Essentials of Nursing Leadership and Management
f i f t h e d i t i o n
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Nursing Leadership and Management
f i f t h e d i t i o n
Diane K. Whitehead, EdD, RN, ANEF Associate Dean, Nursing
Nova Southeastern University
Fort Lauderdale, Florida
Sally A. Weiss, EdD, RN, CNE Associate Chair, Nursing
Nova Southeastern University
Fort Lauderdale, Florida
Ruth M. Tappen, EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor
Florida Atlantic University College of Nursing
Boca Raton, Florida
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Library of Congress Cataloging-in-Publication Data
Whitehead, Diane K., 1945-
Essentials of nursing leadership and management / Diane K. Whitehead, Sally A. Weiss, Ruth M. Tappen. -- 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-2208-1 (pbk. : alk. paper)
1. Nursing services--Administration. 2. Leadership. I. Weiss, Sally A., 1950- II. Tappen, Ruth M. III. Title.
[DNLM: 1. Nursing--United States. 2. Leadership--United States. 3. Nursing--organization & administration--
United States. 4. Nursing Services--organization & administration--United States. WY 16 W592e 2010]
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To my sister Michele:
Your bravery and spirit inspire me every day.
Diane K. Whitehead
To my granddaughter Sydni,
Whose curiosity and wonder continuously remind me
of the reasons I became a nurse educator.
Sally A. Weiss
To students, colleagues, family and friends,
Who have taught me just about everything I know.
Ruth M. Tappen
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We are delighted to bring our readers this Fifth Edition of Essentials of Nursing Leadership and Management. This new edition has been updated to reflect the current health-care environment. As in our
previous editions, the content, examples, and diagrams were
designed with the goal of assisting the new graduate to make the
transition to professional nursing practice.
The Fifth Edition of Essentials of Nursing Leadership and Management focuses on the necessary knowledge and skills needed by the staff nurse as a vital member of the health-care team and manag-
er of patient care. Issues related to setting priorities, delegation, qual-
ity improvement, legal parameters of nursing practice, and ethical
issues were updated for this edition.
We are especially excited to introduce a new chapter, Quality and
Safety. This chapter focuses on the current quality and safety issues
and initiatives that affect the current health-care environment. In
addition, the updated finance chapter and a new chapter on health-
care policy will be available on the F.A. Davis Web site, DavisPlus. We continue to bring you comprehensive, practical information on
developing a nursing career. Updated information on leading, manag-
ing, followership, and workplace issues continues to be included.
Essentials of Nursing Leadership and Management continues to provide a strong foundation for the beginning nurse leader. We want
to thank the people at F.A. Davis for their assistance as well as our
contributors, reviewers, and students for their guidance and support.
Diane K. Whitehead Sally A. Weiss
Ruth M. Tappen
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Patricia Bradley, MEd, PhD, RN Coordinator, Internationally Educated Nurses
Program Faculty, Nursing Department York University Toronto, Ontario, Canada
Kristie Campoe, MSN, RN Adjunct Faculty Nursing Department Nova Southeastern University Fort Lauderdale, Florida
Patricia Welch Dittman, PhD, RN, CDE Graduate Program Director/Assistant Professor Nursing Department Nova Southeastern University Fort Lauderdale, Florida
Denise Howard, BSN, RN Adjunct Faculty Nursing Department Nova Southeastern University Fort Lauderdale, Florida
Marcie Rutherford, PhD, MBA, MSN, RN Assistant Professor Nursing Department Nova Southeastern University Fort Lauderdale, Florida
Wendy Thomson, EdD(c), MSN, BSBA, RN, CNE, IBCLC Assistant Director of Technology and
Simulation/Assistant Professor Nursing Department Nova Southeastern University Fort Lauderdale, Florida
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Table of Contents
unit 1 Professional Considerations
chapter 1 Leadership and Followership 3
chapter 2 Manager 13
chapter 3 Nursing Practice and the Law 21
chapter 4 Questions of Value and Ethics 39
chapter 5 Organizations, Power, and Empowerment 57
unit 2 Working Within the Organization
chapter 6 Getting People to Work Together 73
chapter 7 Dealing With Problems and Conflicts 91
chapter 8 People and the Process of Change 103
chapter 9 Delegation of Client Care 115
chapter 10 Quality and Safety 131
chapter 11 Time Management 157
unit 3 Professional Issues
chapter 12 Promoting a Healthy Workplace 171
chapter 13 Work-Related Stress and Burnout 197
chapter 14 Your Nursing Career 217
chapter 15 Nursing Yesterday and Today 239
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appendix 1 Codes of Ethics for Nurses 257
American Nurses Association Code of Ethics for Nurses 257
Canadian Nurse Association Code of Ethics for Registered Nurses 257
The International Council of Nurses Code of Ethics for Nurses 258
appendix 2 Standards Published by the American Nurses Association 259
appendix 3 Guidelines for the Registered Nurse in Giving, Accepting, or Rejecting a Work Assignment 261
Bonus Chapters on DavisPlus
Triaxial of Action: Policy, Politics, and Nursing
Canadian Nursing Practice and the Law
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chapter 1 Leadership and Followership
chapter 2 Manager
chapter 3 Nursing Practice and the Law
chapter 4 Questions of Values and Ethics
chapter 5 Organizations, Power, and Empowerment
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chapter 1 Leadership and Followership
OBJECTIVES After reading this chapter, the student should be able to: ■ Define the terms leadership and followership.
