family (spouse and one preschool-aged child), you love your job as well because career is very important to you. Recently, you and your spouse decided to have another baby. At that time, you and your spouse reached a joint decision that if you had another baby, you would reduce your work time and spend more time at home with the children. Last week, however, the Director of Human Resources told you that the full-time Director of Health

Care Services for the plant is leaving and that the organization wants to appoint you to the position. You were initially thrilled and excited; however, you found out several days later that you and your spouse are expecting a baby. Last night, you spoke with your spouse about your career future. Your spouse is an attorney whose

practice has suddenly gained momentum. Although the two of you have shared child rearing equally until this point, your spouse is not sure how much longer this can be done if the law practice continues to expand. If you take the position, which you would like to do, it would mean full-time work and more management responsibilities. You want the decision you and your spouse reach to be well-thought-out, as it has far-reaching consequences and concerns many people.

ASSIGNMENT:

Determine what you should do. After you have made your decision, get together in a group (four to six people) and share your decisions. Were they the same? How did you approach the problem solving differently from others in your group? Was a rational systematic problem- solving process used, or was the chosen solution based more on intuition? How many alternatives were generated? Did some of the group members identify alternatives that you had not considered? Was a goal or objective identified? How did your personal values influence your decision?

Intuitive Decision-Making Models

There are theorists who suggest that intuition should always be used as an adjunct to empirical or rational decision-making models. Experienced (expert) nurses often report that gut-level feelings (intuition) encourage them to take appropriate strategic action that impacts patient outcomes (Payne, 2015), although intuition generally serves as an adjunct to decision making founded on a nurse’s scientific knowledge base. Pearson (2013) agrees, suggesting that intuition can and should be used in conjunction with evidence-

based practice and that it deserves to be acknowledged as a factor in achieving good outcomes within clinical practice. Pearson goes on to say that intuition is, in reality, often a rapid, automatic process of recognizing familiar problems instantly and using experience to identify solutions. Thus, intuition may be perceived as a cognitive skill rather than a perception or knowing without knowing how. This recognition of familiar problems and the use of intuition to identify solutions is a focus of

contemporary research on intuitive decision-making research. Klein (2008) developed the recognition- primed decision (RPD) model for intuitive decision making in the mid-1980s to explain how people can make effective decisions under time pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model attempts to understand how humans make relatively quick decisions in complex, real-world settings such as firefighting and critical care nursing without having to compare options. Klein’s (2008) work suggests that instead of using classical rational or systematic decision-making

processes, many individuals act on their first impulse if the “imagined future” looks acceptable. If this turns out not to be the case, another idea or concept is allowed to emerge from their subconscious and is examined for probable successful implementation. Thus, the RPD model blends intuition and analysis, but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible. Reiter-Palmon, Kennel, Allen, Jones, and Skinner (2015) explored naturalistic decision making in

health care by studying how after-action reviews (postfall huddles) could be utilized as a learning tool to reduce errors. Their research found that these self-guided postfall huddles increased over the time of the project, indicating adoption of the process and that the types of errors identified as contributing to patient falls changed, with a reduction in task and coordination errors over time.

Critical Elements In Problem Solving And Decision Making Because decisions may have far-reaching consequences, some problem solving and decision making must be of high quality. Using a scientific approach alone for problem solving and decision making does not, however, ensure a quality decision. Special attention must be paid to other critical elements. The elements in Display 1.6, considered crucial in problem solving, must occur if a high-quality decision is to be made.

DISPLAY 1.6 Critical Elements in Decision Making

1. Define objectives clearly. 2. Gather data carefully. 3. Take the time necessary. 4. Generate many alternatives. 5. Think logically. 6. Choose and act decisively.

Define Objectives Clearly

Decision makers often forge ahead in their problem-solving process without first determining their goals or objectives. However, it is especially important to determine goals and objectives when problems are complex. Even when decisions must be made quickly, there is time to pause and reflect on the purpose of the decision. A decision that is made without a clear objective in mind or a decision that is inconsistent with one’s philosophy is likely to be a poor-quality decision. Sometimes the problem has been identified, but the wrong objectives are set.

If a decision lacks a clear objective or if an objective is not consistent with the individual’s or organization’s stated philosophy, a poor-quality decision is likely.

For example, it would be important for the decision maker in Learning Exercise 1.1 to determine whether her most important objective is career advancement, having more time with family, or meeting the needs of her spouse. None of these goals is more “right” than the others, but not having clarity about which objective is paramount makes decision making very difficult.

Gather Data Carefully

Because decisions are based on knowledge and information available to the problem solver at the time the decision must be made, one must learn how to process and obtain accurate information. The acquisition of information begins with identifying the problem or the occasion for the decision and continues throughout the problem-solving process. Often, the information is unsolicited, but most information is sought actively. Clear (2015) warns, however, that many people experience confirmation bias in their data gathering.

Confirmation bias refers to our tendency to search for and favor information that confirms our beliefs while simultaneously ignoring or devaluing information that contradicts our beliefs (Clear, 2015). The more someone believes he or she knows something, the more he or she filters and ignores information to the contrary. Thus, people negate new information if it does not validate their perceptions or ideas. In addition, acquiring information always involves people, and no tool or mechanism is infallible to

human error. Questions that should be asked in data gathering are shown in Display 1.7.

DISPLAY 1.7 Questions to Examine in Data Gathering

1. What is the setting? 2. What is the problem? 3. Where is it a problem? 4. When is it a problem? 5. Who is affected by the problem? 6. What is happening? 7. Why is it happening? What are the causes of the problem? Can the causes be prioritized? 8. What are the basic underlying issues? What are the areas of conflict? 9. What are the consequences of the problem? Which is the most serious?

In addition, human values tremendously influence our perceptions. Therefore, as problem solvers gather information, they must be vigilant that their own preferences and those of others are not mistaken for facts.

Facts can be misleading if they are presented in a seductive manner, if they are taken out of context, or if they are past oriented.

How many parents have been misled by the factual statement “Johnny hit me”? In this case, the information seeker needs to do more fact finding. What was the accuser doing before Johnny hit him? What was he hit with? Where was he hit? When was he hit? Like the parent, the manager who becomes expert at acquiring adequate, appropriate, and accurate information will have a head start in becoming an expert decision maker and problem solver.

Take the Time Necessary

Most current problem-solving and decision-making theories argue that human decision making is largely based on the quick, automatic, and intuitive processes. Although trivial decisions can be made fairly quickly, slower, more controlled deliberation is needed when outcomes may have significant consequences.

Use an Evidence-Based Approach

To gain knowledge and insight into managerial and leadership decision making, individuals must reach outside their current sphere of knowledge in solving the problems presented in this text. Some data- gathering sources include textbooks, periodicals, experts in the field, colleagues, and current research. Indeed, most experts agree that the best practices in nursing care and decision making are also evidence- based practices (Prevost & Ford, 2017).

Although there is no one universally accepted definition for an evidence-based approach, most definitions suggest the term evidence based can be used synonymously with researchbased or science based. Others suggest that evidence based means that the approach has been reviewed by experts in the field using accepted standards of empirical research and that reliable evidence exists that the approach or practice works to achieve the desired outcomes. Typically, a PICO (patient or population, intervention, comparison, and outcome) format is used in evidence-based practice to guide the search for the current best evidence to address a problem. Given that human lives are often at risk, nurses, then, should feel compelled to use an evidence-based

approach in gathering data to make decisions regarding their nursing practice. Yet, Prevost and Ford (2017) suggest that many practicing nurses feel they do not have the time, access, or expertise needed to search and analyze the research literature to answer clinical questions. In addition, most staff nurses practicing in clinical settings have less than a baccalaureate degree and therefore may not have been exposed to a formal research course. Findings from research studies may also be technical, difficult to understand, and even more difficult to translate into practice. Strategies the new nurse might use to promote evidence-based practice are shown in Display 1.8.

DISPLAY 1.8 Strategies for the New Nurse to Promote Evidence-Based Best Practice

1. Keep abreast of the evidence—subscribe to professional journals and read widely. 2. Use and encourage use of multiple sources of evidence. 3. Use evidence not only to support clinical interventions but also to support teaching strategies. 4. Find established sources of evidence in your specialty—do not reinvent the wheel. 5. Implement and evaluate nationally sanctioned clinical practice guidelines. 6. Question and challenge nursing traditions and promote a spirit of risk taking. 7. Dispel myths and traditions not supported by evidence. 8. Collaborate with other nurses locally and globally. 9. Interact with other disciplines to bring nursing evidence to the table.

Source: Reprinted fromPrevost, S., & Ford, C. D. (2017). Evidence-based practice. In C. Huston (Ed.), Professional issues in nursing: Challenges & opportunities (4th ed., pp. 17–27). Philadelphia, PA: Wolters Kluwer.

Evidence-based decision making and evidence-based practice should be viewed as imperatives for all nurses today as well as for the profession in general.

It is important to recognize that the implementation of evidence-based best practices is not just an individual, staff nurse–level pursuit (Prevost & Ford, 2017). Too few nurses understand what best practices and evidence-based practice are all about, and many organizational cultures do not support nurses who seek out and use research to change long-standing practices rooted in tradition rather than in science. Administrative support is needed to access the resources, provide the support personnel, and

sanction the necessary changes in policies, procedures, and practices for evidence-based data gathering to be a part of every nurse’s practice (Prevost & Ford, 2017). This approach to care is even being recognized as a standard expectation of accrediting bodies such as The Joint Commission, as well as an expectation for Magnet hospital designation.

Generate Many Alternatives

The definition of decision making implies that there are at least two choices in every decision. Unfortunately, many problem solvers limit their choices to two when many more options usually are available. Remember that one alternative in each decision should be the choice not to do anything. When examining decisions to be made by using a formal process, it is often found that the status quo is the right alternative.

The greater the number of alternatives that can be generated, the greater the chance that the final decision will be sound.

Several techniques can help to generate more alternatives. Involving others in the process confirms the adage that two heads are better than one. Because everyone thinks uniquely, increasing the number of people working on a problem increases the number of alternatives that can be generated. Brainstorming is another frequently used technique. The goal in brainstorming is to think of all possible

alternatives, even those that may seem “off target.” By not limiting the possible alternatives to only apparently appropriate ones, people can break through habitual or repressive thinking patterns and allow new ideas to surface. Although most often used by groups, people who make decisions alone also may use brainstorming.

LEARNING EXERCISE 1.2

Possible Alternatives in Problem Solving

In the personal-choice scenario presented in Learning Exercise 1.1, some of the following alternatives could have been generated: Do not take the new position. Hire a full-time housekeeper and take the position. Ask your spouse to quit working. Have an abortion. Ask one of the parents to help. Take the position and do not hire childcare. Take the position and hire childcare. Have your spouse reduce the law practice and continue helping with childcare. Ask the Director of Human Resources if you can work 4 days a week and still have the position. Take the position and wait and see what happens after the baby is born.

ASSIGNMENT:

How many of these alternatives did you or your group generate? What alternatives did you identify that are not included in this list?

Think Logically

During the problem-solving process, one must draw inferences from information. An inference is part of deductive reasoning. People must carefully think through the information and the alternatives. Faulty logic at this point may lead to poor-quality decisions. Primarily, people think illogically in three ways. 1. Overgeneralizing: This type of “crooked” thinking occurs when one believes that because A has a

particular characteristic, every other A also has the same characteristic. This kind of thinking is exemplified when stereotypical statements are used to justify arguments and decisions.

2. Affirming the consequences: In this type of illogical thinking, one decides that if B is good and he or she is doing A, then A must not be good. For example, if a new method is heralded as the best way to perform a nursing procedure and the nurses on your unit are not using that technique, it is illogical to assume that the technique currently used in your unit is wrong or bad.

