Appendix
B
elow is an analysis of how one might approach a problem involving a nonnursing department but affecting the nurses’ work and the nursing staff.Analysis: Data Assessment
1. A copy of the organization chart was given to you when you were hired. The formal structure is a line- and-staff organization. The housekeeping department head is below the nursing director and the nursing section supervisor but at the same level as the immediate clinic supervisor. The housekeeping
department head reports directly to the maintenance and engineering department head.
2. The county administrator has stated that she has an open-door policy. You do not know if this means that bypassing department heads is acceptable or merely that the administrator is interested in the employees. An important reason for not skipping intermediate supervisors when communicating is that they must know what is going on in their departments. A manager’s position, value, and status are strengthened if he or she serves as a vital and essential link in the vertical chain of command.
3. You have twice attempted to talk with your immediate supervisor; however, whether you followed up regarding your supervisor’s action on the complaint is unclear.
4. You are a new employee and therefore probably do not know how the formal or informal structure works. This newness might render the complaints less credible.
5. Possible risks include creating trouble for the housekeeping staff or their immediate supervisor, being labeled a troublemaker by others in the organization, and alienating your immediate supervisor.
6. Before proceeding, you need to assess your own values and determine what is motivating you to pursue this issue.
Alternatives for Action
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here are many choices available to you.1. You can do nothing. This is often a wise choice and should always be an alternative for any problem solving. Some problems solve themselves if left alone. Sometimes, the time is not right to solve the problem.
2. You can talk with the county health administrator. Although this involves some risk, the possibility exists that the administrator will be able to take action. At the very least, you will have unburdened your problem on someone.
3. You can talk directly with the individual housekeepers by using “I” messages, such as, “I get angry when the housekeeping staff take naps, and the bathrooms are dirty.” Perhaps, if feelings and frustrations were shared, you would learn more about the problem. Maybe there is a reason for their behavior; maybe they only socialize during their breaks. This alternative involves some risk: The housekeepers might look on you as a troublemaker.
4. Have all the evening staff sign a petition and give it to the immediate supervisor. Forming a coalition often produces results. However, the supervisor could view this action as overreacting or meddlesome and might feel threatened.
5. Go to the housekeeping staff’s department head and report them. In this way, you are saving some time and going right to the person who is in charge. However, this might be unfair to the housekeepers and certainly will create some enemies for you.
6. Follow up with the immediate supervisor. You could request permission to take action yourself and ask how best to proceed. This would involve your immediate supervisor and keep her informed. However, it also shows that you are willing to take risks and devote some personal time and energy to solving the problem.
Selecting an Alternative
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his problem has no right answer. Under certain conditions, various solutions could be used. Under most circumstances, it is more fair to others and efficient for you to select the third alternative listed. However, because you are new and have little knowledge of the formal and informal organizational structure, yourwisest choice would be alternative 6. New employees need to seek guidance from their immediate supervisors.
For this follow-up session with the supervisor to be successful, you need to do the following:
1. Talk with the supervisor during a quiet time.
2. Admit to personally “owning” the problem without involving colleagues.
3. Acknowledge that legitimate reasons for the housekeepers’ actions may exist.
4. Request permission to talk directly with the housekeepers. Role-play an appropriate approach with the supervisor.
You must accept the consequences of your actions. However, your attempt to correct the problem may motivate your supervisor to pursue the problem directly with the housekeeping staff’s supervisor. If this is the action your supervisor takes, you should ask to speak with the housekeeping staff directly first. If, after talking with the housekeeping staff, you decide a problem still exists and you elect to address that problem, then you should return to your immediate supervisor before proceeding.
Analysis of the Problem Solving
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ould you have solved this problem differently? What are some other alternatives that could have been generated? Have you ever gone outside the chain of command and had a positive experience as a result?LEARNING EXERCISE
13.6
A Shifting of Power
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his is the strategy that Sally Jones used to solve the conflict between her and Bob Black. In analyzing this case, one must forego feelings of resentment regarding Bob’s obvious play for control and power. In reality, what real danger does his empire building pose for the director of nursing? Is not Sally really just ridding herself and her staff of clerical duties and interruptions?A certain amount of power is inherent in the ability to hire. Employees develop a loyalty for the person who actually hires them. Because Sally Jones or her designee will still actually make the final selection, Bob’s proposal should result in little loss of loyalty or power.
Let us look at what the real Sally Jones did to solve this conflict. When she was able to see that Bob was not stripping her of any power, Sally was capable of using some very proactive strategies. Here was a chance for her to appear compromising, thereby increasing her esteem in the chief executive officer’s (CEO’s) eyes and gaining political clout in the organization.