■ Discuss the importance of effective leadership and followership for the new nurse.
■ Discuss the qualities and behaviors that contribute to effective followership.
■ Discuss the qualities and behaviors that contribute to effective leadership.
Are You Ready to Be a Leader?
Becoming a Better Follower
What Makes a Person a Leader?
Task Versus Relationship
Qualities of an Effective Leader
Behaviors of an Effective Leader
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4 unit 1 | Professional Considerations
Nurses work with an extraordinary variety of people:
physicians, respiratory therapists, physical therapists,
social workers, psychologists, technicians, aides, unit
managers, housekeepers, clients, and clients’ families.
The reason why nurses study leadership is to
learn how to work well, or effectively, with other people. In this chapter, leadership and followership and the relationships between them are defined.
The characteristics and behaviors that can make
you, a new nurse, an effective leader and follower
Are You Ready to Be a Leader?
You may be thinking, “I’m just beginning my career
in nursing. How can I be expected to be a leader
now?” This is an important question. You will need
time to refine your clinical skills and learn how to
function in a new environment. But you can begin
to assume some leadership right away within your
new nursing roles. Consider the following example:
Billie Blair Thomas was a new staff nurse at Green Valley Nursing Care Center. After orientation, she was assigned to a rehabilitation unit with high admission and discharge rates. Billie noticed that admissions and discharges were assigned rather hap- hazardly. Anyone who was “free” at the moment was directed to handle them. Sometimes, unlicensed assis- tant personnel were directed to admit or discharge residents. Billie believed that using them was inap- propriate because their assessment skills were limited and they had no training in discharge planning.
Billie thought there was a better way to do this but was not sure that she should say so because she was so new. “Maybe they’ve already thought of this,” she said to a former classmate. “It’s such an obvious solution.” They began to talk about what they had learned in their leadership course before graduation. “I just keep hearing our instructor say- ing, ‘There’s only one manager, but anyone can be a leader of our group.”
“If you want to be a leader, you have to act on your idea,” her friend said.
“Maybe I will,” Billie replied. Billie decided to speak with her nurse manager,
an experienced rehabilitation nurse who seemed not only approachable but also open to new ideas. “I have been so busy getting our new record system on line before the surveyors come that I wasn’t
paying attention to that,” the nurse manager told her. “I’m so glad you brought it to my attention.”
Billie’s nurse manager raised the issue at the next executive meeting, giving credit to Billie for having brought it to her attention. The other nurse man- agers had the same response. “We were so focused on the new record system that we overlooked that. We need to take care of this situation as soon as possible. Billie Blair Thomas has leadership potential.”