3. Arguing from analogy: This thinking applies a component that is present in two separate concepts and then states that because A is present in B, then A and B are alike in all respects. An example of this would be to argue that because intuition plays a part in clinical and managerial nursing, then any characteristic present in a good clinical nurse also should be present in a good nurse-manager. However, this is not necessarily true; a good nurse-manager does not necessarily possess all the same skills as a good nurse-clinician.

Various tools have been designed to assist managers with the important task of analysis. Several of these tools are discussed in this chapter. In analyzing possible solutions, individuals may want to look at the following questions: 1. What factors can you influence? How can you make the positive factors more important and

minimize the negative factors? 2. What are the financial implications in each alternative? The political implications? Who else will

be affected by the decision and what support is available? 3. What are the weighting factors? 4. What is the best solution? 5. What are the means of evaluation? 6. What are the consequences of each alternative?

Choose and Act Decisively

It is not enough to gather adequate information, think logically, select from among many alternatives, and be aware of the influence of one’s values. In the final analysis, one must act. Many individuals delay acting because they do not want to face the consequences of their choices (e.g., if managers granted all employees’ requests for days off, they would have to accept the consequences of dealing with short staffing).

Many individuals choose to delay acting because they lack the courage to face the consequences of their choices.

It may help the reluctant decision maker to remember that even though decisions often have long-term consequences and far-reaching effects, they are not usually cast in stone. Often, judgments found to be ineffective or inappropriate can be changed. By later evaluating decisions, managers can learn more about their abilities and where the problem solving was faulty. However, decisions must continue to be made, although some are of poor quality, because through continued decision making, people develop improved decision-making skills.

Individual Variations in Decision Making If each person receives the same information and uses the same scientific approach to solve problems, an assumption could be made that identical decisions would result. However, in practice, this is not true. Because decision making involves perceiving and evaluating, and people perceive by sensation and intuition and evaluate their perception by thinking and feeling, it is inevitable that individuality plays a part in decision making. Because everyone has different values and life experiences, and each person perceives and thinks differently, different decisions may be made given the same set of circumstances. No discussion of decision making would, therefore, be complete without a careful examination of the role of the individual in decision making.

Gender

New research suggests that gender may play a role in how individuals make decisions, although some debate continues as to whether these differences are more gender role based than gender based. Research does suggest, however, that men and women do have different structures and wiring in the brain and that men and women may use their brains differently (Edmonds, 1998–2016). For example, Harvard researchers have found that parts of the frontal lobe, responsible for problem solving and decision making, and the limbic cortex, responsible for regulating emotions, are larger in women (Hoag as cited in Edmonds, 1998–2016). Men also have approximately 6.5 times more gray matter in the brain than women, but women have about 10 times more white matter than men (Carey as cited in Edmonds, 1998–2016). Researchers believe that men may think more with their gray matter, whereas women think more with the white matter. This use of white matter may allow a woman’s brain to work faster than a man’s (Hotz as cited in Edmonds, 1998–2016).

Values

Individual decisions are based on each person’s value system. No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously. The alternatives generated and the final choices are limited by each person’s value system. For some, certain choices are not possible because of a person’s beliefs. Because values also influence perceptions, they invariably influence information gathering, information processing, and final outcome. Values also determine which problems in one’s personal or professional life will be addressed or ignored.

No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously.

Life Experience

Each person brings to the decision-making task past experiences that include education and decision- making experience. The more mature the person and the broader his or her background, the more alternatives he or she can identify. Each time a new behavior or decision is observed, that possibility is added to the person’s repertoire of choices. In addition, people vary in their desire for autonomy, so some nurses may want more autonomy than

others. It is likely that people seeking autonomy may have much more experience at making decisions than those who fear autonomy. Likewise, having made good or poor decisions in the past will influence a person’s decision making.

Individual Preference

With all the alternatives a person considers in decision making, one alternative may be preferred over another. The decision maker, for example, may see certain choices as involving greater personal risk than others and therefore may choose the safer alternative. Physical, economic, and emotional risks and time and energy expenditures are types of personal risk and costs involved in decision making. For example,

people with limited finances or a reduced energy level may decide to select an alternative solution to a problem that would not have been their first choice had they been able to overcome limited resources.

Brain Hemisphere Dominance and Thinking Styles

Our way of evaluating information and alternatives on which we base our final decision constitutes a thinking skill. Individuals think differently. Some think systematically—and are often called analytical thinkers—whereas others think more intuitively. About 30 years ago, researchers first began arguing that most people have either right- or left-brain hemisphere dominance. They suggested that analytical, linear, left-brain thinkers process information differently from creative, intuitive, right-brain thinkers. Left- brain thinkers were supposed to be better at processing language, logic, and numbers, whereas right-brain thinkers excelled at nonverbal ideation and creativity. Some researchers, including Nobel Prize winner Roger Sperry, suggested that there were actually four

different thinking styles based on brain dominance. Ned Herrmann, a researcher in critical thinking and whole-brain methods, also suggested that there are four brain hemispheres and that decision making varies with brain dominance (12 Manage: The Executive Fast Track, 2016). For example, Herrmann suggested that individuals with upper-left-brain dominance truly are analytical thinkers who like working with factual data and numbers. These individuals deal with problems in a logical and rational way. Individuals with lower-left-brain dominance are highly organized and detail oriented. They prefer a stable work environment and value safety and security over risk taking. In addition, researchers suggested that individuals with upper-right-brain dominance were big picture

thinkers who looked for hidden possibilities and were futuristic in their thinking. They were thought to frequently rely on intuition to solve problems and are willing to take risks to seek new solutions to problems. Individuals with lower-right-brain dominance experienced facts and problem solved in a more emotional way than the other three types. They were sympathetic, kinesthetic, and empathetic and focused more on interpersonal aspects of decision making (12 Manage: The Executive Fast Track, 2016). Nauert (1995–2016) suggests, however, that the existence of left or right brain dominance is too

simplistic. He suggests that newer studies have failed to find evidence that individuals tend to have stronger left- or right-sided brain networks. Cherry (2015) agrees, suggesting that recent research has shown that the brain is not nearly as dichotomous as once thought. For example, abilities in subjects such as math are strongest when both halves of the brain work together. Indeed, both sides of the brain collaborate to perform a broad variety of tasks and the two hemispheres communicate through the corpus callosum (Cherry, 2015). Cherry notes that it is absolutely true that some brain functions occur in one or the other side of the brain (language tends to be on the left and attention more on the right), but people don’t tend to have a stronger left- or right-sided brain network.

New evidence suggests the existence of left or right brain dominance may be an oversimplification.

LEARNING EXERCISE 1.3

Thinking Styles

In small groups, discuss individual variations in thinking. Did some individuals identify themselves as more intuitive thinkers or more linear thinkers? Did group members self-identify with one or more of the four thinking styles noted by Herrmann (12 Manage: The Executive Fast Track, 2016)? Did gender seem to influence thinking style or brain hemisphere dominance? What types of thinkers were represented in group members’ families? Did most group members view variances in a positive way?

Overcoming Individual Vulnerability in Decision Making How do people overcome subjectivity in making decisions? This can never be completely overcome nor should it. After all, life would be boring if everyone thought alike. However, managers and leaders must become aware of their own vulnerability and recognize how it influences and limits the quality of their decision making. Using the following suggestions will help decrease individual subjectivity and increase objectivity in decision making.

Values

Being confused and unclear about one’s values may affect decision-making ability. Overcoming a lack of self-awareness through values clarification decreases confusion. People who understand their personal beliefs and feelings will have a conscious awareness of the values on which their decisions are based. This awareness is an essential component of decision making and critical thinking. Therefore, to be successful problem solvers, managers must periodically examine their values. Values clarification exercises are included in Chapter 7.

Life Experience

It is difficult to overcome inexperience when making decisions. However, a person can do some things to decrease this area of vulnerability. First, use available resources, including current research and literature, to gain a fuller understanding of the issues involved. Second, involve other people, such as experienced colleagues, mentors, trusted friends, and experts, to act as sounding boards and advisors. Third, analyze decisions later to assess their success. By evaluating decisions, people learn from mistakes and are able to overcome inexperience. In addition, novice nurse-leaders of the future may increasingly choose to improve the quality of their

decision making by the use of commercially purchased expert networks—communities of top thinkers, managers, and scientists—to help them make decisions. Such network panels are typically made up of researchers, health-care professionals, attorneys, and industry executives.

Individual Preference

Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking. The need for self-awareness was discussed previously, but it is not enough to be self-aware; people also must be honest with themselves about their choices and their preferences for those choices. In addition, the successful decision maker must take some risks. Nearly every decision has some element of risk, and most decisions involve consequences and accountability.

Those who can do the right but unpopular thing and who dare to stand alone will emerge as leaders.

Individual Ways of Thinking

People making decisions alone are frequently handicapped because they are not able to understand problems fully or make decisions from both analytical and intuitive perspectives. However, most organizations include both types of thinkers. Using group process, talking management problems over with others, and developing whole-brain thinking also are methods for ensuring that both intuitive and analytical approaches will be used in solving problems and making decisions. Use of heterogeneous rather than homogeneous groups will usually result in better quality decision making. Indeed, learning to think “outside the box” is often accomplished by including a diverse group of thinkers when solving problems and making decisions. Although not all experts agree, many consider the following to be qualities of a successful decision

maker:

Courage: Courage is particularly important and involves the willingness to take risks. Sensitivity: Good decision makers seem to have some sort of antenna that makes them particularly sensitive to situations and others. Energy: People must have the energy and desire to make things happen. Creativity: Successful decision makers tend to be creative thinkers. They develop new ways to solve problems.

Decision Making in Organizations In the beginning of this chapter, the need for managers and leaders to make quality decisions was emphasized. The effect of the individual’s values and preferences on decision making was discussed, but it is important for leaders and managers to also understand how the organization influences the decision- making process. Because organizations are made up of people with differing values and preferences, there is often conflict in organizational decision dynamics.

Effect of Organizational Power

Powerful people in organizations are more likely to have decisions made (by themselves or their subordinates) that are congruent with their own preferences and values. On the other hand, people wielding little power in organizations must always consider the preference of the powerful when they

make management decisions. In organizations, choice is constructed and constrained by many factors, and therefore, choice is not equally available to all people. In addition, not only do the preferences of the powerful influence decisions of the less powerful but the

powerful also can inhibit the preferences of the less powerful. This occurs because individuals who remain and advance in organizations are those who feel and express values and beliefs congruent with the organization. Therefore, a balance must be found between the limitations of choice posed by the power structure within the organization and totally independent decision making that could lead to organizational chaos.

The ability of the powerful to influence individual decision making in an organization often requires adopting a private personality and an organizational personality.

For example, some might believe they would have made a different decision had they been acting on their own, but they went along with the organizational decision. This “going along” in itself constitutes a decision. People choose to accept an organizational decision that differs from their own preferences and values. The concept of power in organizations is discussed in more detail in Chapter 13.

Rational and Administrative Decision Making

For many years, it was widely believed that most managerial decisions were based on a careful, scientific, and objective thought process and that managers made decisions in a rational manner. In the late 1940s, Herbert A. Simon’s work revealed that most managers made many decisions that did not fit the objective rationality theory. Simon (1965) delineated two types of management decision makers: the economic man and the administrative man. Managers who are successful decision makers often attempt to make rational decisions, much like the

economic man described in Table 1.2. Because they realize that restricted knowledge and limited alternatives directly affect a decision’s quality, these managers gather as much information as possible and generate many alternatives. Simon (1965) believed that the economic model of man, however, was an unrealistic description of organizational decision making. The complexity of information acquisition makes it impossible for the human brain to store and retain the amount of information that is available for each decision. Because of time constraints and the difficulty of assimilating large amounts of information, most management decisions are made using the administrative man model of decision making.

