Leadership roles and management functions in nursing theory and application

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Leadership Roles and Management Functions in Nursing

Theory and Application

Bessie L. Marquis, RN, MSN Professor Emeritus of Nursing California State University Chico, California

Carol J. Huston, RN, MSN, DPA, FAAN Director, School of Nursing

California State University Chico, California

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8th edition

Copyright © 1992 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S.

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Library of Congress Cataloging-in-Publication Data Marquis, Bessie L., author.

Leadership roles and management functions in nursing: theory and application/Bessie L. Marquis, Carol J. Huston.—8th edition.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4511-9281-0 — ISBN 1-4511-9281-9 I. Huston, Carol Jorgensen, author. II. Title.

[DNLM: 1. Leadership. 2. Nursing, Supervisory. 3. Nurse Administrators. 4. Nursing—organization

& administration. WY 105]

RT89

362.17′3068—dc23

2013036678 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.

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partnerships in my life: my husband, Don Marquis, and my colleague, Carol Huston.

BESSIE L. MARQUIS

I dedicate this book to my mother Marilyn Jorgensen.

You are one of the reasons I have become the capable woman I am today.

CAROL JORGENSEN HUSTON

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Reviewers

Carol Amann, MSN, RN-BC, CDP Instructor

Gannon University Erie, Pennsylvania Joanne Casatelli, DNP Molloy College

Rockville Centre, New York Joanne Clements, MS, RN, ACNP Assistant Professor of Clinical Nursing University of Rochester

Rochester, New York

Margaret Decker, MS, RN, CNE Clinical Assistant Professor Binghamton University Binghamton, New York

Hobie Feagai, EdD, MSN, FNP-BC, APRN-Rx Chair

Department of Baccalaureate Nursing Program Hawaii Pacific University

Kaneohe, Hawaii

Lisa Marie Greenwood, MSN, RN, APRN-BC, CWOCN, CNS Nursing Instructor

Madison Area Technical College Reedsburg, Wisconsin

Vonna Henry, BSN, MPH, RN Assistant Professor

St. Cloud State University St. Cloud, Minnesota

Debora Kirsch, RN, MS, CNS

Director of Undergraduate Nursing Studies SUNY Upstate Medical University Syracuse, New York

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Carole McCue, RN, MS, CNE Instructor

Cochran School of Nursing Yonkers, New York

Jennifer Douglas Pearce, MSN, RN, CNE Professor and Chairperson

University of Cincinnati Blue Ash, Ohio

Tawna Pounders, RN, MNSc

Coordinator and Medical-Surgical Theory Faculty Baton Rouge Community College

Baton Rouge, Louisiana Loretta Quigley, MSN Academic Dean

St. Joseph’s College of Nursing Syracuse, New York

Elaine Rose, RN, BN, MHS, DM(c) Assistant Professor

Mount Royal University Calgary, Alberta, Canada

Charlotte Sortedahl, DNP, MPH, MS, RN Assistant Professor

University of Wisconsin Eau Claire, Wisconsin Patricia Varga, MSN, RN Assistant Professor Alverno College Milwaukee, Wisconsin

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Preface

This book’s philosophy has evolved over the past 30+ 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 to first artificially separate the two components for the reader, and then to reiterate the roles and functions. We do believe strongly, however, 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 and the promotion of whole- brain thinking. We propose that integrating leadership and management and using whole-brain thinking 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 reflects trial-and- error methodologies. For us, then, there is little question that vicarious learning, or learning

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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 problem solving are emphasized.

Our students, once resistant to the experiential approach, are now our most 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.

Two hundred and fifty-nine learning exercises, taken from 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.

We also provide guidelines for instructors on thePoint, Wolters Kluwer Health’s trademarked web-based course and content management system that is available to instructors who adopt the text. We recommend its use. The Web site includes a test bank, an image collection, suggestions for using the learning exercises, a glossary, and a large number of PowerPoint slides with images.

TEXT ORGANIZATION

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 eighth 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. Nineteen new learning exercises have been added to this edition, further strengthening the problem-based element of this text. Almost 200 displays, figures, and tables (46 of which are new) help readers to visualize important concepts.