When she met with Jane Smith and Bob, Sally began by complimenting Bob on his ideas. Then she suggested that because nurses were in the habit of coming to the nursing department to apply for positions and because human resources offices were rather cold and formal places, stationing the new personnel clerk in the nursing office would be more convenient and inviting. Sally knew that the human resources
department lacked adequate space and that the nursing office had some extra room. She went on to say that because some of her unit clerks were very knowledgeable about the hospital organization, Bob might want to interview several of them for the new position. Although an experienced unit clerk would be difficult to replace, Sally said she was willing to make this sacrifice for the new plan to succeed.
The CEO, very impressed with Sally’s generous offer, turned to Bob and said, “I think Sally has an excellent idea. Why don’t you hire one of her clerks and station her in the nursing office?” Jane then said to Sally, “Now, do we understand that the clerk will be Bob’s employee and will work under him?”
Sally agreed with this because she felt she had just pulled off a great power play. Let us examine what Sally won in this political maneuver.
1. She gained by not competing with Bob, therefore not making him her enemy.
2. She gained by impressing the CEO with her flexibility and initiative.
3. She gained a new employee.
Although the new employee would be working for Bob with the salary charged to his cost center, the clerk would be Sally’s former employee. Because the clerk would be working in the nursing office, she would have some allegiance to Sally. In addition, the clerk would be doing all the work that Sally and her assistants had been doing and at no cost to the nursing department.
When Sally first received Bob’s memo, she was angry; her initial reaction was to talk to the CEO privately and complain about Bob. Fortunately, she did not do this. It is nearly always a political mistake for one manager to talk about another behind his or her back and without his or her knowledge. This generally reflects unfavorably on the employee, with a loss of respect from the supervisor.
Another option Sally had was to compete with Bob and be uncooperative. Although this might have delayed centralizing the personnel department, in the end, Bob undoubtedly would have accomplished his goal and Sally would not have been able to reap such a great political victory.
The later effects of this political maneuver were even more rewarding. The personnel clerk remained loyal to Sally. Bob became less adversarial and more cooperative with Sally on other issues. The CEO gave her a sly grin later in the week and said, “Great move with Bob Black.” This case might be concluded by saying that this is an example of someone being given a lemon and then making lemonade.
LEARNING EXERCISE
21.3
Conflicting Personal, Professional, and Organizational Obligations
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he following is conflict resolution strategy used by you when the nursing office supervisor (Carol), who considers you to be competent and responsible, asked you to help cover the workload in the delivery room.Although this supervisor believes you can do the job, you think that you do not know enough about labor and delivery nursing to be effective. Here are some strategies you can use to resolve the conflict.
Analysis
Y
ou need to examine your goal, the supervisor’s goal, and a goal on which you can both agree. Your goal might be protection of your license and doing nothing that would bring harm to a patient. Carol’s goal might be to provide assistance to an understaffed unit. A possible supraordinate goal would be for neither you nor Carol to do anything that would bring risk or harm to the organization.The following conflict resolution strategies were among your choices:
Accommodating. Accommodating is the most obvious wrong choice. If you really believe you are unqualified to work in the delivery room, this strategy could be harmful to patients and your career.
Such a decision would not meet with your goal or the supraordinate goal.
Smoothing or avoiding. Because you have little power and no one is available to intervene on your behalf, you are unable to choose either of these solutions. The problem cannot be avoided, nor will you be able to smooth the conflict away.
Compromising. In similar situations, you might be able to negotiate a compromise. For instance, you might say, “I cannot go to the delivery room, but I will float to another medical–surgical area if there is someone on another medical–surgical unit who has OB experience.” Alternatively, you could
compromise by stating, “I feel comfortable working postpartum and will work in that area if you have a qualified nurse from postpartum that can be sent to the delivery room.” It is possible that either solution could end the conflict, depending on the availability of other personnel and how comfortable you would feel in the postpartum area. Often, someone attempting to solve problems, such as the supervisor in this case, becomes so overburdened and stressed that other alternatives are not apparent to them.
Collaborating. If time allows and the other party is willing to adopt a common goal, this is the preferred method of dealing with conflict. However, the power holder must view the other as having something important to contribute if this method of conflict management is to be successful. Perhaps, you could convince Carol that the hospital and she could be at risk if an unqualified registered nurse (RN) was
assigned to an area requiring special skills. Once the supraordinate goal is adopted, you and Carol would be able to find alternative solutions to the problem. There are always many more ways to solve a problem than any one person can generate.
Competing. Normally, competing is not an attractive alternative for resolving conflict, but sometimes, it is the only recourse. Before using competition as a method to manage this conflict, you need to examine your motives. Are you truly unqualified for work in the delivery room, or are you using your lack of experience as an excuse not to float to an unfamiliar area that would cause you anxiety? If you are truly convinced that you are unqualified, then you possess information that the supervisor does not have (a criterion necessary for the use of competing as a method of conflict resolution). Therefore, if other methods for solving the conflict are not effective, you must use competition to solve the conflict. You must win at the expense of the supervisor’s losing. You risk much when using this type of resolution.