Most management decisions are made by using the administrative man model of decision making.

The administrative man never has complete knowledge and generates fewer alternatives. Simon (1965) argued that the administrative man carries out decisions that are only satisficing, a term used to describe decisions that may not be ideal but result in solutions that have adequate outcomes. These managers want decisions to be “good enough” so that they “work,” but they are less concerned that the alternative selected is the optimal choice. The “best” choice for many decisions is often found to be too costly in terms of time or resources, so another less costly but workable solution is found. Clear (2015) agrees, suggesting that although researchers and economists believed for some time that

humans always made logical, well-considered decisions, more current research suggests that a wide range of mental errors often derail our thinking. Sometimes we make logical decisions, but there are many times when we make emotional, irrational, and confusing choices.

Decision-Making Tools There is always some uncertainty in making decisions. However, management analysts have developed tools that provide some order and direction in obtaining and using information or that are helpful in selecting who should be involved in making the decision. Because there are so many decision aids, this chapter presents selected technology that would be most helpful to beginning- or middle-level managers, including decision grids, payoff tables, decision trees, consequence tables, logic models, and program evaluation and review technique (PERT). It is important to remember, though, that any decision-making tool always results in the need for the person to make a final decision and that all such tools are subject to human error.

Decision Grids

A decision grid allows one to visually examine the alternatives and compare each against the same criteria. Although any criterion may be selected, the same criteria are used to analyze each alternative. An example of a decision grid is depicted in Figure 1.3. When many alternatives have been generated or a

group or committee is collaborating on the decision, these grids are particularly helpful to the process. This tool, for instance, would be useful when changing the method of managing care on a unit or when selecting a candidate to hire from a large interview pool. The unit manager or the committee would evaluate all of the alternatives available using a decision grid. In this manner, every alternative is evaluated using the same criteria. It is possible to weigh some of the criteria more heavily than others if some are more important. To do this, it is usually necessary to assign a number value to each criterion. The result would be a numeric value for each alternative considered.

Payoff Tables

The decision aids known as payoff tables have a cost–profit–volume relationship and are very helpful when some quantitative information is available, such as an item’s cost or predicted use. To use payoff tables, one must determine probabilities and use historical data, such as a hospital census and a report on the number of operating procedures performed. To illustrate, a payoff table might be appropriately used in determining how many participants it would take to make an in-service program break even in terms of costs. If the instructor for the class costs $500, the in-service director would need to charge each of the 20

participants $25 for the class, but for 40 participants, the class would cost only $12.50 each. The in- service director would use attendance data from past classes and the number of nurses potentially available to attend to determine probable class size and thus how much to charge for the class. Payoff tables do not guarantee that a correct decision will be made, but they assist in visualizing data.

Decision Trees

Because decisions are often tied to the outcome of other events, management analysts have developed decision trees. The decision tree in Figure 1.4 compares the cost of hiring regular staff with the cost of hiring

temporary employees. Here, the decision is whether to hire extra nurses at regular salary to perform outpatient procedures on an oncology unit or to have nurses available to the unit on an on-call basis and pay them on-call and overtime wages. The possible consequences of a decreased volume of procedures and an increased volume must be considered. Initially, costs would increase in hiring a regular staff, but over a longer time, this move would mean greater savings if the volume of procedures does not dramatically decrease.

Consequence Tables

Consequence tables demonstrate how various alternatives create different consequences. A consequence table lists the objectives for solving a problem down one side of a table and rates how each alternative would meet the desired objective. For example, consider this problem: “The number of patient falls has exceeded the benchmark rate for

two consecutive quarters.” After a period of analysis, the following alternatives were selected as solutions: 1. Provide a new educational program to instruct staff on how to prevent falls. 2. Implement a night check to ensure that patients have side rails up and beds in low position. 3. Implement a policy requiring direct patient observation by sitters on all confused patients. The decision maker then lists each alternative opposite the objectives for solving the problem, which

for this problem might be (a) reduces the number of falls, (b) meets regulatory standards, (c) is cost- effective, and (d) fits present policy guidelines. The decision maker then ranks each desired objective and examines each of the alternatives through a standardized key, which allows a fair comparison between alternatives and assists in eliminating undesirable choices. It is important to examine long-term effects of each alternative as well as how the decision will affect others. See Table 1.3 for an example of a consequence table.

Logic Models

Logic models are schematics or pictures of how programs are intended to operate. The schematic typically includes resources, processes, and desired outcomes and depicts exactly what the relationships are between the three components.

Program Evaluation and Review Technique

PERT is a popular tool to determine the timing of decisions. Developed by the Booz-Allen-Hamilton organization and the U.S. Navy in connection with the Polaris missile program, PERT is essentially a flowchart that predicts when events and activities must take place if a final event is to occur. Figure 1.5 shows a PERT chart for developing a new outpatient treatment room for oncology procedures. The number of weeks to complete tasks is listed in optimistic time, most likely time, and pessimistic time. The critical path shows something that must occur in the sequence before one may proceed. PERT is especially helpful when a group of people is working on a project. The flowchart keeps everyone up-to- date, and problems are easily identified when they first occur. Flowcharts are popular, and many people use them in their personal lives.

Pitfalls in Using decision-making tools A common flaw in making decisions is to base decisions on first impressions. This then typically leads to confirmation biases. A confirmation bias is a tendency to affirm one’s initial impression and preferences as other alternatives are evaluated. So, even the use of consequence tables, decision trees, and other quantitative decision tools will not guarantee a successful decision. It is also human nature to focus on an event that leaves a strong impression, so individuals may have

preconceived notions or biases that influence decisions. Too often, managers allow the past to unduly influence current decisions.

Many of the pitfalls associated with management decision-making tools can be reduced by choosing the correct decision-making style and involving others when appropriate.

Although there are times when others should be involved, it is not always necessary to involve others in decision making, and frequently, a manager does not have time to involve a large group. However, it is important to separate out those decisions that need input from others and those that a manager can make alone.

Integrating Leadership Roles and Management Functions in Decision Making This chapter has discussed effective decision making, problem solving, critical thinking, and clinical reasoning as requisites for being a successful leader and manager. The effective leader-manager is aware of the need for sensitivity in decision making. The successful decision maker possesses courage, energy, and creativity. It is a leadership skill to recognize the appropriate people to include in decision making and to use a suitable theoretical model for the decision situation. Managers who make quality decisions are effective administrators. The manager should develop a

systematic, scientific approach to problem solving that begins with a fixed goal and ends with an evaluation step. Decision tools exist to help make more effective decisions; however, leader-managers must remember that they are not foolproof and that they often do not adequately allow for the human element in management. In addition, managers should strive to make decisions that reflect research-based best practices and nursing’s scientific knowledge base. Yet, the role of intuition as an adjunct to quality decision making should not be overlooked. The integrated leader-manager understands the significance that gender, personal values, life experience, preferences, willingness to take risks, brain hemisphere dominance, and thinking styles have on selected alternatives in making the decision. The critical thinker pondering a decision is aware of the areas of vulnerability that hinder successful decision making and will expend his or her efforts to avoid the pitfalls of faulty logic and data gathering. Both managers and leaders understand the impact that the organization has on decision making and that

some of the decisions that will be made in the organization will be only satisficing. However, leaders will strive to problem solve adequately in order to reach optimal decisions as often as possible.

KEY CONCEPT

Successful decision makers are self-aware, courageous, sensitive, energetic, and creative. The rational approach to problem solving begins with a fixed goal and ends with an evaluation process.

Naturalistic decision making blends intuition and analysis, but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible.

Evidence-based nursing practice integrates the best evidence available to achieve desirable outcomes.

Typically, a PICO (patient or population, intervention, comparison, and outcome) format is used in evidence-based practice to guide the search for the current best evidence to address a problem.

The successful decision maker understands the significance that gender, personal, individual values, life experience, preferences, willingness to take risks, brain hemisphere dominance, and predominant thinking style have on alternative identification and selection.

Left- and right-brain dominance may be an oversimplification in terms of how individuals think.

The critical thinker is aware of areas of vulnerability that hinder successful decision making and makes efforts to avoid the pitfalls of faulty logic in his or her data gathering.

The act of making and evaluating decisions increases the expertise of the decision maker. There are many models for improving decision making. Using a systematic decision-making or problem-solving model reduces heuristic trial-and-error or rule-of-thumb methods and increases the probability that appropriate decisions will be made.

Two major considerations in organizational decision making are how power affects decision making and whether management decision making needs to be only satisficing.

Management science has produced many tools to help decision makers make better and more objective decisions, but all are subject to human error, and many do not adequately consider the human element.

Additional Learning Exercises and Applications

LEARNING EXERCISE 1.4

Assessing Personal Decision Making

ASSIGNMENT:

Write a two- to three-page response to one of the following prompts: A. Identify a poor decision that you recently made because of faulty data gathering. Have

you ever made a poor decision because necessary information was intentionally or unintentionally withheld from you?

B. Describe the two best decisions that you have made in your life and the two worst. What factors assisted you in making the wise decisions? What elements of critical thinking went awry in your poor decision making? How would you evaluate your decision- making ability?

C. Examine the process that you used in your decision to become a nurse. Would you describe it as fitting a profile of the economic man or the administrative man?

D. Do you typically use a problem-solving or decision-making model to solve problems? Have you ever used an intuitive model? Think of a critical decision that you have made in the last year. Describe what theoretical model, if any, you used to assist you in the process. Did you enlist the help of other experts in solving the problem?

LEARNING EXERCISE 1.5

Sharing Workload

You are a staff nurse on a small telemetry unit. The unit is staffed at a ratio of one nurse for every four patients, and the charge nurse is counted in this staffing because there is a full-time unit secretary and monitor technician to assist at the desk. The charge nurse is responsible for making the daily staffing assignments. Although you recognize that the charge nurse needs to reduce her patient care assignment to have time to perform the charge nurse duties, you have grown increasingly frustrated that she normally assigns herself only one patient, if any, and these patients always have the lowest acuity level on the floor. This has placed a disproportionate burden on the other nurses, who often feel the assignment they are being given may be unsafe. The charge nurse is your immediate supervisor. She has not generally been responsive to concerns expressed by the staff to her about this problem.

ASSIGNMENT:

Decide what the problem is in this scenario and who owns it. Identify at least five alternatives for action and select which one you believe will have the greatest likelihood of successful implementation. How did differences in power and status influence the alternatives you identified? What outcomes must be achieved for you to feel that the choice you made was a good one?

LEARNING EXERCISE 1.6

Considering Critical Elements in decision Making

You are a college senior and president of your student nursing organization. You are on the committee to select a slate of officers for the next academic year. Several of the current officers will be graduating, and you want the new slate of officers to be committed to the organization. Some of the brightest members of the junior class involved in the organization are not well liked by some of your friends in the organization.

ASSIGNMENT:

Looking at the critical elements in decision making, compile a list of the most important points to consider in making the decision for selecting a slate of officers. What must you guard against, and how should you approach the data gathering to solve this problem?

LEARNING EXERCISE 1.7

Examining the Decision-Making Process

You have been a staff nurse for the 3 years since your graduation from nursing school. There is a nursing shortage in your area, and there are many openings at other facilities. In addition, you have been offered a charge nurse position by your present employer. Last, you have always wanted to do community health nursing and know that this is also a possibility. You are self-aware enough to know that it is time for a change, but which change, and how should you make the decision?