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 added a chapter crosswalk (pp. 15–22) 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 Executive (AONE) Competencies; and the Quality and Safety Education for Nurses (QSEN) Competencies. This crosswalk shows 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.

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 eighth edition also includes contemporary research and theory to ensure accuracy of the didactic material.

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. The remaining units are organized using the management processes of planning, organizing, staffing, directing, and controlling.

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LEARNING TOOLS

The eighth 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.

NEW AND EXPANDED CONTENT

Additional content that has been added or expanded in this edition includes:

• Increased focus on evidence-driven leadership and management decision making

• New models for ethical problem solving and an increased emphasis on patient, professional, and subordinate advocacy

• Expanded discussion of full-range leadership theory, transformational leadership, and leadership competency identification

• Emerging leadership theories such as Strengths-Based Leadership and the Positive Psychology Movement, Level 5 leadership, thought leadership, authentic leadership, and servant leadership

• Introduction to Affordable Care Act in 2010, and the new Patient’s Bill of Rights

• Key components of the Patient Protection and Affordable Care Act (PPACA) as well as its implementation plan between 2010 and 2014

• Health-care reform and financing mechanisms, including bundled payments, accountable care organizations, value-based purchasing, medical homes, and health insurance marketplaces

• The shifting in health-care reimbursement from volume to value

• Reflective practice and the professional portfolio

• Transition-to-practice programs/residencies for new graduate nurses

• Civility, incivility, bullying, mobbing, and workplace violence

• Visioning of health care’s future

• A broad discussion of social media as a communication tool and cause for work distraction and the ethical issues encompassed in the topic

• Continuing competence, lifelong learning, nurse residencies, reflective practice, and the professional portfolio

• Interprofessional collaboration including the Multidisciplinary Team Leader, Interprofessional Primary Healthcare Teams, and Interprofessional Primary Health Care Teams (PHCTs)

• The unique needs of a culturally diverse workforce as well as a workforce representing up to four generations at the same time

• Nurse navigators

• Patient- and family-centered care

• Importance of self-care for nurses

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• The use of ISBAR (Introduction, Situation, Background, Assessment, Recommendation) as a tool to promote communication between care providers or between care providers and patients/families

• Social media and organizational communication

• New mergers of collective bargaining agents to form super unions for nurses

• Leapfrog initiatives including electronic health records, computerized provider order entry, evidence-based hospital staffing, and ICU physician staffing

• New Joint Commission core measures and National Patient Safety Goals

• The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey

• Patient safety and quality of care

thePoint (http://thepoint.lww.com), a trademark of Wolters Kluwer Health, is a web-based course and content management system providing every resource that instructors and students need in one easy-to-use site.

Instructor Resources

Advanced technology and superior content combine at thePoint to allow instructors to design and deliver online and off-line courses, maintain grades and class rosters, and communicate with students.

In addition, instructors will find the following content designed specifically for this edition:

• Test bank

• Image bank

• Instructor’s guide, including guidelines for using the experiential learning exercises in the text

• PowerPoint slides with images Student Resources

Students can visit thePoint to access supplemental multimedia resources to enhance their learning experience, download content, upload assignments, and join an online study group.

Students will also find a glossary that defines the italicized terms in the text.

THE CROSSWALK

New to this edition is a chapter crosswalk of content based on the AACN Essentials of Baccalaureate Education for Professional Nursing Practice (2008); the AACN Essentials of Master’s Education in Nursing (2011); the AONE Competencies; and the QSEN Competencies.

A crosswalk is a table that shows elements from different databases or criteria that interface.

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.

Without doubt, some readers will disagree with the author’s determinations of which Essential or Competency has been addressed in each chapter, and certainly, an argument could be made that most chapters address many, if not all, of the Essentials or Competencies in some way. The crosswalks in this book then are intended to note the primary content focus in each chapter although additional Essentials or Competencies may well be a part of the learning experience with each chapter.

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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.

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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).

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: Advanced generalist 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.

TABLe 2 American Association of Colleges of Nursing Essentials of Master’s Education in Nursing

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The Quality and Safety Education for Nurses Competencies

Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute defined six pre-licensure and graduate quality and safety competencies for nursing (Table 3) 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 3 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.

The American Organization of Nurse Executives - Nurse Executive Competencies

In 2004, 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 differed 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 4 (AONE, 2011). 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 (AONE).