Leadership is a much broader concept than is man-
agement. Although managers should also be lead-
ers, management is focused on the achievement of
organizational goals. Leadership, on the other hand:
...occurs whenever one person attempts to influence the behavior of an individual or group—up, down, or sideways in the organization—regardless of the reason. It may be for personal goals or for the goals of others, and these goals may or may not be congru- ent with organizational goals. Leadership is influ- ence (Hersey & Campbell, 2004, p. 12)
In order to lead, one must develop three important
competencies: (1) ability to diagnose or understand
the situation you want to influence, (2) adaptation
in order to allow your behaviors and other resources
to close the gap between the current situation and
what you are hoping to achieve, and (3) communi-
cation. No matter how much you diagnose or
adapt, if you cannot communicate effectively, you
will probably not meet your goal (Hersey &
Effective nurse leaders are those who engage
others to work together effectively in pursuit of a
shared goal. Examples of shared goals are pro-
viding excellent client care, designing a cost-
saving procedure, and challenging the ethics of a
Followership and leadership are separate but recip-
rocal roles. Without followers, one cannot be a
leader; conversely, one cannot be a follower without
a leader (Lyons, 2002).
Being an effective follower is as important to the
new nurse as is being an effective leader. In fact,
most of the time most of us are followers: members
of a team, attendees at a meeting, staff of a nursing
care unit, and so forth.
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chapter 1 | Leadership and Followership 5
Followership is not a passive role. On the contrary,
the most valuable follower is a skilled, self-directed
employee, one who participates actively in setting
the group’s direction, invests his or her time and
energy in the work of the group, thinks critically,
and advocates for new ideas (Grossman & Valiga,
2000). Imagine working on a client care unit where
all staff members, from the unit secretary to the
assistant nurse manager, willingly take on extra
tasks without being asked (Spreitzer & Quinn,
2001), come back early from coffee breaks, com-
plete their charting on time, suggest ways to
improve client care, and are proud of the high qual-
ity care they provide. Wouldn’t it be wonderful to
be a part of that team?
Becoming a Better Follower
There are a number of things you can do to become
a better follower:
■ If you discover a problem, inform your team
leader or manager right away.
■ Even better, include a suggestion in your report
for solving the problem.
■ Freely invest your interest and energy in your
■ Be supportive of new ideas and new directions
suggested by others.
■ When you disagree, explain why you do not
support an idea or suggestion.
■ Listen carefully, and reflect on what your leader
or manager says.
■ Continue to learn as much as you can about
your specialty area.
■ Share what you learn.
Being an effective follower will not only make you
a more valuable employee but will also increase the
meaning and satisfaction that you can get from
Most team leaders and nurse managers will
respond very positively to having staff who are
good followers. Occasionally you will encounter a
poor leader or manager who can confuse, frustrate,
and even distress you. Here are a few suggestions
for handling this:
■ Avoid adopting the ineffective behaviors of this
■ Continue to do your best work and to provide
leadership for the rest of the group.
■ If the situation worsens, enlist the support of
others on your team to seek a remedy; do not
try to do this alone as a new graduate.
■ If the situation becomes intolerable, consider the
option of transferring to another unit or seeking
another position (Deutschman, 2005; Korn, 2004).
What Makes a Person a Leader?
There are many different ideas about how a person
becomes a good leader. Despite years of research on
this subject, no one idea has emerged as the clear
winner. The reason for this may be that different
qualities and behaviors are most important in differ-
ent situations. In nursing, for example, some situa-
tions require quick thinking and fast action. Others
require time to figure out the best solution to a
complicated problem. Different leadership qualities
and behaviors are needed in these two instances. The
result is that there is not yet a single best answer to
the question, “What makes a person a leader?”
Consider some of the best-known leadership
theories and the many qualities and behaviors that
have been identified as those of the effective nurse
leader (Pavitt, 1999; Tappen, 2001).
At one time or another, you have probably heard
someone say, “Leaders are born, not made.” In other
words, some people are natural leaders, and others
are not. In reality, leadership may come more easily
to some than to others, but everyone can be a
leader, given the necessary knowledge and skill.
Research into the traits of leaders is a continuing
process. A 5-year study of 90 outstanding leaders
by Warren Bennis (1984) identified four common
traits shared by all of these leaders. These traits
continue to hold true:
1. Management of attention. These leaders were
able to communicate a sense of goal or direction
to attract followers.
2. Management of meaning. These leaders created
and communicated meaning with clarity and
3. Management of trust. These leaders demon-
strated reliability and consistency.
4. Management of self. These leaders were able to
know self and work within their strengths and
weaknesses (Bennis, 1984).
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6 unit 1 | Professional Considerations
The behavioral theories are concerned with what
the leader does. One of the most influential theo-
ries is concerned with leadership style (White &
Lippitt, 1960) (Table 1-1).