ASSIGNMENT:

Examine both the individual aspects of decision making and the critical elements in making decisions. Make a plan including a goal, a list of information, and data that you need to gather and areas where you may be vulnerable to poor decision making. Examine the consequences of each alternative available to you. After you have done this, as an individual, form a small group and share your decision-making planning with members of your group. How was your decision making like others in the group, and how was it different?

LEARNING EXERCISE 1.8

Decision Making and Risk Taking

You are a new graduate nurse just finishing your 3-month probation period at your first job in acute care nursing. You have been working closely with a preceptor; however, he has been gradually transitioning you to more independent practice. You now have your own patient care assignment and have been giving medications independently for several weeks. Today, your assignment included an elderly confused patient with severe coronary disease. Her medications include antihypertensives, antiarrhythmics, and beta-blockers. It was a very busy morning, and you have barely had a moment to reorganize and collect your thoughts. It is now 2:30 PM, and you are preparing your handoff report. When you review the patient’s 2:00 PM

vital signs, you note a significant rise in this patient’s blood pressure and heart rate. The patient, however, reports no distress. You remember that when you passed the morning medications, the patient was in the middle of her bath and asked that you just set the medications on the bedside table and that she would take them in a few minutes. You meant to return to see that she did but were sidetracked by a problem with another patient. You now go to the patient’s room to see if she indeed did take the pills. The pill cup and pills are not

where you left them, and a search of the wastebasket, patient bed, and bedside table yields nothing. The patient is too confused to be an accurate historian regarding whether she took the pills. No one on your

patient care team noticed the pills. At this point, you are not sure what you should do next. You are frustrated that you did not wait to

give the medications in person but cannot change this now. You charted the medications as being given this morning when you left them at the bedside. You are reluctant to report this as a medication error because you are still on probation and you are not sure that the patient did not take the pills as she said she would. Your probation period has not gone as smoothly as you would have liked anyway, and you are aware that reporting this incident will likely prolong your probation and that a copy of the error report will be placed in your personnel file. The patient’s physician is also frequently short-tempered and will likely be agitated when you report your uncertainty about whether the patient received her prescribed medications. The reality is that if you do nothing, it is likely that no one will ever know about the problem. You do feel responsible, however, for the patient’s welfare. The physician might want to give

additional doses of the medication if indeed the patient did not take the pills. In addition, the rise in heart rate and blood pressure has only just become apparent, and you realize that her heart rate and blood pressure could continue to deteriorate over the next shift. The patient is not due to receive the medications again until 9:00 PM tonight (b.i.d. every 12 hours).

ASSIGNMENT:

Decide how you will proceed. Determine whether you will use a systematic problem-solving model, intuition, or both in making your choices. How did your values, preferences, life experiences, willingness to take risks, and individual ways of thinking influence your decision?

LEARNING EXERCISE 1.9

Determining a Need to Know

You are a nursing student. You are also HIV positive as a result of some high-risk behaviors you engaged in a decade ago. (It seems like a lifetime ago.) You are now in a committed, monogamous relationship, and your partner is aware of your HIV status. You have experienced relatively few side effects from the antiretroviral drugs you take, and you appear to be healthy. You have not shared your sexual preferences, past history, or HIV status with any of your classmates, primarily because you do not feel that it is their business and because you fear being ostracized in the local community, which is fairly conservative. Today, in the clinical setting, one of the students accidentally stuck herself with a needle right before

she injected it into a patient. Laboratory follow-up was ordered to ensure that the patient was not exposed to any blood-borne disease from the student. Tonight, for the first time, you recognize that no matter how careful you are, there is at least a small risk that you could inadvertently expose patients to your bodily fluids and thus to some risk.

ASSIGNMENT:

Decide what you will do. Is there a need to share your HIV status with the school? With future employers? With patients? What determines whether there is “a need to tell” and a “need to know”? What objective weighted most heavily in your decision?

LEARNING EXERCISE 1.10

Using a Flowchart for Project Management

Think of a project that you are working on; it could be a dance, a picnic, remodeling your bathroom, or a semester schedule of activities in a class.

ASSIGNMENT:

Draw a flowchart, inserting at the bottom the date that activities for the event are to be completed. Working backward, insert critical tasks and their completion dates. Refer to your flowchart throughout the project to see if you are staying on target.

LEARNING EXERCISE 1.11

Making A Decision About Your First Job (Marquis & Huston, 2012)

You are about to graduate from a local community college with an associate degree in nursing. Your instructor suggests that a good fit between the new graduate’s skills and abilities and their first job is very important for how they will feel about nursing in the future. Some of your classmates have already made up their mind about the job they want, and they are holding out for a position in pediatrics or the emergency room even if it means they need to relocate. You are unsure what job best fits you, although you most enjoyed your obstetrical rotation; however, your local hospitals rarely hire new graduates directly into the obstetrical unit. So far, you have been interviewed by two local hospitals and have been offered a job in each. One is for working the evening shift on a surgical unit and the other is working day shift in an oncology unit. You are sure you could find other offers if you relocated, but you are not sure you want to relocate at the present time. You have 1 week to make up your mind and let the personnel department know if you want to accept either of the positions you have been offered. How will you decide? Using one of the problem-solving models just presented, outline the steps you would take to ensure

that your decision was based on a rational and well-thought-out process. Determine what you should do. What are the alternatives? What information should you gather? After you have made your decision, get together in a group (four to six people from your class) and share your decisions. Were they the same? How did you approach the problem solving differently from others in your group? Was a rational systematic problem-solving process used? Was a goal or objective identified? How did your personal values influence your decision? Did intuition play a part in your decision making?

LEARNING EXERCISE 1.12

Addressing a Communication Gap (Marquis & Huston, 2012)

You are a new graduate nurse just finishing your 3-month probation period at your first job in acute care nursing. Your usual assignment is to be a team leader for eight patients, with one licensed practical nurse (LPN)/licensed vocational nurse (LVN) and one nursing assistant on your team. Today, your assignment included an elderly confused patient. You requested, during work assignments with your team, that the nursing assistant pay particular attention to this patient’s intake and output as you feel he may need some intravenous fluids if his intake and output (I & O) remain poor. You asked the nursing assistant to notify you if there was significant change so you could notify the physician. It was a very busy day, and you have barely had a moment to reorganize and collect your thoughts. It is now 2:30 PM, and you are preparing your end-of-shift report. When you review the patient’s

2:00 PM intake and output sheet, you note a significant drop in intake and the total output for the shift is only 90 mL. You meant to check the I & O sheet during the day but kept getting sidetracked by problems with other patients. However, you are also upset that the nursing assistant did not keep you informed of this condition. You now go to the patient’s room and assess the patient and find his vital signs and other findings

similar to this morning’s assessment. You check with the nursing assistant to make sure the I & O recorded for the day is accurate and you call the physician to obtain an order to begin intravenous fluids. When you ask the nursing assistant why she did not report the significant drop in output to you, she said, “I forgot.”

At this point, you are not sure what you should do next. You are frustrated that the nursing assistant did not report to you as you had requested. You are not sure what to do further about this situation. You feel you should handle this yourself and not go to the charge nurse. You are a new nurse and do not want to get started on the wrong foot by speaking too harshly to the nursing assistant, yet you feel this lack of following instructions cannot go unanswered. The reality is that if you do nothing, it is likely that no one else will ever know about the problem. The doctor did not seem upset when you called him about the drop in output, he just ordered the

fluids, but the need to start the intravenous line and give report caused you to work overtime. By the time you finished your shift, the nursing assistant had gone home and you are left to spend your evening at home pondering what, if anything, you should do to follow-up on this tomorrow.

ASSIGNMENT:

Decide how you will proceed. Determine whether you will use a systematic problem-solving model, intuition, or both in making your choices. How did your values, preferences, life experiences, willingness to take risks, and individual ways of thinking influence your decision?

LEARNING EXERCISE 1.13

Returning to school for a Bachelor of Science in Nursing Degree (Marquis & Huston, 2012)

You have been a registered nurse (RN) for 5 years. Right after high school, you became a licensed vocational nurse (LVN) and after 6 years decided to attend a local LVN to associate degree in nursing (ADN) program at a local community college. You have become increasingly interested in attending a baccalaureate university to complete requirements for your bachelor of science in nursing degree (BSN). You are still undecided, some of your friends are urging you to do this, and others ask why you need the degree. Not only must you make up your mind about pursuing this option but you also have two different

local opportunities. The regional university is 60 miles away and would require significant amounts of driving if you did the on-campus program; however, the university’s school of nursing also offers an online course that would require only 4 full Saturdays of attendance each semester. Both options have pros and cons. After making a payoff table, calculating chances for advancement and salary increase weighed

against cost of your new degree, you decided that it made economic sense to get a BSN degree.

ASSIGNMENT:

Now that you have decided to get your baccalaureate degree, you must decide between three

alternatives: (a) attending a distant university 60 miles away, (b) attending your local university and enrolling in their on-campus program, or (c) enrolling as an online student. Make a decision grid for the three alternatives, weighting the same criteria for each, using such things as cost, travel, quality of campus life, reputation and quality of the university, and so on. Assign each of your criteria a weighted score for the value that you personally view it. What did your final grid look like and what was your final decision?

LEARNING EXERCISE 1.14

How Good Are Your Decision-Making Skills? Quiz and Key

Instructions: For each statement, mark the box in the column that best describes you. Please answer questions as you actually are (rather than how you think you should be).

As you answered the questions, did you see some common themes? We based our quiz on six essential steps in the decision-making process:

1. Establishing a positive decision-making environment. 2. Generating potential solutions. 3. Evaluating the solutions. 4. Deciding. 5. Checking the decision. 6. Communicating and implementing.

If you are aware of these six basic elements and improve the way you structure them, this will help you develop a better overall decision-making system. Let us look at the six elements individually.

Establishing a Positive Decision-Making Environment (Statements 3, 7, 13, and 16) If you have ever been in a meeting where people seem to be discussing different issues, then you have

seen what happens when the decision-making environment has not been established. It is so important for everyone to understand the issue before preparing to make a decision. This includes agreeing on an objective, making sure the right issue is being discussed, and agreeing on a process to move the decision forward. You also must address key interpersonal considerations at the very beginning. Have you included all

the stakeholders? And do the people involved in the decision agree to respect one another and engage in an open and honest discussion? After all, if only the strongest opinions are heard, you risk not considering some of the best solutions available.

Generating Potential Solutions (Statements 4, 8, and 11) Another important part of a good decision process is generating as many good alternatives as sensibly possible to consider. If you simply adopt the first solution you encounter, then you are probably missing a great many even better alternatives.

Evaluating Alternatives (Statements 1, 6, and 15) The stage of exploring alternatives is often the most time-consuming part of the decision-making process. This stage sometimes takes so long that a decision is never made! To make this step efficient, be clear about the factors you want to include in your analysis. There are three key factors to consider: 1. Risk—Most decisions involve some risk. However, you need to uncover and understand the risks

to make the best choice possible. 2. Consequences—You cannot predict the implications of a decision with 100% accuracy. But you

can be careful and systematic in the way that you identify and evaluate possible consequences. 3. Feasibility—Is the choice realistic and implementable? This factor is often ignored. You usually

have to consider certain constraints when making a decision. As part of this evaluation stage, ensure that the alternative you have selected is significantly better than the status quo.

Deciding (Statements 5, 10, and 17) Making the decision itself can be exciting and stressful. To help you deal with these emotions as objectively as possible, use a structured approach to the decision. This means taking a look at what is most important in a good decision. Take the time to think ahead and determine exactly what will make the decision “right.” This will

significantly improve your decision accuracy.