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REFERENCES

TABLe 4 American Organization of Nurse Executive Competencies

I. Communication and relationship building

• Communication and relationship building includes effective communication; relationship management; influence of behaviors; ability to work with diversity; shared decision making; community involvement; medical staff relationships; and academic relationships.

II. A knowledge of the health-care environment

• Knowledge of the health-care environment includes clinical practice knowledge; patient-care delivery models and work design knowledge; health-care economics knowledge; health-care policy knowledge; understanding of governance;

understanding of evidence-based practice; outcome measurement; knowledge of, and dedication to patient safety;

understanding of utilization/case management; knowledge of quality improvement and metrics; and knowledge of risk management.

III. Leadership

• Leadership skills include foundational thinking skills; personal journey disciplines; the ability to use systems thinking;

succession planning; and change management.

IV. Professionalism

• Professionalism includes personal and professional accountability; career planning; ethics; evidence-based clinical and management practice; advocacy for the clinical enterprise and for nursing practice; and active membership in professional organizations.

V. Business skills

• Business skills include understanding of health-care financing; human resource management and development; strategic management; marketing; and information management and technology.

American Association of Colleges of Nursing (AACN).

(2008, October 20). The essentials of baccalaureate education for professional nursing practice.

Retrieved June 20, 2013, from http://www.aacn.nche .edu/education-resources/baccessentials08.pdf American Association of Colleges of Nursing (AACN).

(2011, March 21) The essentials of master’s education in nursing. Retrieved June 20, 2013, from http://www.aacn.nche.edu/education-resources/

MastersEssentials11.pdf

American Organization of Nurse Executives (2011). The AONE nurse executive competencies. Retrieved June 20, 2013, from http://www.aone.org/resources/

leadership%20tools/nursecomp.shtml

Institute of Medicine. (2003). Health professions education:

A bridge to quality. Washington, DC: National Academies Press.

Quality and Safety Education for Nurses Institute (2013).

Competencies. Retrieved June 20, 2013, from http://

qsen.org/competencies/

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UNIT II

Foundation for Effective Leadership and Management Ethics, Law, and Advocacy 69

4 Ethical Issues 70

Types of Ethical Issues 72

Ethical Frameworks for Decision Making 74 Principles of Ethical Reasoning 75

American Nurses Association Code of Ethics and Professional Standards 79 Ethical Problem Solving and Decision Making 80

The Moral Decision-Making Model 84

Working toward Ethical Behavior as the Norm 86 Ethical Dimensions in Leadership and Management 88

Integrating Leadership Roles and Management Functions in Ethics 89 Key Concepts 90

Additional Learning Exercises and Applications 90

5 Legal and Legislative Issues 94 Sources of Law 95

Types of Laws and Courts 96

Legal Doctrines and the Practice of Nursing 97 Professional Negligence 98

Avoiding Malpractice Claims 101 Extending the Liability 102 Incident Reports 104 Intentional Torts 104

Other Legal Responsibilities of the Manager 105

Legal Considerations of Managing a Diverse Workforce 111 Professional Versus Institutional Licensure 112

Integrating Leadership Roles and Management Functions in Legal and Legislative Issues 113

Key Concepts 114

6 Patient, Subordinate, and Professional Advocacy 117 Becoming an Advocate 118

Patient Advocacy 120 Patient Rights 121

Subordinate and Workplace Advocacy 124 Whistleblowing as Advocacy 125

Professional Advocacy 127

Integrating Leadership Roles and Management Functions in Advocacy 131 Key Concepts 132

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UNIT III

Roles and Functions in Planning 137 7 Strategic and Operational Planning 138

Looking to the Future 140 Proactive Planning 142 Strategic Planning 144

Organizational Planning: The Planning Hierarchy 146 Vision and Mission Statements 147

The Organization’s Philosophy Statement 148 Societal Philosophies and Values 151

Individual Philosophies and Values 151 Goals and Objectives 153

Policies and Procedures 155 Rules 157

Overcoming Barriers to Planning 157

Integrating Leadership Roles and Management Functions in Planning 158

Key Concepts 158

8 Planned Change 162

The Development of Change Theory: Kurt Lewin 164 Lewin’s Driving and Restraining Forces 166