The supervisor might fire you for insubordination or, at best, she may view you as uncooperative. The most appropriate method for using competition in this situation is an assertive approach. An example would be repeating firmly but nonaggressively, “I cannot go to the delivery room to work because I would be putting patients at risk. I am unqualified to work in that area.” This approach is usually effective. You must not work in an area where patient safety would be at risk. It would be morally, ethically, and legally wrong for you to do so. (Note: The legal implications of this case are discussed in Chapter 5.)
LEARNING EXERCISE
21.4
An Exercise in Negotiation Analysis Analysis
A charge nurse’s goal is to be sure that all patients receive safe and adequate care. However, some hidden agendas may exist. One might be that the charge nurse does not want to relinquish any authority or does not want to devote energy to the change that has been proposed. The staff nurses have goals of job satisfaction and providing more continuity of care; however, their hidden agenda is probably the need for more autonomy and control of the work setting.
If the conflict is allowed to escalate, the staff nurses could begin to disrupt the unit because of their dissatisfaction, and the charge nurse could transfer some of the “ringleaders” or punish them in some other way. The charge nurse is wise in reconsidering these nurses’ request. By demonstrating a willingness to talk and negotiate the conflict, the staff will view the charge nurse as cooperative and interested in their job satisfaction.
The staff nurses must realize that they are not going to obtain everything they want in this conflict resolution, nor should they expect that result. To demonstrate their interest, they should develop some sort of workable policy and procedure for patient care assignments, recognizing that the charge nurse will want to modify their procedure. Once the plan is developed, the nurses need to plan their strategy for the coming meeting. The following may be their outline:
1. Select as a spokesperson a member of the group who has the best assertive skills but whose approach is not abrasive or aggressive. This keeps the group from appearing overpowering to the charge nurse. The other group members will be at the meeting lending their support but will speak only when called on by the group leader. Preferably, the spokesperson should be someone whom the charge nurse knows well and whose opinion is respected.
2. The designated leader of the group should begin by thanking the charge nurse for agreeing to the meeting. In this way, the group acknowledges the authority of the charge nurse.
3. There should be a sincere effort by the group to listen to the charge nurse and to follow modifications to their plan. They must be willing to give up something as well, perhaps some modification in the staffing pattern.
4. As the meeting progresses, the leader of the group should continue to express the goal of the group—to provide greater continuity of patient care—rather than focus on how unhappy the group is with the
present system.
5. At some point, the nurses should show their willingness to compromise and offer to evaluate the new plan periodically.
Ideally, the outcome of the meeting would be some sort of negotiated compromise in patient care assignment, which would result in more autonomy and job satisfaction for the nurses, enough authority for the charge nurse to satisfy ongoing responsibilities, and increased continuity of patient care assignment.
LEARNING EXERCISE
23.1
Designing an Audit Tool
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hen writing audit criteria, first define the patient population as clearly as possible so that information can be retrieved quickly. In this case, eliminate patients who had complicated births, births of abnormal newborns, cesarean section births, and home births because these patients will need more assessment and teaching. The performance expectations should be set at 100% compliance with an allowance made for reasonable exceptions. One hundred percent is recommended because if any of these criteria are not recorded in the patient’s record, remedial actions should be taken.Select the patient’s record as the most objective source of information. It should be assumed that if criteria were not charted, they were not met. Audit 30 charts to give the agency enough data to make some assumptions but not too many as to make it economically burdensome to review records. An audit form that could be developed follows:
Nursing Audit Form for Visiting Nurses
Nursing diagnosis: Initial home visit within 72 hours after uncomplicated vaginal delivery, with normal newborn, occurring in a birth center or obstetrical facility
Source of information: Patient’s record
Expected compliance: 100%, unless specific exceptions are noted Number of records to be audited: 30
After the audit committee reviews the records, a summary should be made of the findings. A summary could look like this:
Summary of Audit Findings
Nursing diagnosis: Initial home visit, within 72 hours after uncomplicated delivery with normal newborn occurring in a birth center or obstetrical facility
Number of records audited: 30 Date of audit: 7/6/2016
Summary of findings: 100% compliance in all areas except recording of mother’s temperature (50%
compliance) and of newborn’s temperature (70% compliance)
Suggestions for improving compliance: Remind nurses to record temperature of mother and infant in record, even if normal. Time might be a factor in initial home visit because temperatures for both were generally recorded on subsequent visits. Committee agrees that temperatures on mother and baby should be taken during first home visit and suggests an in-service and staff meeting regarding this area of
noncompliance.
Signed, Chair of the Committee ________________________________________________
The summaries should be forwarded to the individual responsible for quality improvement, in this case the director of the agency. At no time should individual public health nurses be identified as not having met the criteria. Quality improvement must always be separated from performance appraisal.