Checking the Decision (Statements 2 and 9) Remember that some things about a decision are not objective. The decision has to make sense on an intuitive, instinctive level as well. The entire process we have discussed so far has been based on the perspectives and experiences of all the people involved. Now, it is time to check the alternative you have chosen for validity and “making sense.” If the decision is a significant one, it is also worth auditing it to make sure that your assumptions are

correct, and that the logical structure you have used to make the decision is sound.

Communicating and Implementing (Statements 12, 14, and 18) The last stage in the decision-making process involves communicating your choice and preparing to implement it. You can try to force your decision on others by demanding their acceptance. Or you can

gain their acceptance by explaining how and why you reached your decision. For most decisions— particularly those that need participant buy-in before implementation—it is more effective to gather support by explaining your decision. Have a plan for implementing your decision. People usually respond positively to a clear plan—one

that tells them what to expect and what they need to do.

Source: Mind Tools Editorial Team. (1996–2015). How good is your decision-making? Retrieved October 11, 2015, from http://www.mindtools.com/pages/article/newTED_79.htm. Reproduced with permission from MindTools. © Mind Tools Ltd, 1996– 2015.

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2 Classical Views of Leadership and Management

. . . management is efficiency in climbing the ladder of success; leadership determines whether the ladder is leaning against the right wall.

—Stephen R. Covey

. . . no executive has ever suffered because his subordinates were strong and effective. —Peter Drucker

. . . if your actions inspire others to dream more, learn more, do more, and become more, you are a leader.

—John Quincy Adams

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

BSN Essential IX: Baccalaureate generalist nursing practice MSN Essential II: Organizational and systems leadership MSN Essential VII: Interprofessional collaboration for improving patient and population health outcomes

MSN Essential IX: Master’s level nursing practice AONE Nurse Executive Competency I: Communication and relationship building AONE Nurse Executive Competency II: Knowledge of the health-care environment AONE Nurse Executive Competency III: Leadership ANA Standard of Professional Performance 11: Leadership QSEN Competency: Teamwork and collaboration

The learner will:

discuss the historical evolution of management theory correlate management theorists with their appropriate theoretical contributions define the components of the management process differentiate between leadership roles and management functions discuss the historical evolution of leadership theory correlate leadership theorists with their appropriate theoretical contributions identify common leadership styles and describe situations in which each leadership style could be used appropriately

differentiate between authoritative, democratic, and laissez-faire leadership styles describe the differences between interactional and transformational leadership theories identify contextual factors impacting the relationship between leaders and followers, based on full- range leadership theory

analyze why full-range leadership models suggest leaders must have skills in transformational leadership, transactional leadership, and laissez-faire leadership

delineate variables suggested in situational and contingency theories recognize that the integration of both leadership and management skills is critical to the long-term viability of today’s health-care organizations

Introduction The relationship between leadership and management continues to prompt some debate, although there clearly is a need for both. Leadership is viewed by some as one of management’s many functions; others maintain that leadership requires more complex skills than management and that management is only one role of leadership. Still, others suggest that management emphasizes control—control of hours, costs, salaries, overtime, use of sick leave, inventory, and supplies—whereas leadership increases productivity by maximizing workforce effectiveness. Kerr (2015) suggests,

There’s a difference between leadership and management. Leaders look forward and imagine the possibilities that the future may bring in order to set direction. Managers monitor and adjust today’s work, regularly looking backward to ensure that current goals and objectives are being met. The best leaders lead and let their management teams manage the work at hand. (para. 3)

In fact, Kerr (2015) suggests there are 10 important distinctions between leaders and managers and that these differences must be understood and recognized so that an organization can leverage each to the fullest (Display 2.1). Kerr concludes, however, that organizations need both kinds of skills and aptitudes to secure enduring success.

DISPLAY 2.1 Ten Distinctions Between Leaders and Managers (Kerr, 2015)

1. Leadership inspires change; management manages transformation. 2. Leadership requires vision; management requires tenacity. 3. Leadership requires imagination; management requires specifics. 4. Leadership requires abstract thinking; management requires concrete data. 5. Leadership requires ability to articulate; management requires ability to interpret. 6. Leadership requires an aptitude to sell; management requires an aptitude to teach. 7. Leadership requires understanding of the external environment; management requires understanding

of how work gets done inside the organization. 8. Leadership requires risk taking; management requires self-discipline. 9. Leadership requires confidence in the face of uncertainty; management requires blind commitment

to completing the task at hand. 10. Leadership is accountable to the entire organization; management is accountable to the team.

But if a manager guides, directs, and motivates and a leader empowers others, then it could be said that every manager should be a leader. Fowler (2015) agrees, suggesting that not only are the differences between leadership and management difficult to verbalize; for the clinical nurse, it is even more difficult to work out what particular “hat” you are wearing or should be wearing when trying to lead and manage a team through a busy shift. Similarly, leadership without management results in chaos and failure for both the organization and the

individual executive. Thus, the integration of both leadership and management skills is critical to the long- term viability of today’s health-care organizations. Yet, we are all aware of individuals in leadership positions who cannot manage and individuals in management roles who cannot lead. Dignam et al. (2012) suggests that because change is a primary feature of contemporary health-care

environments, managers must be able to shift from a traditional focus on operational task completion to the leadership skills of visioning, motivating, and inspiring others before desired outcomes can be achieved. MacLeod (2012) echoes similar thoughts in his assertion that in the face of significant change, both sound management and strong leadership skills are essential to the long-term viability of today’s health-care organizations. So which is more important—good leadership or good management? Blanchard (2015) says the answer

to this question is “both.” “People want to make a distinction and to compare and rank one as more important over the other—usually leadership over management—but it’s more a question of applying what’s needed in a given situation to improve performance” (para. 1). We are also aware that clinicians act as leaders and managers in the clinical setting, even if not

officially recognized as doing so, and that their success in these roles is critical to high level unit functioning and the attainment of patient goals. Indeed, Fowler (2015) suggests that good clinical leaders must continually find an intersection between good leadership and management skills to be successful. For example, in his interview of clinical nurse leaders, Fowler asked them what good clinical leaders can

do to promote retention (see Examining the Evidence 2.1). The responses clearly show an integration of leadership and management skills.

EXAMINING THE EVIDENCE 2.1

Source: Fowler, J. (2015). What makes a good clinical leader? British Journal of Nursing, 24(11), 598–599.

When asked what skills clinical leaders can employ to promote retention, responses included the following: • Listen to the needs of the staff • Put on training sessions • Support staff in their professional development • Make sure the off-duty rotation is fair and requests are honored wherever possible

• Clinical supervision and mentoring • Staff meetings • Leading from the front (i.e., working clinically and demonstrating good practice)

• Setting high standards, but not unrealistic ones • Saying “thank you” to staff after a particularly busy shift of difficult situation

• Organizing social events

This chapter first artificially differentiates between management and leadership, focusing on theory development in each field of study. A chronological view of the development of management and leadership theory is provided, although the authors recognize that boundaries are blurred between the two areas of theoretical development and that much of the work done by later management theorists and early leadership theorists overlaps. The chapter concludes with a discussion of how closely integrated leadership and management must actually be for individuals in contemporary leadership or management roles.

Managers BusinessDictionary.com (2016) defines management as “the organization and coordination of the activities of a business in order to achieve defined objectives” (para. 1). This definition implies that management is the process of leading and directing all or part of an

organization, through the deployment and manipulation of resources.

Management is the process of leading and directing all or part of an organization through the deployment and manipulation of resources.

Leaders Although the term leader has been in use since the 1300s, the word leadership was not known in the English language until the first half of the 19th century. Despite its relatively new addition to the English language, leadership has many meanings and there is no single definition broad enough to encompass the total leadership process. To examine the word leader, however, is to note that leaders lead. Leaders are those individuals who

are out front, taking risks, attempting to achieve shared goals, and inspiring others to action. Those individuals who choose to follow a leader do so by choice, not because they have to.

Leaders are in the front, moving forward, taking risks, and challenging the status quo.

It is important to remember though that a job title alone does not make a person a leader. Only a person’s behavior determines if he or she holds a leadership role. The manager is the person who brings things about—the one who accomplishes, has the responsibility, and conducts. A leader is the person who influences and guides direction, opinion, and course of action. Other characteristics of leaders include the following:

Leaders often do not have delegated authority but obtain their power through other means, such as influence. Leaders have a wider variety of roles than do managers. Leaders may or may not be part of the formal organization. Leaders focus on group process, information gathering, feedback, and empowering others. Leaders emphasize interpersonal relationships. Leaders direct willing followers. Leaders have goals that may or may not reflect those of the organization.

It is important to remember that all it takes to stop being a leader is to have others stop following you. Leadership then is more dynamic than management, and leaders do make mistakes that can result in the loss of their followers. For example, Zenger and Folkman (2009), using 360-degree feedback data from more than 450 Fortune 500 executives, identified 10 fatal flaws that derail leaders (Display 2.2). Although these flaws seem fairly obvious, many ineffective leaders are unaware that they exhibit these behaviors.

DISPLAY 2.2 Ten Fatal Leadership Flaws

1. A lack of energy and enthusiasm 2. Acceptance of their own mediocre performance 3. Lack of a clear vision and direction

4. Having poor judgment 5. Not collaborating 6. Not walking the talk 7. Resisting new ideas 8. Not learning from mistakes 9. A lack of interpersonal skills 10. Failing to develop others

Source: Zenger, J., & Folkman, J. (2009, June). Ten fatal flaws that derail leaders. Harvard Business Review, 87(6), 18. Retrieved July 30, 2016 from https://hbr.org/2009/06/ten-fatal-flaws-that-derail-leaders/sb1

Display 2.3 includes a partial list of common leadership roles and Display 2.4 contrasts traditional components of leadership and management.

DISPLAY 2.3 Common Leadership Roles

Decision maker Coach Forecaster Communicator Counselor Influencer Evaluator Teacher Creative problem solver Facilitator Critical thinker Change agent Risk taker Buffer Diplomat Mentor Advocate Role model Energizer Visionary Innovator Priority setter Director Encourager

DISPLAY 2.4 A Comparison of Traditional Management and Leadership Components

Managers Are assigned a position by the organization Have a legitimate source of power due to delegated authority that accompanies their position Have specific duties and responsibilities they are expected to carry out Emphasize control, decision making, decision analysis, and results Manipulate people, the environment, money, time, and other resources to achieve the goals of the organization

Have a greater formal responsibility and accountability for rationality and control than leaders Direct willing and unwilling subordinates

Leaders Often do not have delegated authority but obtain power through other means, such as influence Have a wider variety of roles than managers Focus on group process, information gathering, feedback, and empowering others May or may not be part of the formal hierarchy of the organization Emphasize interpersonal relationships Direct willing followers Have goals that may or may not reflect those of the organization

LEARNING EXERCISE 2.1

Leadership Roles and Management Functions

In small or large groups, discuss your views of management and leadership. Do you believe they are the same or different? If you believe that they are different, do you think that they have the same importance for the future of nursing? Do you feel that one is more important than the other? How can novice nurse-managers learn important management functions and develop leadership skills?

Historical Development of Management Theory Management science, like nursing, develops a theory base from many disciplines, such as business, psychology, sociology, and anthropology. Because organizations are complex and varied, theorists’ views of what successful management is and what it should be have changed repeatedly in the last 100 years.

Theorists’ views of what successful management is and what it should be have changed repeatedly in the last 100 years.