A Contemporary Adaptation of Lewin’s Model 167 Classic Change Strategies 167

Resistance: The Expected Response to Change 169 Planned Change as a Collaborative Process 171

The Leader-Manager as a Role Model during Planned Change 171 Organizational Change Associated with Nonlinear Dynamics 172 Organizational Aging: Change as a Means of Renewal 174 Integrating Leadership Roles and Management Functions

in Planned Change 175 Key Concepts 176

9 Time Management 181

Three Basic Steps to Time Management 183 Personal Time Management 191

Integrating Leadership Roles and Management Functions in Time Management 195

Key Concepts 195

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10 Fiscal Planning 204

Balancing Cost and Quality 207

Responsibility Accounting and Forecasting 208 Basics of Budgets 208

Steps in the Budgetary Process 208 Types of Budgets 212

Budgeting Methods 216 Critical Pathways 218

Health-Care Reimbursement 218 Medicare and Medicaid 219

The Prospective Payment System 220 The Managed Care Movement 221

Proponents and Critics of Managed Care Speak Up 223 The Future of Managed Care 224

Health-Care Reform and the Patient Protection and Affordable Care Act 226

Integrating Leadership Roles and Management Functions in Fiscal Planning 228

Key Concepts 228

11 Career Development: From New Graduate to Retirement 235 Career Stages 237

Justifications for Career Development 238

Individual Responsibility for Career Development 238

The Organization’s Responsibility for Career Development 239 Career Coaching 240

Management Development 243

Competency Assessment as Part of Career Development 245 Professional Specialty Certification 246

Reflective Practice and the Professional Portfolio 248 Career Planning and the New Graduate Nurse 249

Transition-to-Practice Programs/Residencies for New Graduate Nurses 249 Resume Preparation 251

Integrating Leadership Roles and Management Functions in Career Development253

Key Concepts 253

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UNIT IV

Roles and Functions in Organizing 259 12 Organizational Structure 260

Formal and Informal Organizational Structure 261 Organizational Theory and Bureaucracy 263 Components of Organizational Structure 264 Limitations of Organization Charts 269 Types of Organizational Structures 270

Decision Making within the Organizational Hierarchy 272 Stakeholders 273

Organizational Culture 274

Shared Governance: Organizational Design for the 21st Century? 277 Magnet Designation and Pathway to Excellence 278

Committee Structure in an Organization 280

Responsibilities and Opportunities of Committee Work 280 Organizational Effectiveness 281

Integrating Leadership Roles and Management Functions Associated with Organizational Structure 282

Key Concepts 283

13 Organizational, Political, and Personal Power 287 Understanding Power 289

The Authority–Power Gap 292 Mobilizing the Power of Nursing 296

Strategies for Building a Personal Power Base 299 The Politics of Power 302

Integrating Leadership Roles and Management Functions When Using Authority and Power in Organizations 305

Key Concepts 306

14 Organizing Patient Care 311

Traditional Modes of Organizing Patient Care 313 Disease Management 323

Selecting the Optimum Mode of Organizing Patient Care 324

Integrating Leadership Roles and Management Functions in Organizing Patient Care 329

Key Concepts 329

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UNIT V

Roles and Functions in Staffing 333

15 Employee Recruitment, Selection, Placement, and Indoctrination 334 Predicting Staffing Needs 336

Is There a Current Nursing Shortage? 336 Recruitment 338

Interviewing as a Selection Tool 339 Tips for the Interviewee 348

Selection 349 Placement 353 Indoctrination 354

Integrating Leadership Roles and Management Functions in Employee Recruitment, Selection, Placement, and Indoctrination 358

Key Concepts 358

Additional Learning Exercises and Applications 359 16 Socializing and Educating Staff for Team Building in a

Learning Organization 363 The Learning Organization 365 Staff Development 366 Learning Theories 367

Assessing Staff Development Needs 371 Evaluation of Staff Development Activities 372

Shared Responsibility for Implementing Evidence-Based Practice 373 Socialization and Resocialization 373

Overcoming Motivational Deficiencies 380 Coaching as a Teaching Strategy 381

Meeting the Educational Needs of a Culturally Diverse Staff 382

Integrating Leadership and Management in Team Building through Socializing and Educating Staff for Team Building in a Learning Organization 383 Key Concepts 384