The three styles are:
■ Autocratic leadership (also called directive, con- trolling, or authoritarian). The autocratic leader gives orders and makes decisions for the group.
For example, when a decision needs to be made,
an autocratic leader says, “I’ve decided that this
is the way we’re going to solve our problem.”
Although this is an efficient way to run things,
it usually dampens creativity and may inhibit
■ Democratic leadership (also called participative). Democratic leaders share leadership. Important
plans and decisions are made with the team
(Chrispeels, 2004). Although this is often a less
efficient way to run things, it is more flexible
and usually increases motivation and creativity.
Democratic leadership is characterized by guid-
ance from rather than control by the leader.
■ Laissez-faire leadership (also called permissive or nondirective). The laissez-faire (“let someone do”) leader does very little planning or decision
making and fails to encourage others to do so.
It is really a lack of leadership. For example,
when a decision needs to be made, a laissez-faire
leader may postpone making the decision or
never make the decision. In most instances, the
laissez-faire leader leaves people feeling con-
fused and frustrated because there is no goal, no
guidance, and no direction. Some very mature
individuals thrive under laissez-faire leadership
because they need little guidance. Most people,
however, flounder under this kind of leadership.
Pavitt summed up the difference among these three
styles: a democratic leader tries to move the group
toward its goals; an autocratic leader tries to move
the group toward the leader’s goals; and a laissez-
faire leader makes no attempt to move the group
(1999, pp. 330ff ).
Task Versus Relationship
Another important distinction in leadership style is
between a task focus and a relationship focus
(Blake, Mouton, & Tapper, 1981). Some nurses
emphasize the tasks (e.g., reducing medication
errors, completing patient records) and fail to real-
ize that interpersonal relationships (e.g., attitude of
physicians toward nursing staff, treatment of
housekeeping staff by nurses) affect the morale and
productivity of employees. Other nurses focus on
the interpersonal aspects and ignore the quality of
the job being done as long as people get along with
each other. The most effective leader is able to bal-
ance the two, attending to both the task and the
relationship aspects of working together.
The concept of motivation seems fairly simple. We
do things to get what we want and avoid things that
we don’t want. However, motivation is still sur-
rounded in mystery. The study of motivation as a
focus of leadership began in the 1920s with the
historic Hawthorne study. Several experiments were
conducted to see if increasing light and, later,
improved working conditions would improve pro-
ductivity of workers in the Hawthorne, Illinois,
Comparison of Autocratic, Democratic, and Laissez-Faire Leadership Styles Autocratic Democratic Laissez-Faire
Amount of freedom Little freedom Moderate freedom Much freedom
Amount of control High control Moderate control Little control
Decision making By the leader Leader and group together By the group or by no one
Leader activity level High High Minimal
Assumption of responsibility Leader Shared Abdicated
Output of the group High quantity, good Creative, high quality Variable, may be poor quality
Efficiency Very efficient Less efficient than Inefficient
Adapted from White, R.K., & Lippitt, R. (1960). Autocracy and Democracy: An Experimental Inquiry. New York: Harper & Row.
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chapter 1 | Leadership and Followership 7
electrical plant. Those workers who had the
improved working conditions taken away continued
to show improved productivity. Therefore, the
answers were found not in the conditions of the experiments but in the attention given to the work- ers by the experimenters. Similar to the 1954
Maslow Hierarchy of Needs theory, the 1959
Motivation-Hygiene theory developed by Frederick
Herzberg looked at factors that motivated workers
in the workplace. Following closely after Herzberg
was David McClelland and his 1961 Theory of
Needs. Clayton Alderfer responded to Maslow’s
theory with his own Existence, Relatedness, and
Growth (ERG) theory. Table 1-2 summarizes these
four historical motivation theories.
The relationship aspects of leadership are a focus
of the work on emotional intelligence (Goleman,
Boyatzes, & McKee, 2002). Part of what distin-
guishes ordinary leaders from leadership “stars”
is consciously addressing the effect of people’s
feelings on the team’s emotional reality. How is
First, learn how to recognize and understand
your own emotions, and learn how to manage
them, channel them, stay calm and clear-headed,
and suspend judgment until all the facts are in
when a crisis occurs (Baggett & Baggett, 2005).
The emotionally intelligent leader welcomes con-
structive criticism, asks for help when needed, can
juggle multiple demands without losing focus, and
can turn problems into opportunities.