Scientific Management (1900 to 1930)

Frederick W. Taylor, the “father of scientific management,” was a mechanical engineer in the Midvale and Bethlehem Steel plants in Pennsylvania in the late 1800s. Frustrated with what he called “systematic soldiering,” where workers achieved minimum standards doing the least amount of work possible, Taylor postulated that if workers could be taught the “one best way to accomplish a task,” productivity would increase. Borrowing a term coined by Louis Brandeis, a colleague of Taylor’s, Taylor called these

principles scientific management. The four overriding principles of scientific management as identified by Taylor (1911) are the following:

1. Traditional “rule of thumb” means of organizing work must be replaced with scientific methods. In other words, by using time and motion studies and the expertise of experienced workers, work could be scientifically designed to promote greatest efficiency of time and energy.

2. A scientific personnel system must be established so that workers can be hired, trained, and promoted based on their technical competence and abilities. Taylor thought that each employee’s abilities and limitations could be identified so that the worker could be best matched to the most appropriate job.

3. Workers should be able to view how they “fit” into the organization and how they contribute to overall organizational productivity. This provides common goals and a sharing of the organizational mission. One way Taylor thought that this could be accomplished was by the use of financial incentives as a reward for work accomplished. Because Taylor viewed humans as “economic animals” motivated solely by money, workers were reimbursed according to their level of production rather than by an hourly wage.

4. The relationship between managers and workers should be cooperative and interdependent, and the work should be shared equally. Their roles, however, were not the same. The role of managers, or functional foremen as they were called, was to plan, prepare, and supervise. The worker was to do the work (Fig. 2.1).

What was the result of scientific management? Productivity and profits rose dramatically. Organizations were provided with a rational means of harnessing the energy of the industrial revolution. Some experts have argued that Taylor (1911) lacked humanism and that his scientific principles were not in the best interest of unions or workers. However, it is important to remember the era in which Taylor did his work. During the Industrial Revolution, laissez-faire economics prevailed, optimism was high,

and a Puritan work ethic prevailed. Taylor maintained that he truly believed managers and workers would be satisfied if financial rewards were adequate as a result of increased productivity. As the cost of labor rises in the United States, many organizations are taking a new look at scientific management with the implication that we need to think of new ways to do traditional tasks so that work is more efficient. About the same time that Taylor (1911) was examining worker tasks, Max Weber, a well-known

German sociologist, began to study large-scale organizations to determine what made some workers more efficient than others. Weber saw the need for legalized, formal authority and consistent rules and regulations for personnel in different positions; he thus proposed bureaucracy as an organizational design. His essay “Bureaucracy” was written in 1922 in response to what he perceived as a need to provide more rules, regulations, and structure within organizations to increase efficiency. Much of Weber’s work and bureaucratic organizational design are still evident today in many health-care institutions. His work is discussed further in Chapter 12.

LEARNING EXERCISE 2.2

Strategies for Efficiency

In small groups, discuss some work routines carried out in health-care organizations that seem to be inefficient. Could such routines or the time and motion involved to carry out a task be altered to improve efficiency without jeopardizing quality of care? Make a list of ways that nurses could work more efficiently. Do not limit your examination to only nursing procedures and routines but examine the impact that other departments or the arrangement of the nurse’s work area may have on preventing nurses from working more efficiently. Share your ideas with your peers.

Management Functions Identified

Henri Fayol (1925) first identified the management functions of planning, organization, command, coordination, and control. Luther Gulick (1937) expanded on Fayol’s management functions in his introduction of the “seven activities of management”—planning, organizing, staffing, directing, coordinating, reporting, and budgeting—as denoted by the mnemonic POSDCORB. Although often modified (either by including staffing as a management function or renaming elements), these functions or activities have changed little over time. Eventually, theorists began to refer to these functions as the management process. The management process, shown in Figure 2.2, is this book’s organizing framework. Brief descriptions

of the five functions for each phase of the management process follow:

1. Planning encompasses determining philosophy, goals, objectives, policies, procedures, and rules; carrying out long- and short-range projections; determining a fiscal course of action; and managing planned change.

2. Organizing includes establishing the structure to carry out plans, determining the most appropriate type of patient care delivery, and grouping activities to meet unit goals. Other functions involve working within the structure of the organization and understanding and using power and authority appropriately.

3. Staffing functions consist of recruiting, interviewing, hiring, and orienting staff. Scheduling, staff development, employee socialization, and team building are also often included as staffing functions.

4. Directing sometimes includes several staffing functions. However, this phase’s functions usually entail human resource management responsibilities, such as motivating, managing conflict, delegating, communicating, and facilitating collaboration.

5. Controlling functions include performance appraisals, fiscal accountability, quality control, legal and ethical control, and professional and collegial control.

Human Relations Management (1930 to 1970)

During the 1920s, worker unrest developed. The Industrial Revolution had resulted in great numbers of relatively unskilled laborers working in large factories on specialized tasks. Thus, management scientists and organizational theorists began to look at the role of worker satisfaction in production. This human relations era developed the concepts of participatory and humanistic management, emphasizing people rather than machines. Mary Parker Follett (1926) was one of the first theorists to suggest basic principles of what today

would be called participative decision making or participative management. In her essay “The Giving of Orders,” Follett espoused her belief that managers should have authority with, rather than over, employees. Thus, solutions could be found that satisfied both sides without having one side dominate the other. The human relations era also attempted to correct what was perceived as the major shortcoming of the

bureaucratic system—a failure to include the “human element.” Studies done at the Hawthorne Works of the Western Electric Company near Chicago between 1927 and 1932 played a major role in this shifting

focus. The studies, conducted by Elton Mayo and his Harvard associates, began as an attempt to look at the relationship between light illumination in the factory and productivity. Mayo and his colleagues discovered that when management paid special attention to workers,

productivity was likely to increase, regardless of the environmental working conditions. This Hawthorne effect indicated that people respond to the fact that they are being studied, attempting to increase whatever behavior they feel will continue to warrant the attention. Mayo (1953) also found that informal work groups and a socially informal work environment were factors in determining productivity, and Mayo recommended more employee participation in decision making. Douglas McGregor (1960) reinforced these ideas by theorizing that managerial attitudes about

employees (and, hence, how managers treat those employees) can be directly correlated with employee satisfaction. He labeled this Theory X and Theory Y. Theory X managers believe that their employees are basically lazy, need constant supervision and direction, and are indifferent to organizational needs. Theory Y managers believe that their workers enjoy their work, are self-motivated, and are willing to work hard to meet personal and organizational goals. Chris Argyris (1964) supported McGregor (1960) and Mayo (1953) by saying that managerial

domination causes workers to become discouraged and passive. He believed that if self-esteem and independence needs are not met, employees will become discouraged and troublesome or may leave the organization. Argyris stressed the need for flexibility within the organization and employee participation in decision making. The human relations era of management science brought about a great interest in the study of workers.

Many sociologists and psychologists took up this challenge, and their work in management theory contributed to our understanding about worker motivation, which will be discussed in Chapter 18. Table 2.1 summarizes the development of management theory up to 1970. By the late 1960s, however, there was growing concern that the human relations approach to management was not without its problems. Most people continued to work in a bureaucratic environment, making it difficult to always apply a participatory approach to management. The human relations approach was time consuming and often resulted in unmet organizational goals. In addition, not every employee liked working in a less structured environment. This resulted in a greater recognition of the need to intertwine management and leadership than ever before.

Historical Development of Leadership Theory (1900 to Present)

Because strong management skills were historically valued more than strong leadership skills, the scientific study of leadership did not begin until the 20th century. Early works focused on broad conceptualizations of leadership, such as the traits or behaviors of the leader. Contemporary research focuses more on leadership as a process of influencing others within an organizational culture and the interactive relationship of the leader and follower. To better understand newer views about leadership, it is necessary to look at how leadership theory has evolved over the last century.

Like management theory, leadership theory has been dynamic; that is, what is “known” and believed about leadership continues to change over time.

The Great Man Theory/Trait Theories (1900 to 1940)

The Great Man theory and trait theories were the basis for most leadership research until the mid- 1940s. The Great Man theory, from Aristotelian philosophy, asserts that some people are born to lead, whereas others are born to be led. It also suggests that great leaders will arise when the situation demands it. Trait theories assume that some people have certain characteristics or personality traits that make them

better leaders than others. To determine the traits that distinguish great leaders, researchers studied the lives of prominent people throughout history. The effect of followers and the impact of the situation were ignored. Although trait theories have obvious shortcomings (e.g., they neglect the impact of others or the situation on the leadership role), they are worth examining. Many of the characteristics identified in trait theories (Display 2.5) are still used to describe successful leaders today. Contemporary opponents of these theories argue, however, that leadership skills can be developed, not just inherited.

DISPLAY 2.5 Characteristics Associated With Leadership

Intelligence Adaptability Ability Knowledge Creativity Able to enlist cooperation Judgment Cooperativeness Interpersonal skills Decisiveness Alertness Tact Oral fluency Self-confidence Diplomacy Emotional intelligence Personal integrity Prestige Independence Emotional balance and control Social participation Personable Risk taking Charisma Skilled communicator Critical thinking Collaborative priority setting

Perhaps leaders are both born and made that way.

Behavioral Theories (1940 to 1980)

During the human relations era, many behavioral and social scientists studying management also studied leadership. For example, McGregor’s (1960) theories had as much influence on leadership research as they did on management science. As leadership theory developed, researchers moved away from studying what traits the leader had and placed emphasis on what he or she did—the leader’s style of leadership. A major breakthrough occurred when Lewin (1951) and White and Lippitt (1960) isolated common

leadership styles. Later, these styles came to be called authoritarian, democratic, and laissez-faire.

LEARNING EXERCISE 2.3

Effective Leadership

In groups or individually, list additional characteristics that you believe an effective leader possesses. Which leadership characteristics do you have? Do you believe that you were born with leadership skills, or have you consciously developed them during your lifetime? If so, how did you develop them?

The authoritarian leader is characterized by the following behaviors:

Strong control is maintained over the work group. Others are motivated by coercion. Others are directed with commands. Communication flows downward. Decision making does not involve others. Emphasis is on difference in status (“I” and “you”). Criticism is punitive.

Authoritarian leadership results in well-defined group actions that are usually predictable, reducing frustration in the work group and giving members a feeling of security. Productivity is usually high, but creativity, self-motivation, and autonomy are reduced. Authoritarian leadership is frequently found in very large bureaucracies such as the armed forces. The democratic leader exhibits the following behaviors:

Less control is maintained. Economic and ego awards are used to motivate. Others are directed through suggestions and guidance. Communication flows up and down. Decision making involves others.

Emphasis is on “we” rather than I and you. Criticism is constructive.

Democratic leadership, appropriate for groups who work together for extended periods, promotes autonomy and growth in individual workers. Democratic leadership is particularly effective when cooperation and coordination between groups are necessary. Studies have shown, however, that democratic leadership may be less efficient quantitatively than authoritative leadership.

Because many people must be consulted, democratic leadership takes more time and, therefore, may be frustrating for those who want decisions made rapidly.

The laissez-faire leader is characterized by the following behaviors:

Is permissive, with little or no control Motivates by support when requested by the group or individuals Provides little or no direction Uses upward and downward communication between members of the group Disperses decision making throughout the group Places emphasis on the group Does not criticize

LEARNING EXERCISE 2.4

What Is Your Predominant Leadership Style?

Define your predominant leadership style (authoritarian, democratic, or laissez-faire). Ask those who work with you if in their honest opinion this is indeed the leadership style that you use most often. What style of leadership do you work best under? What leadership style best describes your present or former managers?

Because it is nondirected leadership, the laissez-faire style can be frustrating; group apathy and disinterest can occur. However, when all group members are highly motivated and self-directed, this leadership style can result in much creativity and productivity. Laissez-faire leadership is appropriate when problems are poorly defined and brainstorming is needed to generate alternative solutions.