17 Staffing Needs and Scheduling Policies 388

Unit Manager’s Responsibilities in Meeting Staffing Needs 390 Centralized and Decentralized Staffing 390

Complying with Staffing Mandates 391 Staffing and Scheduling Options 393 Workload Measurement Tools 397

The Relationship between Nursing Care Hours, Staffing Mix, and Quality of Care 401

Managing a Diverse Staff 402

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Generational Considerations for Staffing 403

The Impact of Nursing Staff Shortages upon Staffing 404 Fiscal and Ethical Accountability for Staffing 405

Developing Staffing and Scheduling Policies 406

Integrating Leadership Roles and Management Functions in Staffing and Scheduling 407

Key Concepts 408

UNIT VI

Roles and Functions in Directing 413 18 Creating a Motivating Climate 414

Intrinsic Versus Extrinsic Motivation 416 Motivational Theory 417

Creating a Motivating Climate 422

Strategies for Creating a Motivating Climate 424 Promotion: A Motivational Tool 426

Promoting Self-Care 428

Integrating Leadership Roles and Management Functions in Creating a Motivating Climate at Work 429

Key Concepts 430

19 Organizational, Interpersonal, and Group Communication 436 The Communication Process 438

Variables Affecting Organizational Communication 440 Organizational Communication Strategies 441

Communication Modes 443

Elements of Nonverbal Communication 444 Verbal Communication Skills 446

Listening Skills 449

Written Communication within the Organization 450

The Impact of Technology on Contemporary Organizational Communication 452 Communication, Confidentiality, and Health Insurance Portability and

Accountability Act 454 Group Dynamics 457

Integrating Leadership and Management in Organizational, Interpersonal, and Group Communication 459

Key Concepts 460

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20 Delegation 466

Delegating Effectively 468 Common Delegation Errors 471

Delegation as a Function of Professional Nursing 473 Delegating to a Transcultural Work Team 479

Integrating Leadership Roles and Management Functions in Delegation 480

Key Concepts 481

21 Effective Conflict Resolution and Negotiation 487 The History of Conflict Management 489

Categories of Conflict: Intergroup, Intrapersonal, and Interpersonal 490

The Conflict Process 493 Conflict Management 495 Managing Unit Conflict 498 Negotiation 500

Alternative Dispute Resolution 505 Seeking Consensus 506

Integrating Leadership Skills and Management Functions in Managing Conflict 506

Key Concepts 507

22 Collective Bargaining, Unionization, and Employment Laws 514 Unions and Collective Bargaining 516

Historical Perspective of Unionization in America 517 Union Representation of Nurses 518

American Nurses Association and Collective Bargaining 519 Employee Motivation to Join or Reject Unions 520

Averting the Union 522

The Nurse as Supervisor: Eligibility for Protection Under the National Labor Relations Act 523

Union-Organizing Strategies 524

Managers’ Role During Union-Organizing 525 Steps to Establish a Union 526

Effective Labor–Management Relations 526 Employment Legislation 528

State Health Facilities Licensing Boards 535

Integrating Leadership Skills and Management Functions When Working with Collective Bargaining, Unionization and Employment Laws 536

Key Concepts 536

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UNIT VII

Roles and Functions in Controlling 541 23 Quality Control 542

Defining Quality Health Care 545 Quality Control as a Process 546 The Development of Standards 548 Audits as a Quality Control Tool 551 Standardized Nursing Languages 553 Quality Improvement Models 554

Who Should Be Involved in Quality Control? 556 Quality Measurement as an Organizational Mandate 556 Centers for Medicare and Medicaid Services 559

Medical Errors: An Ongoing Threat to Quality of Care 562

Integrating Leadership Roles and Management Functions with Quality Control 565

Key Concepts 566

24 Performance Appraisal 573

Using the Performance Appraisal to Motivate Employees 575

Strategies to Ensure Accuracy and Fairness in the Performance Appraisal 576 Performance Appraisal Tools 579

Planning the Appraisal Interview 587

Overcoming Appraisal Interview Difficulties 587 Performance Management 590

Coaching: A Mechanism for Informal Performance Appraisal 590 Becoming an Effective Coach 591