Second, the emotionally intelligent leader listens
attentively to others, perceives unspoken concerns,
acknowledges others’ perspectives, and brings peo-
ple together in an atmosphere of respect, coopera-
tion, collegiality, and helpfulness so they can direct
their energies toward achieving the team’s goals.
“The enthusiastic, caring, and supportive leader
generates those same feelings throughout the
team,” wrote Porter-O’Grady of the emotionally
intelligent leader (2003, p. 109).
People and leadership situations are far more complex
than the early theories recognized. In addition, situa-
tions can change rapidly, requiring more complex
Leading Motivation Theories Theory Summary of Motivation Requirements
Maslow, 1954 Categories of Need: Lower needs (below, listed first) must be fulfilled before others are activated.
Alderfer, 1972 Three categories of needs, also ordered into a hierarchy:
1. Existence: Physical well-being
2. Relatedness: Satisfactory relations with others
3. Growth: Development of competence and realization of potential
Herzberg, 1959 Two factors that influence motivation. The absence of hygiene factors can create job dissatisfaction, but their presence does not motivate or increase satisfaction.
1. Hygiene factors: Company policy, supervision, interpersonal relations, working conditions, salary
2. Motivators: Achievement, recognition, the work itself, responsibility, advancement
McClelland, 1961 Motivation results from three dominant needs. Usually all three needs are present in each individual but vary in importance depending on the position a person has in the workplace. Needs are also shaped over time by culture and experience.
1. Need for achievement: Performing tasks on a challenging and high level
2. Need for affiliation: Good relationships with others
3. Need for power: Being in charge
Adapted from Hersey, P. & Campbell, R. (2004). Leadership: A Behavioral Science Approach. Calif.: Leadership Studies Publishing.
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8 unit 1 | Professional Considerations
theories to explain leadership (Bennis, Spreitzer, &
Adaptability is the key to the situational
approach (McNichol, 2000). Instead of assuming
that one particular approach works in all situations,
situational theories recognize the complexity of work
situations and encourage the leader to consider many
factors when deciding what action to take.
Situational theories emphasize the importance
of understanding all the factors that affect a partic-
ular group of people in a particular environment.
The most well-known and still practiced theory is
the Situational Leadership Model by Dr. Paul
Hersey. The appeal of this model is that it focuses
on the task and the follower. The key is to marry
the readiness of the follower with the task behav-
ior at hand. “Readiness is defined as the extent to
which a follower demonstrates the ability and will-
ingness to accomplish a specific task” (Hersey &
Campbell, 2004, p. 114). The task behavior is
defined as “the extent to which the leader engages
in spelling out the duties and responsibilities of an
individual and a group” (Hersey & Campbell,
2004, p. 114).
Followers’ readiness levels can range from unable
and unwilling (or insecure) to able, willing, and
confident. The leader’s behavior will focus on appro-
priately fulfilling the follower’s needs, which are iden-
tified by their readiness level and the task. Leader
behaviors will range from telling, guiding, and direct-
ing to delegating, observing, and monitoring.
Where did you fall in this model during your first
clinical rotation compared with where you are now?
In the beginning, the clinical instructor was giving
you clear instructions and guiding and directing you.
Now, she or he is most likely delegating, observing,
and monitoring. However, as you move into your
first nursing position, you may return to the guiding
and directing stage. On the other hand, you may
have become a leader/instructor for new students,
and you may be guiding and directing them.
Although the situational theories were an improve-
ment over earlier theories, there was still something
missing. Meaning, inspiration, and vision were
not given enough attention (Tappen, 2001). These
are the distinguishing features of transformational
The transformational theory of leadership
emphasizes that people need a sense of mission
that goes beyond good interpersonal relationships
or the appropriate reward for a job well done (Bass
& Avolio, 1993). This is especially true in nursing.
Caring for people, sick or well, is the goal of the
profession. Most people chose nursing in order to
do something for the good of humankind: this is
their vision. One responsibility of leadership is to
help nurses achieve their vision.
Transformational leaders can communicate
their vision in a manner that is so meaningful and
exciting that it reduces negativity (Leach, 2005)
and inspires commitment in the people with whom
they work (Trofino, 1995). If successful, the goals of
the leader and staff will “become fused, creating
unity, wholeness, and a collective purpose” (Barker,
1992, p. 42).
The corporate scandals of recent …