A person’s leadership style has a great deal of influence on the climate and outcome of the work group.

For some time, theorists believed that leaders had a predominant leadership style and used it consistently.

During the late 1940s and early 1950s, however, theorists began to believe that most leaders did not fit a textbook picture of any one style but rather fell somewhere on a continuum between authoritarian and laissez-faire. They also came to believe that leaders moved dynamically along the continuum in response to each new situation. This recognition was a forerunner to what is known as situational or contingency leadership theory.

Situational and Contingency Leadership Theories (1950 to 1980)

The idea that leadership style should vary according to the situation or the individuals involved was first suggested almost 100 years ago by Mary Parker Follett, one of the earliest management consultants and among the first to view an organization as a social system of contingencies. Her ideas, published in a series of books between 1896 and 1933, were so far ahead of their time that they did not gain appropriate recognition in the literature until the 1970s. Her law of the situation, which said that the situation should determine the directives given after allowing everyone to know the problem, was contingency leadership in its humble origins. Fiedler’s (1967) contingency approach reinforced these findings, suggesting that no one leadership

style is ideal for every situation. Fiedler felt that the interrelationships between the group’s leader and its members were most influenced by the manager’s ability to be a good leader. The task to be accomplished and the power associated with the leader’s position also were cited as key variables. In contrast to the continuum from autocratic to democratic, Blake and Mouton’s (1964) grid showed

various combinations of concern or focus that managers had for or on productivity, tasks, people, and relationships. In each of these areas, the leader-manager may rank high or low, resulting in numerous combinations of leadership behaviors. Various formations can be effective depending on the situation and the needs of the worker. Hersey and Blanchard (1977) also developed a situational approach to leadership. Their

tridimensional leadership effectiveness model predicts which leadership style is most appropriate in each situation on the basis of the level of the followers’ maturity. As people mature, leadership style becomes less task focused and more relationship oriented. Tannenbaum and Schmidt (1958) built on the work of Lewin (1951) as well as White and Lippitt

(1960), suggesting that managers need varying mixtures of autocratic and democratic leadership behavior. They believed that the primary determinants of leadership style should include the nature of the situation, the skills of the manager, and the abilities of the group members. Although situational and contingency theories added necessary complexity to leadership theory and

continue to be applied effectively by managers, by the late 1970s, theorists began arguing that effective leadership depended on an even greater number of variables, including organizational culture, the values of the leader and the followers, the work, the environment, the influence of the leader-manager, and the complexities of the situation. Efforts to integrate these variables are apparent in more contemporary interactional and transformational leadership theories.

Interactional Leadership Theories (1970 to Present)

The basic premise of interactional theory is that leadership behavior is generally determined by the relationship between the leader’s personality and the specific situation. Schein (1970), an interactional

theorist, was the first to propose a model of humans as complex beings whose working environment was an open system to which they responded. A system may be defined as a set of objects, with relationships between the objects and between their attributes. A system is considered open if it exchanges matter, energy, or information with its environment. Schein’s model, based on systems theory, had the following assumptions:

People are very complex and highly variable. They have multiple motives for doing things. For example, a pay raise might mean status to one person, security to another, and both to a third. People’s motives do not stay constant; instead, they change over time. Goals can differ in various situations. For example, an informal group’s goals may be quite distinct from a formal group’s goals. A person’s performance and productivity are affected by the nature of the task and by his or her ability, experience, and motivation. No single leadership strategy is effective in every situation.

To be successful, the leader must diagnose the situation and select appropriate strategies from a large repertoire of skills. Hollander (1978) was among the first to recognize that both leaders and followers have roles outside of the leadership situation and that both may be influenced by events occurring in their other roles. With leader and follower contributing to the working relationship and both receiving something from it,

Hollander (1978) saw leadership as a dynamic two-way process. According to Hollander, a leadership exchange involves three basic elements:

The leader, including his or her personality, perceptions, and abilities The followers, with their personalities, perceptions, and abilities The situation within which the leader and the followers function, including formal and informal group norms, size, and density

Leadership effectiveness, according to Hollander (1978), requires the ability to use the problem- solving process; maintain group effectiveness; communicate well; demonstrate leader fairness, competence, dependability, and creativity; and develop group identification. Ouchi (1981) was a pioneer in introducing interactional leadership theory in his application of

Japanese style management to corporate America. Theory Z, the term Ouchi used for this type of management, is an expansion of McGregor’s Theory Y and supports democratic leadership. Characteristics of Theory Z include consensus decision making, fitting employees to their jobs, job security, slower promotions, examining the long-term consequences of management decision making, quality circles, guarantee of lifetime employment, establishment of strong bonds of responsibility between superiors and subordinates, and a holistic concern for the workers (Ouchi, 1981). Ouchi was able to find components of Japanese style management in many successful American companies. In the 1990s, Theory Z lost its favor with many management theorists. American managers seemed

unable to put these same ideas into practice in the United States. Instead, many continued to boss-manage workers in an attempt to make them do what they do not want to do. Although Theory Z is more comprehensive than many of the earlier theories, it too neglects some of the variables that influence leadership effectiveness. It has the same shortcomings as situational theories in inadequately recognizing

the dynamics of the interaction between the worker and the leader. One of the pioneering leadership theorists of this time was Kanter (1977), who developed the theory

that the structural aspects of the job shape a leader’s effectiveness. She postulated that the leader becomes empowered through both formal and informal systems of the organization. A leader must develop relationships with a variety of people and groups within the organization in order to maximize job empowerment and be successful. The three major work empowerment structures within the organization are opportunity, power, and proportion. Kanter asserts that these work structures have the potential to explain differences in leader responses, behaviors, and attitudes in the work environment. Nelson and Burns (1984) suggested that organizations and their leaders have four developmental levels

and that these levels influence productivity and worker satisfaction. The first of these levels is reactive. The reactive leader focuses on the past, is crisis driven, and is frequently abusive to subordinates. In the next level, responsive, the leader is able to mold subordinates to work together as a team, although the leader maintains most decision-making responsibility. At the proactive level, the leader and followers become more future oriented and hold common driving values. Management and decision making are more participative. At the last level, high-performance teams, maximum productivity and worker satisfaction are apparent. Kanter (1989) perhaps best summarized the work of the interactive theorists by her assertion that title

and position authority were no longer sufficient to mold a workforce where subordinates are encouraged to think for themselves, and instead managers must learn to work synergistically with others.

Transactional and Transformational Leadership

Similarly, Burns (2003), a noted scholar in the area of leader–follower interactions, was among the first to suggest that both leaders and followers have the ability to raise each other to higher levels of motivation and morality. Identifying this concept as transformational leadership, Burns maintained that there are two primary types of leaders in management. The traditional manager, concerned with the day- to-day operations, was termed a transactional leader. The manager who is committed, has a vision, and is able to empower others with this vision was termed a transformational leader. A composite of the two different types of leaders is shown in Table 2.2.

Transactional leaders focus on tasks and getting the work done. Transformational leaders focus on vision and empowerment.

Similarly, Bass and Avolio (1994) suggested that transformational leadership leads followers to levels of

higher morals because such leaders do the right thing for the right reason, treat people with care and compassion, encourage followers to be more creative and innovative, and inspire others with their vision. This new shared vision provides the energy required to move toward the future. Similarly, Huber (2015) notes that one of the most important tenants of transformational leadership is collective empowerment. This means that both the leader and the people they are leading are working together to achieve a shared goal. Similarly, the American Nurses Association (2016) suggests that leaders do more than delegate, dictate, and direct; they help others achieve their highest potential. Kouzes and Posner (2012) are perhaps the best known authors to further the work on transformational

leadership in the past decade. Kouzes and Posner suggest that exemplary leaders foster a culture in which relationships between aspiring leaders and willing followers can thrive. This requires the development of the five practices shown in Display 2.6. Kouzes and Posner suggest that when these five practices are employed, anyone can further their ability to lead others to get extraordinary things done.

DISPLAY 2.6 Kouzes and Posner’s Five Practices for Exemplary Leadership

1. Modeling the way: requires value clarification and self-awareness so that behavior is congruent with values

2. Inspiring a shared vision: entails visioning which inspires followers to want to participate in goal attainment

3. Challenging the process: identifies opportunities and taking action 4. Enabling others to act: fosters collaboration, trust, and the sharing of power 5. Encouraging the heart: recognizes, appreciates, and celebrates followers and the achievement of

shared goals

Source: Kouzes, J., & Posner, B. (2012). The leadership challenge (5th ed.). San Francisco, CA: Jossey-Bass.

Although the transformational leader is held as the current ideal, many management theorists sound a warning about transformational leadership. Although transformational qualities are highly desirable, they must be coupled with the more traditional transactional qualities of the day-to-day managerial role. In addition, both sets of characteristics need to be present in the same person in varying degrees. The transformational leader will fail without traditional management skills. Indeed, Avolio, Walumbwa, and Weber (2009) note that much of the disillusionment with leadership theory and research in the early 1980s was related to “the fact that most models of leadership and measures accounted for a relatively small percentage of variance in performance outcomes such as productivity and effectiveness” (p. 428). Indeed, some leaders are not very visionary or inspiring. Still others are inspiring and passionate but their vision and desired outcomes are flawed. DeMers (2015) agrees, suggesting that

Unfortunately, the world isn’t perfect, and some ideals simply aren’t possible to execute practically. As a leader, your ideas must be grounded in pragmatism, meaning instead of relying on your ideals to

dictate your approach, you must consider how your ideals can be shaped to realistically fit into a practical world. (para. 18)

Although transformational qualities are highly desirable, they must be coupled with the more traditional transactional qualities of the day-to-day managerial role or the leader will fail.

Full-Range Leadership Model/Theory

It is this idea that context is an important mediator of transformational leadership that led to the creation of a full-range leadership model (FRLM) late in the 20th century. Bass and Avolio (1993) first described a full-range leader as a leader who could apply principles of three specific styles of leadership at any given time: transformational, transactional, and laissez-faire. MacKie (2014) suggests the FRLM “encompasses both the transformational elements of leadership

(that is building trust, acting with principle and integrity, inspiring others, innovating, and developing others), transactional elements (that includes both constructive elements, e.g., contingent reward and corrective elements and management by exception) and avoidant or laissez-faire leadership behaviors” (pp. 120–121). Thus, transformational leadership was thought to add to the benefits of transactional leadership through an augmentation effect where the transformational engagement of followers encouraged their enhanced performance through increased discretionary effort. Thus, the more transactional elements of leadership such as goal setting can be enhanced with the addition of transformational elements of leadership where followers are inspired to give more of their time and effort by the vision and charisma of the leader (MacKie, 2014). Thus, the transformational leadership helps the full-range leader motivate his or her team and allows

the leader to be viewed as an example of what they can become. Transactional leadership, however, is still needed to reinforce or modify behavior respectively, and laissez-faire leadership is included because there will be times when the full-range leader needs to step back and do nothing because the team is fully capable of doing the work on its own (AdviseAmerica, 2016). Thus, full-range leaders evolve and adapt their leadership style based on which leadership styles are needed for a given situation. Further work by Antonakis, Avolio, and Sivasubramaniam (2003), suggested there are nine factors

impacting leadership style and its impact on followers in the FRLM; five are transformational, three are transactional, and one is a nonleadership or laissez-faire leadership factor (Rowold & Schlotz, 2009; Display 2.7).