Using Leadership Skills and Management Functions in Conducting Performance Appraisals591

Key Concepts 591

25 Problem Employees: Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired 596

Constructive Versus Destructive Discipline 599 Self-Discipline and Group Norms 600

Fair and Effective Rules 600

Discipline as a Progressive Process 601

Disciplinary Strategies for the Nurse-Manager 604 Transferring the Problem Employee 609

Grievance Procedures 610

Disciplining the Unionized Employee 611

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The Marginal Employee 612

The Chemically Impaired Employee 614

Recognizing the Chemically Impaired Employee 615

Integrating Leadership Roles and Management Functions through Dealing with Problem Employees 622

Key Concepts 623

Appendix 627

Solutions to Selected Learning Exercises 627 Index 637

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The Critical Triad:

Decision Making, Management, and Leadership

UNIT I

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2

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

CROSSWALK

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 QSEN Competency: informatics

MSN Essential IV: Translating and integrating scholarship into practice

AONE Nurse Executive Competency I: communication and relationship building AONE Nurse Executive Competency III: Leadership

QSEN Competency: evidence-based practice

LEARNING OBJECTIVES

The learner will:

l differentiate between problem solving, decision making, critical thinking, and clinical reasoning

l describe how case studies, simulation, and problem-based learning can be used to improve the quality of decision making

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

l identify characteristics of successful decision makers

l select appropriate models for decision making in specific situations

l describe the importance of the individual in the decision-making process

l identify critical elements of decision making

l explore his or her personal propensity for risk taking in decision making

l discuss the effect of organizational power on decision making

l differentiate between the economic man and the administrative man in decision making

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l select appropriate management decision-making tools that would be helpful in making specific decisions

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

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 (2013, 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 manner 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 (2013) defines critical thinking as “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion”

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(para 1). Critical thinking also involves reflecting upon the meaning of statements, examining the offered evidence and reasoning, and forming judgments about facts.

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

communicator “Outside-the-box” thinker circular thinking

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

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 upon the process used to arrive at a diagnosis; this is known as clinical reasoning (Linn, Khaw, Kildea, & Tonkin, 2012). 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 (Russell, Geist, & Maffett, 2013). 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

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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 since 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. Based on chosen alternatives, the simulation can determine the relative performance of patient throughputs, the timeliness of care, and the appropriateness of resource utilization, thus integrating management priorities and operational decision making (Hamrock, Paige, Parks, Scheulen, & Levin, 2013).

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. In addition, simulation allows students to apply and improve the critically important “nontechnical” skills of communication, teamwork, leadership, and decision making (Lewis, Strachan, & Smith, 2012). (See Examining the Evidence 1.1.)

Source: Lewis, R., Strachan, A., & Smith, M. (2012). Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. Open Nursing Journal, 6, 82–89.

This literature review suggested that simulation was positively associated with significantly improved interpersonal communication skills at patient handover as well as improved team performance in the management of crisis situations. It also appeared to enable the development of transferable, transformational leadership skills, improved students’ critical thinking and clinical reasoning in complex care situations, and aided in the development of students’ self-efficacy and confidence in their own clinical abilities. The authors concluded that simulation provides a learning environment in which both technical and nontechnical skills can be improved without fear of compromising patient safety.

Examining the Evidence 1.1

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, while 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

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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.

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

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.

Didactic theory

Personalized learning

Group process Problem

solving

FIGURE 1.1 • The Marquis-huston critical thinking teaching model.

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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 upon 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.

For example, a study by Muoni (2012) found that nurse midwives often use heuristics (which are defined as shortcut mental strategies that help simplify information), coupled with intuition, to make clinical decisions. While Muoni notes that the use of such heuristics does allow midwives to make decisions more quickly, she questions the reliability of heuristics and suggests that clinical decisions should always be evidence based and follow a systematic continuum that clearly portrays the process used to make the decision.

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 follow in Display 1.2. (Decision-making occurs at step 5.)

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

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.

DISPLAy 1.2 Traditional Problem Solving Process

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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 (2006–2013) includes the six steps shown in Display 1.3.

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.

DISPLAy 1.3 Managerial Decision Making Model

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