DISPLAY 2.7 Nine Factors in the Full-Range Leadership Model (as described by Rowold & Schlotz, 2009)

In describing these factors, Rowold and Schlotz (2009) suggest that the first factor, inspirational motivation, is characterized by the leader’s articulation and representation of vision. Idealized influence (attributed), the second factor, relies on the charisma of the leader to create emotional ties with followers that build trust and confidence. The third factor, idealized influence (behavior), results in the leader creating a collective sense of mission and values and prompting followers to act on these values. With the fourth factor, intellectual stimulation, leaders challenge the assumptions of followers’ beliefs as well as analyze subordinates’ problems and possible solutions. The final transformational factor, individualized consideration, occurs when the leader is able to individualize his or her followers, recognizing and appreciating their unique needs, strengths, and challenges. The first transactional factor, as described by Rowold and Schlotz (2009), is contingent reward. Here,

the leader is task oriented in providing followers with meaningful rewards based on successful task completion. Active management-by-exception, the second transactional factor, suggests that the leader watches and searches actively for deviations from rules and standards and takes corrective actions when necessary. In contrast, the third transactional factor, management-by-exception passive, describes a leader who intervenes only after errors have been detected or standards have been violated. Finally, the ninth factor of full-range leadership theory is the absence of leadership. Thus, laissez-faire is a contrast to the active leadership styles of transformational and transactional leadership exemplified in the first eight factors.

Leadership Competencies

Just as Fayol (1925) and Gulick (1937) identified management functions, contemporary leadership experts suggest that there are certain competencies (skills, knowledge, and abilities) health-care leaders need to be successful. The American College of Healthcare Executives, the American College of Physician Executives, the American Organization of Nurse Executives, the Healthcare Information and Management Systems Society, the Healthcare Financial Management Association, and the Medical Group Management Association have collaborated to identify leadership competencies, which included leadership skills and behavior, organizational climate and culture, communicating vision, and managing change (Esparza & Rubino, 2014).

Integrating Leadership Roles and Management Functions Because rapid, dramatic change will continue in nursing and the health-care industry, it has grown increasingly important for nurses to develop skill in both leadership roles and management functions. For

managers and leaders to function at their greatest potential, the two must be integrated. Gardner (1990) asserted that integrated leader-managers possess six distinguishing traits: 1. They think longer term: They are visionary and futuristic. They consider the effect that their

decisions will have years from now as well as their immediate consequences. 2. They look outward, toward the larger organization: They do not become narrowly focused. They

are able to understand how their unit or department fits into the bigger picture. 3. They influence others beyond their own group: Effective leader-managers rise above an

organization’s bureaucratic boundaries. 4. They emphasize vision, values, and motivation: They understand intuitively the unconscious and

often nonrational aspects that are present in interactions with others. They are very sensitive to others and to differences in each situation.

5. They are politically astute: They are capable of coping with conflicting requirements and expectations from their many constituencies.

6. They think in terms of change and renewal: The traditional manager accepts the structure and processes of the organization, but the leader-manager examines the ever-changing reality of the world and seeks to revise the organization to keep pace.

Leadership and management skills can and should be integrated as they are learned. Table 2.3 summarizes the development of leadership theory through the end of the 20th century. Newer (21st century) and emerging leadership theories are discussed in Chapter 3.

In examining leadership and management, it becomes clear that these two concepts have a symbiotic or synergistic relationship. Every nurse is a leader and manager at some level, and the nursing role requires leadership and management skills. The need for visionary leaders and effective managers in nursing precludes the option of stressing one role over the other. Highly developed management skills are needed to maintain healthy organizations. So too are the visioning and empowerment of subordinates through an organization’s leadership team. Because rapid, dramatic change will continue in nursing and the health- care industry, it continues to be critically important for nurses to develop skill in both leadership roles and management functions and to strive for the integration of leadership characteristics throughout every phase of the management process.

KEY CONCEPT

Management functions include planning, organizing, staffing, directing, and controlling. These are incorporated into what is known as the management process.

Classical, or traditional, management science focused on production in the workplace and on delineating organizational barriers to productivity. Workers were assumed to be motivated solely by economic rewards, and little attention was given to worker job satisfaction.

The human relations era of management science emphasized concepts of participatory and humanistic management.

Three primary leadership styles have been identified: authoritarian, democratic, and laissez- faire.

Research has shown that the leader-manager must assume a variety of leadership styles, depending on the needs of the worker, the task to be performed, and the situation or environment. This is known as situational or contingency leadership theory.

Leadership is a process of persuading and influencing others toward a goal and is composed of a wide variety of roles.

Early leadership theories focused on the traits and characteristics of leaders. Interactional leadership theory focuses more on leadership as a process of influencing others within an organizational culture and the interactive relationship of the leader and follower.

The manager who is committed, has a vision, and is able to empower others with this vision is termed a transformational leader, whereas the traditional manager, concerned with the day- to-day operations, is called a transactional leader.

Full-range leadership theory suggests that context is an important mediator of transformational leadership.

Full-range leaders evolve and adapt their leadership style based on which leadership styles are needed for a given situation but need transformational, transactional, and laissez-faire leadership skills to be successful.

Integrating leadership skills with the ability to carry out management functions is necessary if an individual is to become an effective leader-manager.

The integration of both leadership and management skills is critical to the long-term viability of today’s health-care organizations.

Additional Learning Exercises and Applications

LEARNING EXERCISE 2.5

When Culture and Policy Clash

You are the nurse-manager of a medical unit. Recently, your unit admitted a 16-year-old East Indian boy who has been newly diagnosed with insulin-dependent diabetes. The nursing staff has been interested in his case and has found him to be a delightful young man—very polite and easygoing. However, his family has been visiting in increasing numbers and bringing him food that he should not have. The nursing staff has come to you on two occasions and complained about the family’s

noncompliance with visiting hours and unauthorized food. Normally, the nursing staff on your unit has tried to develop a culturally sensitive nursing care plan for patients with special cultural needs, so their complaints to you have taken you by surprise. Yesterday, two of the family members visited you and complained about hospital visitor policies and

what they took to be rudeness by two different staff members. You spent time talking to the family, and when they left, they seemed agreeable and understanding. Last night, one of the staff nurses told the family that according to hospital policy, only two members

could stay (this is true) and if the other family members did not leave, she would call hospital security. This morning, the boy’s mother and father have suggested that they will take him home if this matter is not resolved. The patient’s diabetes is still not controlled, and you feel that it would be unwise for this to happen.

ASSIGNMENT:

Leadership is needed to keep this situation from deteriorating further. Divide into groups. Develop a plan of action for solving this problem. First, select three desired objectives for solving the problem and then proceed to determine what you would do that would enable you to meet your objectives. Be sure that you are clear as to who you consider your followers to be and what you expect from each of them.

LEARNING EXERCISE 2.6

Delineating Leadership Roles and Management Functions

Examine the scenario in Learning Exercise 2.5. How would you divide the management functions and leadership roles in this situation? For example, you might say that having the nurse-manager adhere to hospital policy was a management function and that counseling staff was a leadership role.

ASSIGNMENT:

List at least five management functions and five leadership roles that you could also delineate in this scenario. Share these with your group.

LEARNING EXERCISE 2.7

What Is Your Management Style?

Recall times when you have been a manager. This does not only mean a nursing manager. Perhaps you were a head lifeguard or an evening shift manager at a fast-food restaurant. During those times, do you think you were a good manager? Did you involve others in your management decision making appropriately? How would you evaluate your decision-making ability? Make a list of your management strengths and a list of management skills that you felt you were lacking.

LEARNING EXERCISE 2.8

Leadership Challenges for Health-Care Leaders

Mary Starmann Harrison, president and chief executive officer (CEO) of Hospital Sisters Health System, was quoted in an article by Smith (2012) that the greatest challenge for health-care leaders today is the transition from volume to value, including a determination of how best to guide the organization through that transition as well as the timing to do so. Doug Smith, president and CEO of B.E. Smith, suggests that the greatest challenges for contemporary health-care leaders are large turnover numbers and an inability or unwillingness to change. Carol Dozer, CEO of Ivinson Memorial Hospital, suggests it is the need to cut costs and preserve resources while bringing in the resources needed to operate under a value-based system.

ASSIGNMENT:

Interview the CEO or top nursing executive at a local health-care agency. Ask them what they perceive to be the top five leadership challenges encountered by health-care leaders today. Then ask them to identify five management challenges. Did these health-care leaders differentiate between leadership and management challenges? Did they feel that the leadership or management challenges were greater?

LEARNING EXERCISE 2.9

Quiet at Night?

You are the night shift charge nurse on a busy surgical unit in a large, urban teaching hospital. Surgeries occur around the clock, and frequently, noise levels are higher than desired because of the significant number of nurses, physicians, residents, interns, and other health-care workers who gather at the nurses’ station or in the halls outside of patient rooms. Today, the unit manager has come to you because the hospital’s score on the Centers for Medicare and Medicaid Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for the category Always Quiet at Night falls far below the desired benchmark. She has asked you to devise a plan to address this quality of care issue. The management goal in this situation is to achieve an HCAHPS score on Always Quiet at Night that meets the accepted best practices benchmark, thus assuring that patients get the rest they need to promote their recovery. The leadership goal is to foster a shared commitment among all health- care professionals working on the unit to achieve the Always Quiet at Night goal.

ASSIGNMENT:

1. Identify five management strategies you might use to address the problem of excessive noise on the unit at night. For example, your list might include structural environmental changes or work redesign.

2. Then identify five leadership strategies you might use to promote buy-in of the Quiet at Night initiative by all health-care professionals on the unit. How will you inspire these individuals to work with you in achieving this critically important goal? What incentives might you use to reward behavior conducive to meeting this goal?

3. Discuss whether you feel this goal could be achieved by employing only the management strategies you identified. Could it be achieved only with the implementation of leadership strategies for team building?

LEARNING EXERCISE 2.10

Leadership as a New Nurse (Marquis & Huston, 2012)

Sally Jones is a 36-year-old new registered nurse (RN) who graduated 6 months ago from a community college with an associate degree in nursing. Sally worked her way through school as a licensed practical nurse in a pediatric unit of a local hospital. After passing her RN exams, she moved to a larger city and was hired to work the evening shift on the pediatric unit as a primary care nurse. Her patient load is usually six pediatric patients, and she has a nursing assistant working under her supervision.

Sally has been bothered recently by discrepancies regarding the credits of intravenous (IV) solutions given in handoff report. For example, she was told at report yesterday that 150 mL remained in one patient’s bag of IV solution, but upon making initial patient rounds, she found the IV machine beeping and had to hurriedly replace the bag. At the previous hospital where she had worked, it was a unit policy that all pediatric patients have their IV solutions observed by both oncoming and outgoing primary nurse at the end of report so such discrepancies could be discovered and corrected prior to departure of the outgoing shift. She feels this was a good policy and would like to see a similar policy implemented at her new place of employment. If you were Sally what would you do in this situation? Answer the following questions to help

decide what to do.

1. Is it appropriate for a new nurse to take a leadership role to address this problem? 2. What are some possible steps you could take in correcting this situation? 3. Would a followership role be better suited to solve this issue? 4. Should you act alone or involve others?

LEARNING EXERCISE 2.11

Choosing a Leadership Style (Marquis & Huston, 2012)

You are a team leader with one licensed practical nurse/licensed vocational nurse (LPN/LVN) and one nursing assistant on your team. You also share the unit clerical person with two other team leaders and the charge nurse. You have found the LPN/LVN to be a seasoned team member and very reliable. The nursing assistant is young and very new and seems a bit disorganized but is a very willing team member. At various times, you will be directing these three individuals during your workday, that is, asking them to do things, supervising their work, and so on.

ASSIGNMENT:

What leadership style (authoritative, democratic or laissez-faire) should you use with each person or would it be the same with all three? Would you be justified in using only one leadership style? If an emergency situation occurred, would your leadership style change or remain the same? Discuss solutions to this scenario in class.

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